Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

Identifying depression among adolescents using three key questions: a validation study in primary care

Background

Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.

Aim

To determine if three verbally asked key questions are valid for identifying depression in adolescents.

Design and setting

A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.

Method

A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14–16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger’s H, Cronbach’s α, and prevalence of depression.

Results

The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer ‘yes’ to either screening question and of 0.73 for the answer ‘yes’ to the help question. The positive predictive value was 31% and the negative predictive value was 97%.

Conclusion

The three key questions are useful for identifying depression in adolescents in primary health care.     

GPs’ responses to adolescents presenting with psychological difficulties: a conceptual model of fixers,future planners,and collaborators

Background

Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.

Aim

To explore the relationship between the above three influences to develop an overarching conceptual model.

Design and setting

Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.

Method

Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.

Results

In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.

Conclusion

The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents.     

What happens when doctors are patients? Qualitative study of GPs

Background

Current evidence about the experiences of doctors who are unwell is limited to poor quality data.

Aim

To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.

Design of study

Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.

Setting

Two primary care trusts in the West of England.

Method

A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis

Results

Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.

Conclusion

Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.     

Long-term prescribing of antidepressants in the older population: a qualitative study

Background

High rates of long-term antidepressant prescribing have been identified in the older population.

Aims

To explore the attitudes of older patients and their GPs to taking long-term antidepressant therapy, and their accounts of the influences on long-term antidepressant use.

Design of study

Qualitative study using in-depth semi-structured interviews.

Setting

One primary care trust in North Bradford.

Method

Thirty-six patients aged ≥75 years and 10 GPs were interviewed. Patients were sampled to ensure diversity in age, sex, antidepressant type, and home circumstances.

Results

Participants perceived significant benefits and expressed little apprehension about taking long-term antidepressants, despite being aware of the psychological and social factors involved in onset and persistence of depression. Barriers to discontinuation were identified following four themes: pessimism about the course and curability of depression; negative expectations and experiences of ageing; medicine discontinuation perceived by patients as a threat to stability; and passive (therapeutic momentum) and active (therapeutic maintenance) decisions to accept the continuing need for medication.

Conclusion

There is concern at a public health level about high rates of long-term antidepressant prescribing, but no evidence was found of a drive for change either from the patients or the doctors interviewed. Any apprehension was more than balanced by attitudes and behaviours supporting continuation. These findings will need to be incorporated into the planning of interventions aimed at reducing long-term antidepressant prescribing in older people.     

Presenting symptoms of children with cancer: a primary-care population-based study

Background

Knowledge of how children with cancer present in general practice is sparse. Timely referral from general practice is important to ensure early diagnosis.

Aim

To investigate the presenting symptoms and GPs’ interpretations of symptoms of children with cancer.

Design and setting

A Danish nationwide population-based study including children (<15 years) with an incident cancer diagnosis (January 2007 to December 2010).

Method

A questionnaire on symptoms and their interpretation was mailed to GPs (n?=?363). Symptoms were classified according to the International Classification of Primary Care (ICPC)-2 classification.

Results

GPs’ response rate was 87% (315/363) and GPs were involved in the diagnostic process of 253 (80.3%) children. Symptoms were few (2.4 per child) and most fell into the category ‘general and unspecified’ (71.9%), apart from patients with tumours of the central nervous system (CNS), whose symptoms fell mostly in the category ‘neurological’ (for example, headache). Symptoms like pain, swelling/lump, or fatigue were reported in 25% of the patients and they were the most commonly reported symptoms. GPs interpreted children’s symptoms as alarm symptoms in 20.2%, as serious (that is, not alarm) symptoms in 52.9%, and as vague symptoms in 26.9%. GPs’ interpretation varied significantly by diagnosis (P<0.001).

Conclusion

Children with cancer presented with few symptoms in general practice, of which most were ‘general and unspecified’ symptoms. Only 20% presented alarm symptoms, while 27% presented vague and non-specific symptoms. This low level of alarm symptoms may influence the time from symptom presentation in general practice to final diagnosis.     

The ‘added value’ GPs bring to commissioning: a qualitative study in primary care

Background

The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.

Aim

To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.

Design and setting

In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.

Method

A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.

Results

Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.

Conclusion

GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration.     

Hospital admissions from nursing homes: a qualitative study of GP decision making

Background

Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As ‘gatekeepers’ to NHS, GPs are expected to make best use of resources and may be criticised for ‘inappropriate’ admissions. Little is understood about the influences on GPs as they make such decisions

Aim

To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital.

Design and setting

A purposive sample of 21 GPs from two counties in the South of England.

Method

Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.

Results

This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients’ and relatives’ preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable.

Conclusion

Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.     

Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study

Background

Antidepressant prescribing continues to rise. Contributing factors are increased long-term prescribing and possibly the use of higher selective serotonin re-uptake inhibitor (SSRI) doses.

Aim

To review general practice patients prescribed the same antidepressant long-term (≥2 years) and evaluate prescribing and management pre and post-review.

Design and setting

Prospective observational cohort study using routine data from 78 urban general practices, Scotland.

Method

All patients prescribed antidepressants (excluding amitriptyline) for ≥2 years were identified from records November 2009 to March 2010. GPs selected patients for face-to-face review of clinical condition and medication, December 2009 to September 2010. Pre- and post-review data were collected; average antidepressant doses and changes in prescribed daily doses were calculated. Onward referral to support services was recorded.

Results

8.6% (33 312/388 656) of all registered patients were prescribed an antidepressant, 47.1% (15 689) were defined as long-term users and 2849 (18.2%) were reviewed. 811 (28.5%) patients reviewed had a change in antidepressant therapy: 7.0% stopped, 12.8% reduced dose, 5.3% increased dose, and 3.4% changed antidepressant, resulting in 9.5% (95% CI = 9.1% to 9.8% P<0.001) reduction in prescribed daily dose and 8.1% reduction in prescribing costs. 6.3% were referred onwards, half to NHS Mental Health Services. Pre-review SSRI doses were 10–30% higher than previously reported.

Conclusion

Almost half of all people prescribed antidepressants were long-term users. Appropriate reductions in prescribing can be achieved by reviewing patients. Higher SSRI doses may be contributing to current antidepressant growth.     

Reasons why doctors choose or reject careers in general practice: national surveys

Background

Less than one-third of newly qualified doctors in the UK want a career in general practice. The English Department of Health expects that half of all newly qualified doctors will become GPs.

Aim

To report on the reasons why doctors choose or reject careers in general practice, comparing intending GPs with doctors who chose hospital careers.

Design and setting

Questionnaire surveys in all UK medical graduates in selected qualification years.

Method

Questions about specialty career intentions and motivations, put to the qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, and 2009, 1 year after qualification, and at longer time intervals thereafter.

Results

‘Enthusiasm for and commitment to the specialty’ was a very important determinant of choice for intending doctors, regardless of chosen specialty. ‘Hours and working conditions’ were a strong influence for intending GPs (cited as having had ‘a great deal’ of influence by 75% of intending GPs in the first year after qualification), much more so than for doctors who wanted a hospital career (cited by 30%). Relatively few doctors had actually considered general practice seriously but then rejected it; 78% of the doctors who rejected general practice gave ‘job content’ as their reason, compared with 32% of doctors who rejected other specialties.

Conclusion

The shortfall of doctors wanting a career in general practice is not accounted for by doctors considering and rejecting it. Many do not consider it at all. There are very distinctive factors that influence choice for, and rejection of, general practice.     

Patient-reported areas for quality improvement in general practice: a cross-sectional survey

Background

GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.

Aim

To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.

Design and setting

Cross-sectional survey of patients attending Australian general practice clinics.

Method

Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.

Results

In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).

Conclusion

Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required.     

Screening older people with musculoskeletal pain for depressive symptoms in primary care

Background

Older patients presenting to GPs with musculoskeletal pain are at high risk of having concurrent depression.

Aim

To investigate the performance of ultra-short (1–4 items tools) screening questions used during the consultation, and through a patient questionnaire to detect depressive symptoms among older adults presenting with musculoskeletal pain to general practice.

Design of study

Cross-sectional survey, linked GP consultation data.

Setting

General practices in central Cheshire, UK.

Method

Consecutive patients aged ≥50 years presenting with non-inflammatory musculoskeletal pain were eligible to participate. GPs screened all patients in the consultation for the presence of depressive symptoms using two questions. All patients were sent a postal questionnaire within 1 week of consultation containing the Hospital Anxiety and Depression Scale and the written version of the depression screening questions.

Results

The total number of patients included in the study was 428. In total, 35.5% of consulters had comorbid depressive symptoms, with 13.5% experiencing moderate or severe symptoms. Just over half of participants (n = 218/242; 51.4%) screened positive on self-administered screening at home compared with only 78 (20.8%) on GP-administered screening in the consultation. There was little difference between GPadministered and self-administered screening in the probability of depressive symptoms among those who screened positive with regard to exhibiting signs of having depressive symptoms.

Conclusion

Older patients consulting their GP with musculoskeletal pain frequently have comorbid mental ill health. Ultrashort depression screening questions administered during the consultation miss a large number of those with depressive symptoms, including six out of eight patients with severe symptoms. An improvement in the performance of screening questions in this patient group or narrowing the definition of ‘high risk’ from all patients aged ≥50 years presenting with musculoskeletal pain could help to improve detection.