Why do patients with cancer access out-of-hours primary care? A retrospective study

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.     

Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups

Background

Antibiotics are of limited overall clinical benefit for uncomplicated lower respiratory tract infection (LRTI) but there is uncertainty about their effectiveness for patients with features associated with higher levels of antibiotic prescribing.

Aim

To estimate the benefits and harms of antibiotics for acute LRTI among those producing coloured sputum, smokers, those with fever or prior comorbidities, and longer duration of prior illness.

Design and setting

Secondary analysis of a randomised controlled trial of antibiotic placebo for acute LRTI in primary care.

Method

Two thousand and sixty-one adults with acute LRTI, where pneumonia was not suspected clinically, were given amoxicillin or matching placebo. The duration of symptoms, rated moderately bad or worse (primary outcome), symptom severity on days 2–4 (0–6 scale), and the development of new or worsening symptoms were analysed in pre-specified subgroups of interest. Evidence of differential treatment effectiveness was assessed in prespecified subgroups by interaction terms.

Results

No subgroups were identified that were significantly more likely to benefit from antibiotics in terms of symptom duration or the development of new or worsening symptoms. Those with a history of significant comorbidities experienced a significantly greater reduction in symptom severity between days 2 and 4 (interaction term −0.28, P = 0.003; estimated effect of antibiotics among those with a past history −0.28 [95% confidence interval = −0.44 to −0.11], P = 0.001), equivalent to three people in 10 rating symptoms as a slight rather than a moderately bad problem. For subgroups not specified in advance antibiotics provided a modest reduction in symptom severity for non-smokers and for those with short prior illness duration (<7 days), and a modest reduction in symptom duration for those with short prior illness duration.

Conclusion

There is no clear evidence of clinically meaningful benefit from antibiotics in the studied high-risk groups of patients presenting in general practice with uncomplicated LRTIs where prescribing is highest. Any possible benefit must be balanced against the side-effects and longer-term effects on antibiotic resistance.     

Older patients and their GPs: shared decision making in enhancing trust

Background

Older patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients.

Aim

This study explored older patients’ trust in their GPs and their perceptions of shared decision making.

Design and setting

Qualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK.

Method

A constant comparative approach was applied to thematic analysis of transcribed interviews.

Results

All participants valued feeling involved in decisions but differed regarding how they felt involved. Trust influenced preferences for shared decision making: a trusted GP ‘ally’, to competently manage participants’ increasing health-information requirements throughout the vulnerable ageing process, was important. Trust was affected by factors contributing to the facilitation of involvement. GP characteristics, communication skills, consultation duration, and continuity of care were common themes.

Conclusion

Although limited geographically and subsequently by ethnic group, the present sample allows for reasonable transferability of the study to other UK populations. A range of factors are highlighted for consideration when planning primary healthcare delivery: to facilitate the optimal involvement of older patients in decisions about their health care, while enhancing their trust in the GP; to help minimise potential health inequalities for this patient group.     

Visual identification of obesity by healthcare professionals: an experimental study of trainee and qualified GPs

Background

Guidelines suggest that GPs should intervene on patients’ weight, but to do so GPs must first recognise that a patient may have a weight problem and weigh them.

Aim

To examine whether GPs and trainee GPs can identify overweight and obese body weights by sight, and if this influences whether they would discuss weight with a potential patient.

Design and setting

Study of GPs and trainee GPs on the lists of the UK NHS Workforce West Midlands Deanery and NHS Sandwell and West Birmingham Clinical Commissioning Group.

Method

Participants viewed 15 standardised photographs of healthy-weight, overweight, and obese young males, and estimated their BMI, classified their weight status, and reported whether they would be likely to make a brief intervention for weight loss with that person.

Results

The sample of GPs and trainee GPs correctly classified a mean of 4.0/5.0 of the healthy weight males, a mean of 2.4/5.0 of the overweight, and a mean of 1.7/5.0 of the obese males. For each 1 kg/m² increase in actual BMI, participants underestimated BMI by −0.21 (95% CI = −0.22 to −0.18), meaning that participants would underestimate the BMI of a man of 30 kg/m² by approximately 2.5 kg/m², but were more accurate for lower body weights. Participants were more likely to intervene with those with a higher estimated BMI (OR 1.53, 95% CI = 1.49 to 1.58).

Conclusion

This sample of predominantly trainee GPs perceived overweight and obese weights as being of lower BMI and weight status than they actually are, and this was associated with a lower intention of discussing weight management with a potential patient. This was found to be true for trainee and fully qualified GPs who participated in the study. Healthcare professionals should not rely on visual judgements when identifying patients who may benefit from weight management treatment.     

Living in uncertain times: trajectories to death in residential care homes

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.     

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

Background

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

Aim

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

Design and setting

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

Method

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

Results

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

Conclusion

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

Evaluating pancreatitis in primary care: a population-based cohort study

Background

Pancreatitis is an important condition with significant mortality. Primary care may have an important role to play in its prevention, early diagnosis, and ongoing management.

Aim

To evaluate incidence, case fatality, and clinical features of acute and chronic pancreatitis in a large population.

Design and setting

Population-based cohort study using a primary care database in the UK from 1990 to 2013.

Method

Use of general practice records from 16 491 patients diagnosed with pancreatitis. Age-standardised incidence rates and case fatality were estimated. Clinical features, aetiology, and patterns of recurrence were evaluated.

Results

Incidence of pancreatitis increased from 14.8 in 100 000 (1990–1994) to 31.2 in 100 000 (2010–2013) in males, and from 14.5 to 28.3 in 100 000 in females (2010–2013). Overall case fatality after diagnosis was 4.3% (95% CI = 4.0% to 4.6%) at 90 days and 7.9% (95% CI = 7.5% to 8.4%) at 365 days. In 1990–1994, 10% of patients with acute pancreatitis were recorded as heavy drinkers, increasing to 12% in 2010–2012; for patients with chronic pancreatitis the proportions were 13%, rising to 21%. Among patients who died in the 90 days after diagnosis, 92% consulted with their general practice in the 2 months before first diagnosis.

Conclusion

The incidence of pancreatitis is increasing over time. Alcohol abuse may now account for at least one in eight cases of acute, and one in five cases of chronic pancreatitis. Consultations among those who subsequently died may have offered potential for earlier diagnosis and intervention.     

Attitudes towards domestic violence in Lebanon: a qualitative study of primary care practitioners

Background

Domestic violence (DV) is highly prevalent in the developing and developed world. Healthcare systems internationally are still not adequately addressing the needs of patients experiencing violence.

Aim

To explore physicians’ attitudes about responding to DV, their perception of the physician’s role, and the factors that influence their response.

Design and setting

Qualitative study using individual interviews among primary care practitioners working in Lebanon.

Method

Primary care clinicians practising for >5 years and with >100 patient consultations a week were interviewed. Physicians were asked about their practice when encountering women disclosing abuse, their opinion about the engagement of the health services with DV, their potential role, and the anticipated reaction of patients and society to this extended role.

Results

Physicians felt that they were well positioned to play a pivotal role in addressing DV; yet they had concerns related to personal safety, worry about losing patients, and opposing the norms of a largely conservative society. Several physicians justified DV or blamed the survivor rather than the perpetrator for triggering the violent behaviour. Moreover, religion was perceived as sanctioning DV.

Conclusion

Perceived cultural norms and religious beliefs seem to be major barriers to physicians responding to DV in Lebanon, and possibly in the Arab world more generally. Financial concerns also need to be addressed to encourage physicians to address DV.     

Deletion of the α2A/α2C‐adrenoceptors accelerates cutaneous wound healing in mice

The α2‐adrenoceptors regulate the sympathetic nervous system, controlling presynaptic catecholamine release. However, the role of the α2‐adrenoceptors in cutaneous wound healing is poorly understood. Mice lacking both the α2A/α2C‐adrenoceptors were used to evaluate the participation of the α2‐adrenoceptor during cutaneous wound healing. A full‐thickness excisional lesion was performed on the dorsal skin of the α2A/α2C‐adrenoceptor knockout and wild‐type mice. Seven or fourteen days later, the animals were euthanized and the lesions were formalin‐fixed and paraffin‐embedded or frozen. Murine skin fibroblasts were also isolated from α2A/α2C‐adrenoceptor knockout and wild‐type mice, and fibroblast activity was evaluated. The in vivo study demonstrated that α2A/α2C‐adrenoceptor depletion accelerated wound contraction and re‐epithelialization. A reduction in the number of neutrophils and macrophages was observed in the α2A/α2C‐adrenoceptor knockout mice compared with wild‐type mice. In addition, α2A/α2C‐adrenoceptor depletion enhanced the levels of nitrite and hydroxyproline, and the protein expression of transforming growth factor‐β and vascular endothelial growth factor. Furthermore, α2A/α2C‐adrenoceptor depletion accelerated blood vessel formation and myofibroblast differentiation. The in vitro study demonstrated that skin fibroblasts isolated from α2A/α2C‐adrenoceptor knockout mice exhibited enhanced cell migration, α‐smooth muscle actin _protein expression and collagen deposition compared with wild‐type skin fibroblasts. In conclusion, α2A/α2C‐adrenoceptor deletion accelerates cutaneous wound healing in mice.