Prevalence and Characteristics of Patients Being at Risk of Deteriorating and Dying in Primary Care

Objective The process of detecting people at high risk of schizophrenia from a community sample is a major challenge for prevention of psychotic disorders. The aim of this paper is to describe early detection procedures that can be implemented in primary care settings. Methods A selected literature review is supplemented by experiences and data obtained during the Buckingham Integrated Mental Health Care Project. Results General medical practitioners have been favoured as the agents most likely to prove helpful in detecting the key risk factors that predict the onset of schizophrenic disorders, as well as in recognising the earliest signs and symptoms of these conditions. However, the practical problems of screening for multiple and subtle risk factors in general practice are substantial, and general practitioners (GPs) often have difficulty recognising the earliest signs of a psychotic episode. A range of strategies to assist GPs detect early signs of psychosis in their patients are considered. Conclusions It is feasible to implement primary care setting early detection procedures for people at risk of schizophrenia. Implementation is aided by the use of a brief screening questionnaire, training sessions and case supervision; and increased collaboration with mental health services and other community agencies.

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Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr07140 ◽

2019 ◽

Vol 7 (14) ◽

pp. 1-288 ◽

Cited By ~ 1

Author(s):

John L Campbell ◽

Emily Fletcher ◽

Gary Abel ◽

Rob Anderson ◽

Rupatharshini Chilvers ◽

...

Keyword(s):

Primary Care ◽

At Risk ◽

General Practice ◽

Mixed Methods ◽

Patient Care ◽

Mixed Methods Study ◽

Direct Patient Care ◽

South West ◽

Career Break ◽

South West England

BackgroundUK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.Objectives(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.DesignThis was a comprehensive, mixed-methods study.SettingThis study took place in primary care in England.ParticipantsGeneral practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.Main outcome measuresSystematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.ResultsPast research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.LimitationsThe survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.ConclusionsThis research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.Study registrationThis study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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146 Improving Outcomes in Aspiration Pneumonia: A Collaborative Approach

Age and Ageing ◽

10.1093/ageing/afab030.107 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

S Richards-Taylor ◽

R Kitchener ◽

M Whiffen ◽

D Tiwari

Keyword(s):

Primary Care ◽

At Risk ◽

Aspiration Pneumonia ◽

Clinical Care ◽

Collaborative Approach ◽

Bed Elevation ◽

Pdsa Cycle ◽

Mouth Care ◽

Referral Form ◽

Expected Mortality

Abstract Introduction Aspiration pneumonia is a major cause of morbidity and mortality especially in older adults. Our Trust recorded higher than expected mortality ratios in this group of patients. Aim To investigate reasons behind higher than expected mortality and improve outcomes. Intervention We developed a collaborative approach of investigating mortality in aspiration pneumonia with joint input from Speech and Language (SALT) specialists. Method We conducted structured retrospective review of annual mortality in aspiration pneumonia in 3 PDSA (plan, do, study, and act) cycles in 2015/18/20. We collected data on clinical care, diagnostic accuracy, SALT referral/input, feeding at risk discussion, communication with primary care. We monitored mortality ratios on national systems. Results We improved clinical and nursing care by auditing mouth care, bed elevation and safe feeding. We also developed electronic-SALT referral form to improve timings for the reviews (first PDSA cycle). SALT team developed “feeding at risk proforma” to formalise risk feeding where safe swallow plan was not possible (second PDSA cycle). We modified discharge summaries and made this a multidisciplinary document in the Trust so that SALT can communicate feeding plans to primary care (third PDSA cycle). Mortality ratios improved significantly in this period from Relative risk of 152 (higher than expected range) in 14/15 to 86 (within expected range) in 19/20. Conclusion We have demonstrated significant improvement in hospital mortality ratios from aspiration pneumonia and therefore improved care by collaboratively working with SALT team and bringing changes in stepwise manner. Multidisciplinary mortality reviews are key to improving outcomes for our patients.

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Current Approaches to the Provision of Integrated Primary Care to People at Risk of Substance Abuse

Family Medicine ◽

10.30841/2307-5112.5-6.2019.193221 ◽

2019 ◽

Vol 0 (5-6) ◽

pp. 8-12 ◽

Cited By ~ 1

Author(s):

Л. Г. Матвієць

Keyword(s):

Primary Care ◽

At Risk ◽

Substance Abuse ◽

Integrated Primary Care

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The Effects of a Co-design Based Invitation Strategy on Participation in a Preventive Health Check Program: A Randomized Controlled Trial (Preprint)

10.2196/preprints.25617 ◽

2020 ◽

Author(s):

Trine Thilsing ◽

Lars Bruun Larsen ◽

Anders Larrabee Sonderlund ◽

Signe Skaarup Andreassen ◽

Jeanette Reffstrup Christensen ◽

...

Keyword(s):

Primary Care ◽

At Risk ◽

Pilot Study ◽

Educational Attainment ◽

Design Process ◽

Family Income ◽

Target Group ◽

Control Group ◽

Participation Rates ◽

Lifestyle Related Diseases

BACKGROUND Primary-care-based preventive programs that aim to reduce morbidity and mortality from lifestyle-related diseases often suffer from low to moderate participation rates. Improving participation rates is essential to clinical effect and cost effectiveness. In 2016-2017 we conducted the first pilot study (TOF pilot1) testing a primary-care-based preventive program (the TOF intervention) comprising systematic identification of individuals at risk of lifestyle-related diseases, and subsequent targeted preventive services offered to the at-risk population. A total of 40.2% of the invited patients consented to take part in the study with the highest participation rates obtained among women and patients with higher income, education, and employment. OBJECTIVE The aim of this study was to evaluate the effect of a revised invitation strategy targeting men and patients of low educational attainment on overall participation rate and participant demography. METHODS This study was embedded in the second pilot study (initiated in October 2018) testing an adjusted TOF intervention (TOF pilot2). The revised invitation strategy comprised a pre-notification postcard and a new invitation targeting men and patients of low educational attainment. The new invitation was developed in a co-design process involving communication professionals and target group representatives. The study sample consisted of 4633 patients aged 29-59 years and residing in two municipalitites in the Region of Southern Denmark. Eligible patients were randomly assigned to four invitation groups receiving either 1) The original invitation used in TOF pilot1 (Control group), 2) The original invitation and the pre-notification postcard, 3) The new, revised invitation and the pre-notification postcard, or 4) The new invitation only. RESULTS Overall, 2171 (46.9%) patients consented to participate. Compared to receiving the original invitation alone, participation rates increased significantly for those groups who received the new revised invitation alone (p<.001), the new invitation with the pre-notification postcard (p<.001), and the original invitation with the pre-notification postcard (p<.001). Participation across the three intervention groups was increased among women as well as men, patients of high as well as low educational attainment and patients of low as well as higher family income. The largest relative increase in participation was seen among males, patients with low educational attainment, and patients with low family income. No significant increase in participation was detected among unemployed patients and patients of non-Danish origin. CONCLUSIONS The results showed that significant improvements in participation rates can be obtained from pre-notification postcards and invitations that have undergone a co-design process, involving communication professionals and target group representatives. Although firm conclusions can not be made from the present study, the apparent increased effect on participation among men and patients of low socioeconomic status may be relevant in programs that aim to reduce inequality in health. In order to reach the most socioeconomically disadvantaged groups, the invitation strategy should probably be combined with other more individual-oriented recruitment approaches. CLINICALTRIAL Clinical Trial Gov (NCT03913585)

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Corrigendum: Screening for At-Risk Alcohol Consumption in Primary Care: A Randomized Evaluation of Screening Approaches

Alcohol and Alcoholism ◽

10.1093/alcalc/agy022 ◽

2018 ◽

Vol 53 (4) ◽

pp. 499-499

Author(s):

Simon Coulton ◽

Veronica Dale ◽

Paolo Deluca ◽

Eilish Gilvarry ◽

Christine Godfrey ◽

...

Keyword(s):

Primary Care ◽

At Risk ◽

Alcohol Consumption ◽

Randomized Evaluation ◽

Screening Approaches

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Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice

British Journal of General Practice ◽

10.3399/bjgp18x695489 ◽

2018 ◽

Vol 68 (669) ◽

pp. e279-e285 ◽

Cited By ~ 2

Author(s):

Tom Margham ◽

Natalie Symes ◽

Sally A Hull

Keyword(s):

Primary Care ◽

At Risk ◽

General Practice ◽

Patient Safety ◽

Ease Of Use ◽

High Yield ◽

Case Review ◽

Patients At Risk ◽

Barriers To Implementation ◽

Narrative Evaluation

BackgroundIdentifying patients at risk of harm in general practice is challenging for busy clinicians. In UK primary care, trigger tools and case note reviews are mainly used to identify rates of harm in sample populations.AimThis study explores how adaptions to existing trigger tool methodology can identify patient safety events and engage clinicians in ongoing reflective work around safety.Design and settingMixed-method quantitative and narrative evaluation using thematic analysis in a single East London training practice.MethodThe project team developed and tested five trigger searches, supported by Excel worksheets to guide the case review process. Project evaluation included summary statistics of completed worksheets and a qualitative review focused on ease of use, barriers to implementation, and perception of value to clinicians.ResultsTrigger searches identified 204 patients for GP review. Overall, 117 (57%) of cases were reviewed and 62 (53%) of these cases had patient safety events identified. These were usually incidents of omission, including failure to monitor or review. Key themes from interviews with practice members included the fact that GPs’ work is generally reactive and GPs welcomed an approach that identified patients who were ‘under the radar’ of safety. All GPs expressed concern that the tool might identify too many patients at risk of harm, placing further demands on their time.ConclusionElectronic trigger tools can identify patients for review in domains of clinical risk for primary care. The high yield of safety events engaged clinicians and provided validation of the need for routine safety checks.

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