Assessing physical activity in general practice: a disconnect between clinical practice and public health?

Background

GPs comply poorly to public health recommendations to routinely assess their patients'' physical activity. The reasons for this disconnect between recommended practice and GPs'' actual practice are unclear.

Aim

To investigate GPs'' perceptions of assessing physical activity, and to explore how GPs assess their patients'' physical activity.

Design of the study

Qualitative study.

Setting

General practice.

Method

Semi-structured interviews were performed with 15 randomly selected southern Tasmanian GPs, with stratification to include GPs with a range of demographic characteristics. Each interview was recorded, transcribed in full, and analysed using an iterative thematic approach to identify major themes.

Results

GPs recognised the importance of assessing physical activity, but rather than assessing every patient, they target at-risk patients and those with conditions likely to benefit from increased physical activity. Depth of assessment and GPs'' definition of sufficient physical activity varied according to the clinical and social context of each patient. Major barriers were the time needed to perform an adequate assessment and lack of time to deal with physical inactivity in patients once it was identified.

Conclusion

GPs'' assessment of physical activity is a complex and highly individualised process that cannot be divorced from the issue of managing physical inactivity once it is identified. Expectations that GPs will assess physical activity levels in all their patients are unlikely to be met. This must be taken into account when developing strategies to improve physical activity assessment in general practice, and should be considered in policy decisions about approaches to take to improve physical activity levels at a population level.     

General practitioners' perceptions of vaccination controversies: a French nationwide cross-sectional study

ObjectivesWe aimed to study general practitioners' (GPs') perceptions of vaccines that have been a subject of controversy in France.MethodsA cross-sectional survey in 2014 asked a representative national sample of GPs, randomly selected from the exhaustive database of health professionals in France, about their perceptions of the likelihood of serious adverse events potentially associated with six different vaccines: for two of them the association was based on some scientific evidence, whereas for the other four this is not the case. We performed a cluster analysis to construct a typology of GPs' perceptions about the likelihood of these potential six associations. Factors associated with certain clusters of interest were identified using logistic regression models.ResultsOverall, 1582 GPs participated in the questionnaire survey (1582/1712 GPs who agreed to participate, 92%). Cluster analysis identified four groups of GPs according to their susceptibility to vaccine controversies: 1) limited susceptibility to controversies (52%); 2) overall unsure, but rejected the association between hepatitis B vaccine and multiple sclerosis (32%); 3) highly susceptible to controversies (11%); and 4) unsure (5%). We found that GPs who occasionally practised alternative medicine (OR 2.71, 95% CI 1.65-4.45), and those who considered information provided by mass media as reliable (OR 2.04, 95% CI 1.65-3.99) were more susceptible to controversies.ConclusionsGPs had different profiles of susceptibility to vaccination controversies, and most of their perceptions of these controversies were not based on scientific evidence.     

Addressing the epidemic of antibiotic “allergy” over-diagnosis

ObjectiveAn epidemic of antibiotic allergy is occurring.Data SourcesArticles published since 2008.Study SelectionsArticles on antibiotic allergy and stewardship.ResultsA number of overlapping factors contribute. The most important factor is antibiotic overuse. Antibiotics are commonly used in situations in which no antibiotics are indicated. Thirty percent to 50% of ambulatory antibiotic use may be inappropriate. The duration of indicated antibiotic use is often excessive, which leads to more side effects. All antibiotic use can result in adverse reactions, and a fraction of these will be dutifully recorded as an allergy in the electronic health record (EHR). Most EHRs are not well structured to accurately convey information on expected side effects that have occurred, metabolic or other contraindications, dose-related or situational toxicities, personal preferences, clinically significant immunologically mediated hypersensitivity, and other reasons a particular patient may not want or should not be given a specific drug or type of drug in the future. As populations age, their accumulated baggage of reported antibiotic allergies increase. Suspected antibiotic allergy is rarely confirmed with appropriate testing or rechallenge. Patients then receive suboptimal antibiotic therapy and experience more side effects, treatment failures, and serious antibiotic-resistant infections. Reporting an antibiotic allergy in the EHR is nominally done to improve patient safety, but unfortunately, this is often not the actual result.ConclusionAudit and feedback, to help ensure adherence to Choosing Wisely recommendations and good antibiotic stewardship practices, can help reduce inappropriate antibiotic use. Restructuring EHRs to facilitate correct drug intolerance reporting, along with active antibiotic allergy delabeling programs, can help stem this epidemic.     

How does the general practitioner understand the patient? A qualitative study about psychological interventions in general practice

Objectives General practitioners (GPs) treat more than 90% of common mental disorders. However, the content of their interventions remains undefined. The present study aimed to explore GPs' processes of understanding the patients with emotional problems. Design The study was qualitative using semi‐structured interviews with 14 general practitioners sampled purposively. Observation was done in the surgeries of four of the GPs. Methods Analysis of the interviews was made by Interpretative Phenomenological Analysis (IPA). Observation notes were analysed from a hermeneutic‐phenomenological perspective, inspired by IPA. Results GPs had very different approaches to patients with emotional problems. Physical symptoms were the usual reason for consulting the GP. Understanding patients' perception of the meaning of their bodily symptoms in their complex life‐situation was considered important by some of the participants. Arriving at this understanding often occurred through the narrative delivered in different narrative styles mirroring the patients' mental state. Awareness of relational factors and self‐awareness and self‐reflexivity on the part of the GP influenced this process. Other participants did not enter this process of understanding patients' emotional problems. Conclusions The concept of mentalization could be used to describe GPs' processes of understanding their patients when making psychosocial interventions and could form an important ingredient in a general practice theory in this field. Only some participants had a mentalizing approach. The study calls attention to the advantage of training this capacity for promoting professional treatment of patients and a professional dialogue across sector borders.     

Antibiotic prescribing practices in three neonatology units in Kigali,Rwanda. – an observational study

IntroductionThere is limited published data on antibiotic use in neonatal units in resource-poor settings.ObjectivesThis study sought to describe antibiotic prescribing practices in three neonatology units in Kigali, Rwanda.MethodsA multi-center, cross-sectional study conducted in two tertiary and one urban district hospital in Kigali, Rwanda. Participants were neonates admitted in neonatology who received a course of antibiotics during their admission. Data collected included risk factors for neonatal sepsis, clinical signs, symptoms, investigations for neonatal sepsis, antibiotics prescribed, and the number of deaths in the included cohort.Results126 neonates were enrolled with 42 from each site. Prematurity (38%) followed by membrane rupture more than 18 hours (25%) were the main risk factors for neonatal sepsis. Ampicillin and Gentamicin (85%) were the most commonly used first-line antibiotics for suspected neonatal sepsis. Most neonates (87%) did not receive a second-line antibiotic. Cefotaxime (11%), was the most commonly used second-line antibiotic. The median duration of antibiotic use was four days in all surviving neonates (m=113). In neonates with negative blood culture and normal C-reactive protein (CRP), the median duration of antibiotics was 3.5 days; and for neonates, with positive blood cultures, the median duration was 11 days. Thirteen infants died (10%) at all three sites, with no significant difference between the sites.ConclusionThe median antibiotic duration for neonates with normal lab results exceeded the recommended duration mandated by the national neonatal protocol. We recommend the development of antibiotic stewardship programs in neonatal units in Rwanda to prevent the adverse effects which may be caused by inappropriate or excessive use of antibiotics.     

GPs' views in five European countries of interventions to promote prudent antibiotic use

Background

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

Aim

To explore GPs'' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

Design and setting

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

Method

Fifty-two semi-structured interviews explored GPs'' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

Results

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

Conclusion

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.     

Holding relationships in primary care: a qualitative exploration of doctors' and patients' perceptions

BackgroundOngoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.AimTo explore urban GPs'' and patients'' experiences of the management of chronic illness, with a particular focus on holding relationships.MethodParticipating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.ResultsGP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.ConclusionHolding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.     

Knowledge,attitudes, beliefs and practices of general practitioners towards measles and MMR vaccination in southeastern France in 2012

As a result of sub-optimal immunization levels, measles has re-emerged in the EU since 2008 (30 567 cases in 2011), and nearly half of the cases reported are in France. Our objectives were to assess knowledge, attitudes, beliefs and practices of French general practitioners (GPs) towards measles and measles–mumps–rubella (MMR) vaccination. In 2012, we surveyed 329 GPs in southeastern France. Forty-five percent reported that they saw patients with measles in 2011. They considered the risk of complications low among 2–5-year-old children and young adults without co-morbidity. Twenty percent knew that two MMR doses are 99% effective in preventing measles. Nearly all (95%) GPs stated that they verified the MMR status for patients <30 years old in 2011 (42% systematically, 37% often, 15% sometimes). Seventy-nine percent reported proposing MMR vaccination to non-immune relatives in contact with a patient with measles. Participation in continuing medical education courses and considering measles to be a serious disease were independently associated with such post-exposure vaccination. GPs considered the following were potential barriers to the second dose of MMR (MMR2): parents/patients' belief that measles is harmless (80%), parents/patients' fear of the vaccine's side effects (50%), difficulty in documenting vaccination (48%) and lack of reminders for MMR2 (16%). Finally, some GPs also had misconceptions about the severity of measles (13%) and the usefulness of MMR2 (12%), which also served as barriers. In conclusion, it is essential to raise GPs' awareness of this disease and fill any gaps in their knowledge, by providing them with evidence-based information on measles and MMR vaccination.