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1.
Stefan B?sner Simone Hartel Judith Diederich Erika Baum 《The British journal of general practice》2014,64(626):e532-e537
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. 相似文献2.
Anna Willis Jennifer Swann Joanne Thompson 《The British journal of general practice》2015,65(638):e593-e600
Background
Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.Aim
To explore practitioners’ views of supporting children with LTCs and their families in primary care.Design and setting
Qualitative interview study in primary care settings in South Yorkshire, England.Method
Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.Results
Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.Conclusion
Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners. 相似文献3.
Risto Raivio Doris Holmberg-Marttila Kari J Mattila 《The British journal of general practice》2014,64(627):e657-e663
Background
Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.Aim
To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.Design and setting
A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.Method
The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.Results
Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96).Conclusion
Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland. 相似文献4.
Jill Phillips Constance Dimity Pond Nerida Elizabeth Paterson Cate Howell Allan Shell Nigel P Stocks Susan M Goode John E Marley 《The British journal of general practice》2012,62(601):e546-e553
Background
Dementia is an insidious and stigmatised condition, and research indicates that GPs find communicating this diagnosis particularly problematic. Delays in diagnosis may impede optimal patient care. Little research has been published on Australian GPs’ perceptions of barriers to disclosing the diagnosis of dementia.Aim
To explore GPs’ perceptions of barriers to disclosing the diagnosis of dementia.Design and setting
Qualitative study in the general practice consultation context.Method
Semi-structured, audiorecorded interviews were conducted with GPs from three capital cities and one regional centre in Australia. Interviews were transcribed verbatim and thematic analysis was conducted.Results
GPs’ lack of confidence in having a correct diagnosis, concern to act in patients’ best interests, and the stigma associated with the ‘dementia’ label influenced the disclosure process. GPs found it challenging to identify dementia in the consultation context. It was difficult to raise the issue when both the patient and their family/carer(s) ignore/are unaware of symptoms of cognitive decline. Referral to a specialist was favoured to confirm suspicions, although this did not always result in a definitive diagnosis. Opinions differed as to whether the GP or the specialist was better placed to deliver the diagnosis. GPs preferred disclosure to the patient with his/her family/carer(s) present; associated issues of confidentiality and the importance of offering hope emerged. The severity of the patient’s dementia also guided the diagnostic disclosure process. GPs often used euphemisms for dementia when disclosing the diagnosis, to soften the message.Conclusion
Complex issues surround the disclosure of dementia. Communicating this diagnosis remains particularly challenging for many GPs. 相似文献5.
Jette M?ller Ahrensberg Rikke Pilegaard Hansen Frede Olesen Henrik Schr?der Peter Vedsted 《The British journal of general practice》2012,62(600):e458-e465
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. 相似文献6.
Fiona Fox Michael Harris Gordon Taylor Karen Rodham Jane Sutton Brian Robinson Jenny Scott 《The British journal of general practice》2009,59(568):811-818
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 analysisResults
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. 相似文献7.
Neil Perkins Anna Coleman Michael Wright Erica Gadsby Imelda McDermott Christina Petsoulas Kath Checkland 《The British journal of general practice》2014,64(628):e728-e734
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. 相似文献8.
Mark Ashworth Peter Schofield Stevo Durbaba Sanjiv Ahluwalia 《The British journal of general practice》2014,64(620):e168-e177
Background
Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.Aim
The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.Design and setting
Retrospective cross-sectional study in general practices in England.Method
Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.Results
GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.Conclusion
Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’. 相似文献9.
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11.
Gijs Elshout Marijke Kool Arthur M Bohnen Bart W Koes Henri?tte A Moll Marjolein Y Berger 《The British journal of general practice》2015,65(638):e578-e584
Background
Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care.Aim
To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.Design and setting
A prospective cohort study at a GPs’ cooperative (GPC) out-of-hours service.Method
Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact.Results
Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that ‘sore throat’ (OR 2.8; 95% CI = 1.30 to 6.01) and ‘lymph nodes palpable’ (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01).Conclusion
The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted. 相似文献12.
Marjolein Helena Johanna van de Pol Cornelia Rita Maria Gertruda Fluit Joep Lagro Danielle Niessen Marcellinus Gerardus Maria Olde Rikkert Antoinette Leonarda Maria Lagro-Janssen 《The British journal of general practice》2015,65(637):e500-e507
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. 相似文献13.
Stephen Barclay Katherine Froggatt Clare Crang Elspeth Mathie Melanie Handley Steve Iliffe Jill Manthorpe Heather Gage Claire Goodman 《The British journal of general practice》2014,64(626):e576-e583
Background
Older people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes.Aim
To describe care home residents’ trajectories to death and care provision in their final weeks of life.Design and setting
Prospective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire.Method
Case note reviews and interviews with residents, care home staff, and healthcare professionals.Results
Twenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: ‘anticipated dying’ with an identifiable end-of-life care period and death in the care home (n = 9); ‘unexpected dying’ with death in the care home that was not anticipated and often sudden (n = 3); ‘uncertain dying’ with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and ‘unpredictable dying’ with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study.Conclusion
For some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events. 相似文献14.
Yvonne M Drewes Julia M Koenen Wouter de Ruijter DJ Annemarie van Dijk-van Dijk Gerda M van der Weele Barend JC Middelkoop Ria Reis Willem JJ Assendelft Jacobijn Gussekloo 《The British journal of general practice》2012,62(604):e765-e772
Background
Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important.Aim
To explore GPs’ perspectives on preventive care for older people.Design and setting
Qualitative study comprising six focus groups with GPs in the Netherlands.Method
The focus-group discussions with 37 GPs were analysed using the framework analysis method.Results
Whether or not to implement preventive care for older people depends on the patient’s individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient’s request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs’ different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline).Conclusion
GPs’ perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline. 相似文献15.
Alice Malpass Alison Shaw David Kessler Deborah Sharp 《The British journal of general practice》2010,60(575):e231-e238
Background
In 2009, a new indicator (DEP 3) was introduced into the Quality and Outcomes Framework. GPs are now encouraged to assess response to antidepressant treatment 5–12 weeks after the initial assessment, to guide clinical decision making. The Patient Health Questionnaire (PHQ-9) is one of the validated instruments that GPs can use to assess the patient''s clinical state.Aims
To explore the extent to which changes in PHQ-9 score over time reflect patients’ accounts of their experiences of depression during the same period; and to explore patients’ experiences of using the PHQ-9 within primary care consultations.Design of study
Mixed methods.Setting
Primary care.Method
Patients were recruited through six GP practices. The PHQ-9 and in-depth interviews were used at the same three time points over a 6-month period during a new or first episode of depression.Results
Patterns in the total PHQ-9 score broadly reflected patients’ accounts of the severity of their depression over time. However, the PHQ-9 was inaccurate in its assessment of the presence and intensity of thoughts of self-harm, and missed symptoms that are meaningful to patients. At the diagnostic primary care consultation, patients viewed their score as a ‘tangible’ measure of their condition. Some patients requested the PHQ-9 subsequently as a way to measure their own treatment response and recovery process.Conclusion
The potential therapeutic value of the PHQ-9 may be dependent upon the GP''s willingness to openly discuss the results and what they may mean for the patient. 相似文献16.
Yvette van Ierland Gijs Elshout Henri?tte A Moll Ruud G Nijman Yvonne Vergouwe Johan van der Lei Marjolein Y Berger Rianne Oostenbrink 《The British journal of general practice》2014,64(618):e1-e9
Background
The diagnostic value of alarm features of serious infections in low prevalence settings is unclear.Aim
To explore to what extent alarm features play a role in referral to the emergency department (ED) by GPs who face a febrile child during out-of-hours care.Design and setting
Observational study using semi-structured, routine clinical practice data of febrile children (<16 years) presenting to GP out-of-hours care.Method
Logistic regression analyses were performed to assess the association between alarm features of serious infections (selected from two guidelines and one systematic review) and referral to the ED. Adherence to the guideline was explored by a 2×2 contingency table.Results
In total 794 (8.1%) of 9794 eligible patients were referred to the ED. Alarm signs most strongly associated with referral were ‘age <1 month’, ‘decreased consciousness’, ‘meningeal irritation’, and ‘signs of dehydration’. Nineteen percent of 3424 children with a positive referral indication according to the guideline were referred to the ED. The majority of those not referred had only one or two alarm features present. A negative referral indication was adhered to for the majority of children. Still, in 20% of referred children, alarm features were absent.Conclusion
In contrast to guidance, GPs working in primary out-of-hours care seem more conservative in referring febrile children to the ED, especially if only one or two alarm features of serious infection are present. In addition, in 20% of referred children, alarm features were absent, which suggests that other factors may be important in decisions about referral of febrile children to the hospital ED. 相似文献17.
Barbara AM Snoeker Aeilko H Zwinderman Cees Lucas Robert Lindeboom 《The British journal of general practice》2015,65(637):e523-e529
Background
In primary care, meniscal tears are difficult to detect. A quick and easy clinical prediction rule based on patient history and a single meniscal test may help physicians to identify high-risk patients for referral for magnetic resonance imaging (MRI).Aim
The study objective was to develop and internally validate a clinical prediction rule (CPR) for the detection of meniscal tears in primary care.Design and setting
In a cross-sectional multicentre study, 121 participants from primary care were included if they were aged 18–65 years with knee complaints that existed for <6 months, and who were suspected to suffer from a meniscal tear.Method
One diagnostic physical meniscal test and 14 clinical variables were considered to be predictors of MRI outcome. Using known predictors for the presence of meniscal tears, a ‘quick and easy’ CPR was derived.Results
The final CPR included the variables sex, age, weight-bearing during trauma, performing sports, effusion, warmth, discolouration, and Deep Squat test. The final model had an AUC of 0.76 (95% CI = 0.72 to 0.80). A cut-point of 150 points yielded an overall sensitivity of 86.1% and a specificity of 45.5%. For this cut-point, the positive predictive value was 55.0%, and the negative predictive value was 81.1%. A scoring system was provided including the corresponding predicted probabilities for a meniscal tear.Conclusion
The CPR improved the detection of meniscal tears in primary care. Further evaluation of the CPR in new primary care patients is needed, however, to assess its usefulness. 相似文献18.
Rosalind Adam Patrick Wassell Peter Murchie 《The British journal of general practice》2014,64(619):e99-e104
Background
Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care.Aim
To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department.Design and setting
A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011.Method
Subjects were identified by filtering the OOH computer database using the Read Codes ‘neoplasm’, ‘terminal care’, and ‘terminal illness’. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s).Results
Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication.Conclusion
Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning. 相似文献19.
20.
Jonathan Hammond Katja Gravenhorst Emma Funnell Susan Beatty Derek Hibbert Jonathan Lamb Heather Burroughs Marija Kovand?i? Mark Gabbay Christopher Dowrick Linda Gask Waquas Waheed Carolyn A Chew-Graham 《The British journal of general practice》2013,63(608):e177-e184