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Jo B Middlemass research fellow Momina F Yazdani Joe Kai Penelope J Standen Nadeem Qureshi 《The British journal of general practice》2014,64(622):e282-e289
Background
While primary care systematically offers conventional cardiovascular risk assessment, genetic tests for coronary heart disease (CHD) are increasingly commercially available to patients. It is unclear how individuals may respond to these new sources of risk information.Aim
To explore how patients who have had a recent conventional cardiovascular risk assessment, perceive additional information from genetic testing for CHD.Design and setting
Qualitative interview study in 12 practices in Nottinghamshire from both urban and rural settings.Method
Interviews were conducted with 29 adults, who consented to genetic testing after having had a conventional cardiovascular risk assessment.Results
Individuals’ principal motivation for genetic testing was their family history of CHD and a desire to convey the results to their children. After testing, however, there was limited recall of genetic test results and scepticism about the value of informing their children. Participants dealt with conflicting findings from the genetic test, family history, and conventional assessment by either focusing on genetic risk or environmental lifestyle factors. In some participants, genetic test results appeared to reinforce healthy behaviour but others were falsely reassured, despite having an ‘above-average’ conventional cardiovascular risk score.Conclusion
Although genetic testing was acceptable, participants were unclear how to interpret genetic risk results. To facilitate healthy behaviour, health professionals should explore patients’ understanding of genetic test results in light of their family history and conventional risk assessment. 相似文献3.
Robert Fleetcroft Sheetal Parekh-Bhurke Amanda Howe Richard Cookson Louise Swift Nicholas Steel 《The British journal of general practice》2010,60(578):e345-e352
Background
General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.Aim
To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.Design of study
Cross-sectional and modelling study.Setting
Primary care in England.Method
Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available.Results
The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower–upper estimates 7–16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29–81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.Conclusion
The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered. 相似文献4.
Toll‐like receptor variants and cervical Atopobium vaginae infection in women with pelvic inflammatory disease
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Brandie D. Taylor Patricia A. Totten Sabina G. Astete Michael J. Ferris David H. Martin Roberta B. Ness Catherine L. Haggerty 《American journal of reproductive immunology (New York, N.Y. : 1989)》2018,79(2)
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Eike Adams Mary Boulton Peter Rose Susi Lund Alison Richardson Sue Wilson Eila Watson 《The British journal of general practice》2011,61(585):e173-e182
Background
The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.Aim
To describe: (1) implementation of the QOF cancer care review; (2) patients'' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients'' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.Design of study
Qualitative study using thematic analysis and a framework approach.Setting
Six general practices in the Thames Valley area.Method
Semi-structured interviews with cancer patients and focus groups with primary care teams.Results
Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients'' needs and closer links with secondary care to facilitate a more involved role.Conclusion
Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care. 相似文献6.
Abigail Moore Anthony Harnden Richard Mayon-White 《The British journal of general practice》2014,64(625):e477-e483
Background
Kawasaki disease is a rare childhood illness that can present non-specifically, making it a diagnostic challenge. The clinical presentation of Kawasaki disease has not been previously described in primary care.Aim
To describe how children with an eventual diagnosis of Kawasaki disease initially present to primary care in the UK.Design and setting
The Clinical Practice Research Datalink was used to find cases coded as Kawasaki disease. Hospital Episode Statistics, hospital admissions, and hospital outpatient attendances were used to identify the children with a convincing diagnosis of Kawasaki disease.Method
Questionnaires and a request for copies of relevant hospital summaries, discharge letters, and reports were sent to GPs of the 104 children with a diagnosis of Kawasaki disease between 2007 and 2011.Results
Most children presented with few clinical features typical of Kawasaki disease. Of those with just one feature, a fever or a polymorphous rash were the most common. By the time that most children were admitted to hospital they had a more recognisable syndrome, with three or more clinical features diagnostic of Kawasaki disease. Most GPs did not consider Kawasaki disease among their differential diagnoses, but some GPs did suspect that the child’s illness was unusual.Conclusion
The study highlighted the difficulty of early diagnosis, with most children having a non-specific presentation to primary care. GPs are encouraged to implement good safety netting, and to keep Kawasaki disease in mind when children present with fever and rashes. 相似文献7.
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Lindsay McMahon Karin M Foran Stephen D Forrest Michelle L Taylor Graham Ingram Madhuri Rajwal Peter L Cornwall R Hamish McAllister-Williams 《The British journal of general practice》2007,57(544):880-885
BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial. 相似文献
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BACKGROUND: Primary care mental health workers are a new role recently introduced into primary care in England to help manage patients with common mental health problems. AIM: To explore the views of GPs, primary care teams and patients on the value and development of the new role of primary care mental health workers in practice. DESIGN OF STUDY: Qualitative study. SETTING: The Heart of Birmingham Primary Care Teaching Trust in the West Midlands, UK. METHOD: Thirty-seven semi-structured interviews involving seven primary care mental health workers, 21 patients and 11 focus groups involving 38 members of primary care teams were held with six teams with a worker. Two teams asked for the worker to be removed. Six practice managers also took part in the study. RESULTS: A number of different approaches were used to implement this new role. Strategies that incorporated the views of primary care trust senior management, primary care teams and workers' views appeared most successful. Rapid access to a healthcare professional at times of stress and the befriending role of the worker were also highly valued. Workers felt that their role left them professionally isolated at times. A number of workers described tension around ownership of the role. CONCLUSION: Primary care mental health workers appear to provide a range of skills valued by patients and the primary care teams and can increase patient access and choice in this area of health care. Successful implementation strategies highlighted in this study may be generalisable to other new roles in primary care. 相似文献
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Kirsty Boyd Bruce Mason Marilyn Kendall Stephen Barclay David Chinn Keri Thomas Aziz Sheikh Scott A Murray 《The British journal of general practice》2010,60(581):e449-e458
Background
Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.Aim
To assess the feasibility of implementing advance care planning in UK primary care.Design of study
Mixed methods evaluation of a pilot educational intervention.Setting
Four general practices in south-east Scotland.Method
Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.Results
End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.Conclusion
A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes. 相似文献12.
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Alex N Bastick Janet Wesseling Jurgen Damen Saskia PJ Verkleij Pieter J Emans Patrick JE Bindels Sita MA Bierma-Zeinstra 《The British journal of general practice》2016,66(642):e32-e39
Background
GPs have high consultation rates for symptoms related to knee osteoarthritis (OA). Many risk factors for symptomatic knee OA progression remain unknown.Aim
To define distinct knee pain trajectories in individuals with early symptomatic knee OA and determine the risk factors for these pain trajectories.Design and setting
Data were obtained from the multicentre prospective Cohort Hip and Cohort Knee study in the Netherlands. Participants with knee OA, according to the clinical criteria of the American College of Rheumatology, and a completed 5-year follow-up were included.Method
Baseline demographic, anamnestic, and physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale for pain. Pain trajectories were retrieved by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios.Results
In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. Statistically significant differences were found in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories. Higher BMI, lower level of education, greater comorbidity, higher activity limitation scores, and joint space tenderness were more often associated with trajectories characterised by more pain at first presentation and pain progression — compared with the reference group with a mild pain trajectory. No association was found for baseline radiographic features.Conclusion
These results can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a ‘wait-and-see’ policy seems justifiable. Radiography provided no additional benefit over clinical diagnosis of early symptomatic knee OA in general practice. 相似文献14.
Anthony Harnden Richard Mayon-White David Mant Deirdre Kelly Gale Pearson 《The British journal of general practice》2009,59(568):819-824
Background
In 2006 the Confidential Enquiry into Maternal and Perinatal Deaths was extended to pilot a collection of child deaths. This helped optimise data collection for local safeguarding children''s boards, which, since April 2008, have a statutory responsibility to review all child deaths. Reviewing primary care records may highlight areas in which systems, skills, and care could be improved.Aim
To review the role and quality of primary care in child deaths.Design of study
Confidential enquiry into child deaths.Setting
Five regions of the UK: North-East, South-West and West Midlands, Wales, and Northern Ireland.Method
The confidential enquiry collected core data for all child deaths (age range 28 days to 17 years) and an age-stratified sample was assessed by multidisciplinary panels for avoidable factors. An independent detailed review was conducted of the primary care records on all children in the North-East region and all children who were reviewed by panel in the other four regions.Results
Primary care records were reviewed for 168 child deaths. There were 25 (15%) deaths from acute infection, 22 (13%) from cancer, and 11 (7%) from asthma or epilepsy. Fifty-nine (35%) deaths were sudden: sudden unexplained death in infancy, suicides, and assaults. Of 149 with immunisation records, only 88 (59%) had been fully vaccinated on time. One or more primary care professionals were involved in the management of 90 (54%) children. Avoidable primary care factors were identified in 18 (20%) of these deaths. Avoidable primary care factors included failure in the recognition and management of serious infection, failure to vaccinate, and inadequate management of asthma and epilepsy.Conclusion
Decisions made about diagnosis and management in primary care may affect the cause, time, and circumstances of a child''s death. Maintaining skills in assessing the acutely ill child remains an essential part of good clinical practice. 相似文献15.
Elizabeth Shephard Richard Neal Peter Rose Fiona Walter William T Hamilton 《The British journal of general practice》2013,63(609):e250-e255
Background
Kidney cancer accounts for over 4000 UK deaths annually, and is one of the cancer sites with a poor mortality record compared with Europe.Aim
To identify and quantify all clinical features of kidney cancer in primary care.Design
Case-control study, using General Practice Research Database records.Method
A total of 3149 patients aged ≥40 years, diagnosed with kidney cancer between 2000 and 2009, and 14 091 age, sex and practice-matched controls, were selected. Clinical features associated with kidney cancer were identified, and analysed using conditional logistic regression. Positive predictive values for features of kidney cancer were estimated.Results
Cases consulted more frequently than controls in the year before diagnosis: median 16 consultations (interquartile range 10–25) versus 8 (4–15): P<0.001. Fifteen features were independently associated with kidney cancer: visible haematuria, odds ratio 37 (95% confidence interval [CI] = 28 to 49), abdominal pain 2.8 (95% CI = 2.4 to 3.4), microcytosis 2.6 (95% CI = 1.9 to 3.4), raised inflammatory markers 2.4 (95% CI = 2.1 to 2.8), thrombocytosis 2.2 (95% CI = 1.7 to 2.7), low haemoglobin 1.9 (95% CI = 1.6 to 2.2), urinary tract infection 1.8 (95% CI = 1.5 to 2.1), nausea 1.8 (95% CI = 1.4 to 2.3), raised creatinine 1.7 (95% CI = 1.5 to 2.0), leukocytosis 1.5 (95% CI = 1.2 to 1.9), fatigue 1.5 (95% CI = 1.2 to 1.9), constipation 1.4 (95% CI = 1.1 to 1.7), back pain 1.4 (95% CI = 1.2 to 1.7), abnormal liver function 1.3 (95% CI = 1.2 to 1.5), and raised blood sugar 1.2 (95% CI = 1.1 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was 1.0% (95% CI = 0.8 to 1.3).Conclusion
Visible haematuria is the commonest and most powerful single predictor of kidney cancer, and the risk rises when additional symptoms are present. When considered alongside the risk of bladder cancer, the overall risk of urinary tract cancer from haematuria warrants referral. 相似文献16.
Lydia RM French Debbie J Sharp Katrina M Turner 《The British journal of general practice》2015,65(638):e570-e577
Background
It is known that couples may experience emotional distress while undergoing infertility treatment, but less is known about their experience of pregnancy following successful conception. Typically, couples are discharged from the fertility clinic to receive standard antenatal care. Recent research has raised questions about whether this care adequately meets their needs.Aim
To explore the antenatal experiences of females and males who have successfully conceived through infertility treatment.Design and setting
An exploratory qualitative approach was undertaken, using individual, in-depth interviews with females and males who had successfully undergone infertility treatment in one of three fertility clinics in the south of England.Method
Twenty participants were interviewed (12 females and eight male partners) when their pregnancy had reached 28 weeks’ gestation. Participants were asked about their experiences of infertility treatment, pregnancy, and antenatal care. Interviews were audiorecorded, transcribed, and analysed thematically.Results
Analysis of the interviews suggested females and males experienced a ‘gap’ in their care, in terms of time and intensity, when discharged from the fertility clinic to standard antenatal care. This gap, combined with their previous experience of infertility treatment, heightened their fear of pregnancy loss and increased their need for support from their health professionals. Participants’ previous experience of infertility treatment also appeared to deter them from preparing for the birth and parenthood, and disclosing negative feelings to others about the pregnancy.Conclusion
Females and males who have successfully undergone infertility treatment may require additional support in primary care to address anxiety during pregnancy, enable disclosure of negative feelings, and to help them prepare for childbirth and parenthood. 相似文献17.
Caroline Eyles Michael Moore Nicholas Sheron Paul Roderick Wendy O’Brien Geraldine M Leydon 《The British journal of general practice》2013,63(613):e516-e522
Background
It is estimated that one-quarter of adults in the UK drink at harmful/hazardous levels leading to increased mortality and alcohol liver disease (ALD). The Alcohol Liver Disease Detection Study (ALDDeS) aimed to test out in primary care the feasibility of alcohol misuse screening in adults, using the AUDIT questionnaire, and to assess screening harmful/hazardous alcohol users for ALD using newer non-invasive serum markers of fibrosis.Aim
To explore patients’ experiences of taking part in ALDDeS and understanding of the delivery and process of screening for ALD using self-report questionnaires and feedback of liver fibrosis risk using levels of non-invasive serum markers.Design and setting
A nested qualitative study based in five primary care practices in the UK.Method
From a sample of patients who were identified as drinking at harmful/hazardous levels, 30 participants were identified by maximum variation sampling for qualitative in-depth interviews. Using the principles of constant comparison the transcribed interviews were thematically analysed.Results
Receiving a postal AUDIT questionnaire was viewed as acceptable by participants. For some completing the AUDIT increased awareness of their hazardous alcohol use and a positive blood test indicating liver fibrosis was a catalyst for behaviour change. For others, a negative blood test result provided a licence to continue drinking at hazardous levels. A limited understanding of safe drinking and of ALD was common.Conclusion
Educational and training needs of primary care professionals must be taken into account, so that patients with marker levels indicating low risk of fibrosis are correctly informed about the likely risks of continuing to drink at the same levels. 相似文献18.
Tim A Holt Tina D Hunter Candace Gunnarsson Nada Khan Paul Cload Gregory YH Lip 《The British journal of general practice》2012,62(603):e710-e717
Background
Oral anticoagulants substantially reduce the risk of stroke in atrial fibrillation but are underutilised in current practice.Aim
To measure the distribution of stroke risk in patients with atrial fibrillation (using the CHADS2 and CHA2DS2-VASc scores) and changes in oral anticoagulant use during 2007–2010.Design and setting
Longitudinal series of cross-sectional survey in 583 UK practices linked to the QResearch® database providing 99 351 anonymised electronic records from people with atrial fibrillation.Method
The proportion of patients in each CHADS2 and CHA2DS2-VASc risk band in 2010 was calculated; for each of the years 2007–2010, the proportions with risk scores ≥2 that were using anticoagulants or antiplatelet agents were estimated. The proportions identified at high risk were re-estimated using alternative definitions of hypertension based on coded data. Finally, the prevalence of comorbid conditions in treated and untreated high-risk (CHADS2 ≥2) groups was derived.Results
The proportion at high risk of stroke in 2010 was 56.9% according to the CHADS2 ≥2 threshold, and 84.5% according to CHA2DS2-VASc ≥2 threshold. The proportions of these groups receiving anticoagulants were 53.0% and 50.7% respectively and increased during 2007–2010. The means of identifying the population of individuals with hypertension significantly influenced the estimated proportion at high risk. Comorbid conditions associated with avoidance of anticoagulants included history of falls, use of nonsteroidal anti-inflammatory drugs, and dementia.Conclusion
Oral anticoagulant use in atrial fibrillation has increased in UK practice since 2007, but remains suboptimal. Improved coding of hypertension is required to support systematic identification of individuals at high risk of stroke and could be assisted by practice-based software. 相似文献19.