scholarly journals Factors shaping the implementation and use of Clinical Cancer Decision Tools by GPs in primary care: a qualitative framework synthesis

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e043338
Author(s):  
Paula Theresa Bradley ◽  
Nicola Hall ◽  
Gregory Maniatopoulos ◽  
Richard D Neal ◽  
Vinidh Paleri ◽  
...  
Keyword(s):  
Primary Care ◽  
Secondary Care ◽  
Grey Literature ◽  
Signs And Symptoms ◽  
Clinical Work ◽  
Assessment Tools ◽  
Normalisation Process Theory ◽  
Decision Tools ◽  
Clinical Cancer ◽  
The Impact

ObjectiveClinical Cancer Decision Tools (CCDTs) aim to alert general practitioners (GPs) to signs and symptoms of cancer, supporting prompt investigation and onward referral. CCDTs are available in primary care in the UK but are not widely utilised. Qualitative research has highlighted the complexities and mechanisms surrounding their implementation and use; this has focused on specific cancer types, formats, systems or settings. This study aims to synthesise qualitative data of GPs’ attitudes to and experience with a range of CCDTs to gain better understanding of the factors shaping their implementation and use.DesignA systematic search of the published (MEDLINE, CINAHL, Web of Science and EMBASE) and grey literature (July 2020). Following screening, selection and assessment of suitability, the data were analysed and synthesised using normalisation process theory.ResultsSix studies (2011 to 2019), exploring the views of GPs were included for analysis. Studies focused on the use of several different types of CCDTs (Risk Assessment Tools (RAT) or electronic version of RAT (eRAT), QCancer and the 7-point checklist). GPs agreed CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. They had concerns about the impact on trust in their own clinical acumen, whether secondary care clinicians would consider referrals generated by CCDT as valid and whether integration of the CCDTs within existing systems was achievable.ConclusionsCCDTs might be a helpful adjunct to clinical work in primary care, but without careful development to legitimise their use GPs are likely to give precedence to clinical acumen and gut instinct. Stakeholder consultation with secondary care clinicians and consideration of how the CCDTs fit into a GP consultation are crucial to successful uptake. The role and responsibilities of a GP as a clinician, gatekeeper, health promoter and resource manager affect the interaction with and implementation of innovations such as CCDTs.

scholarly journals Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e039809
Author(s):  
Sharon Dixon ◽  
Claire Duddy ◽  
Gabrielle Harrison ◽  
Chrysanthi Papoutsi ◽  
Sue Ziebland ◽  
...  
Keyword(s):  
Primary Care ◽  
Grey Literature ◽  
Relevant Literature ◽  
Theory Development ◽  
Realist Review ◽  
Primary Outcome Measure ◽  
Mandatory Reporting ◽  
Programme Theory ◽  
Genital Mutilation ◽  
The Impact

ObjectivesLittle is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.SettingPrimary care in England.Data sourcesRealist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.Primary outcome measureThis realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.Results124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.ConclusionsThere is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities’ health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.PROSPERO registration numberCRD42018091996.

Recognition and assessment of dementia in primary care

2019 ◽  
Vol 30 (9) ◽  
pp. 438-443
Author(s):  
Karen Harrison-Dening
Keyword(s):  
Primary Care ◽  
Care Setting ◽  
Primary Care Setting ◽  
Signs And Symptoms ◽  
Assessment Tools ◽  
Long Term Conditions ◽  
Practice Nurses ◽  
Memory Assessment ◽  
Neurology Clinic

While patients diagnosed with dementia will require management from specialist neurology clinics, practice nurses play an important role in their health. Karen Harrison-Dening explains what assessment tools are available for patients with particular health needs The majority of patients are diagnosed in a memory assessment service or a neurology clinic. However, early detection of a possible dementia is often done in a primary care setting. Dementia diagnosis has been seen by some as a ‘tick-box exercise’ but there are significant benefits to patients and their families when screening or testing for dementia is carried out early, especially in supporting the patients management of other comorbid or long-term conditions. Nurses working in primary care have a key role in identifying patients who may have the signs and symptoms of dementia by enabling them to access a timely diagnosis.

scholarly journals Cross-sectional observation study to investigate the impact of risk-based stratification on care pathways for patients with chronic kidney disease: protocol paper

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e027315 ◽  
Author(s):  
Harjeet Kaur Bhachu ◽  
Paul Cockwell ◽  
Anuradhaa Subramanian ◽  
Krishnarajah Nirantharakumar ◽  
Derek Kyte ◽  
...  
Keyword(s):  
Primary Care ◽  
Kidney Disease ◽  
Secondary Care ◽  
Health Improvement ◽  
Cross Sectional ◽  
Risk Equation ◽  
Failure Risk ◽  
The Health Improvement Network ◽  
The Uk ◽  
The Impact

IntroductionChronic kidney disease (CKD) management in the UK is usually primary care based, with National Institute for Health and Care Excellence (NICE) guidelines defining criteria for referral to secondary care nephrology services. Estimated glomerular filtration rate (eGFR) is commonly used to guide timing of referrals and preparation of patients approaching renal replacement therapy. However, eGFR lacks sensitivity for progression to end-stage renal failure; as a consequence, the international guideline group, Kidney Disease: Improving Global Outcomes has recommended the use of a risk calculator. The validated Kidney Failure Risk Equation may enable increased precision for the management of patients with CKD; however, there is little evidence to date for the implication of its use in routine clinical practice. This study will aim to determine the impact of the Kidney Failure Risk Equation on the redesignation of patients with CKD in the UK for referral to secondary care, compared with NICE CKD guidance.Method and analysisThis is a cross-sectional population-based observational study using The Health Improvement Network database to identify the impact of risk-based designation for referral into secondary care for patients with CKD in the UK. Adult patients registered in primary care and active in the database within the period 1 January 2016 to 31 March 2017 with confirmed CKD will be analysed. The proportion of patients who meet defined risk thresholds will be cross-referenced with the current NICE guideline recommendations for referral into secondary care along with an evaluation of urinary albumin–creatinine ratio monitoring.Ethics and disseminationApproval was granted by The Health Improvement Network Scientific Review Committee (Reference number: 18THIN061). Study outcomes will inform national and international guidelines including the next version of the NICE CKD guideline. Dissemination of findings will also be through publication in a peer-reviewed journal, presentation at conferences and inclusion in the core resources of the Think Kidneys programme.

scholarly journals Impact of rurality on processes and outcomes in melanoma care: results from a whole-Scotland melanoma cohort in primary and secondary care

2018 ◽  
Vol 68 (673) ◽  
pp. e566-e575 ◽  
Author(s):  
Peter Murchie ◽  
Rosalind Adam ◽  
Wei L Khor ◽  
Edwin A Raja ◽  
Lisa Iversen ◽  
...  
Keyword(s):  
Primary Care ◽  
Rural Areas ◽  
Secondary Care ◽  
Urban Areas ◽  
Proportional Hazards ◽  
Binary Logistic Regression ◽  
Small Towns ◽  
Cox Proportional Hazards ◽  
Current Evidence ◽  
The Impact

BackgroundThose living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory.AimTo investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort.Design and settingAnalysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005–December 2013, in primary and secondary care.MethodMultivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders.ResultsIn total 9519 patients were included (54.3% [n = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% (n = 8598) were in secondary care and 8.1% (n = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality.ConclusionPatients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations.

Measuring integrated care at the interface between primary care and secondary care: a scoping review

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Aimee O'Farrell ◽  
Geoff McCombe ◽  
John Broughan ◽  
Áine Carroll ◽  
Mary Casey ◽  
...  
Keyword(s):  
Primary Care ◽  
Scoping Review ◽  
Full Text ◽  
Secondary Care ◽  
Research Question ◽  
Grey Literature ◽  
Problem Area ◽  
Cochrane Library ◽  
Comprehensive Overview ◽  
Content Type

PurposeIn many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of disease. The interface between primary and secondary care has been identified as a problem area. This paper aims to undertake a scoping review to gain a deeper understanding of the markers of integration across the primary–secondary interface.Design/methodology/approachA search was conducted of PubMed, SCOPUS, Cochrane Library and the grey literature for papers published in English using the framework described by Arksey and O'Malley. The search process was guided by the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA).FindingsThe initial database search identified 112 articles, which were screened by title and abstract. A total of 26 articles were selected for full-text review, after which nine articles were excluded as they were not relevant to the research question or the full text was not available. In total, 17 studies were included in the review. A range of study designs were identified including a systematic review (n = 3), mixed methods study (n = 5), qualitative (n = 6) and quantitative (n = 3). The included studies documented integration across the primary–secondary interface; integration measurement and factors affecting care coordination.Originality/valueMany studies examine individual aspects of integration. However, this study is unique as it provides a comprehensive overview of the many perspectives and methodological approaches involved with evaluating integration within the primary–secondary care interface and primary care itself. Further research is required to establish valid reliable tools for measurement and implementation.

scholarly journals Systematic review of integrated models of health care delivered at the primary–secondary interface: how effective is it and what determines effectiveness?

2015 ◽  
Vol 21 (4) ◽  
pp. 391 ◽  
Author(s):  
Geoffrey K. Mitchell ◽  
Letitia Burridge ◽  
Jianzhen Zhang ◽  
Maria Donald ◽  
Ian A. Scott ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Service Delivery ◽  
Disease Control ◽  
Usual Care ◽  
Clinical Outcomes ◽  
Secondary Care ◽  
Design Elements ◽  
Primary Care Practitioners ◽  
The Impact

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary–secondary care. Six elements were identified that were common to these models of integrated primary–secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary–secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

scholarly journals Impact of coronavirus disease 2019 on urgent referrals to secondary care otolaryngology: a prospective case series

2020 ◽  
pp. 1-4
Author(s):  
M S Osborne ◽  
E Bentley ◽  
A Farrow ◽  
J Chan ◽  
J Murphy
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Perceived Risk ◽  
Secondary Care ◽  
Case Series ◽  
Medical Setting ◽  
Accident And Emergency ◽  
Accident And Emergency Department ◽  
Prospective Case Series ◽  
The Impact

Abstract Objective As the novel coronavirus disease 2019 changed patient presentation, this study aimed to prospectively identify these changes in a single ENT centre. Design A seven-week prospective case series was conducted of urgently referred patients from primary care and accident and emergency department. Results There was a total of 133 referrals. Referral rates fell by 93 per cent over seven weeks, from a mean of 5.4 to 0.4 per day. Reductions were seen in referrals from both primary care (89 per cent) and the accident and emergency department (93 per cent). Presentations of otitis externa and epistaxis fell by 83 per cent, and presentations of glandular fever, tonsillitis and peritonsillar abscess fell by 67 per cent. Conclusion Coronavirus disease 2019 has greatly reduced the number of referrals into secondary care ENT. The cause for this reduction is likely to be due to patients’ increased perceived risk of the virus presence in a medical setting. The impact of this reduction is yet to be ascertained, but will likely result in a substantial increase in emergency pressures once the lockdown is lifted and the general public's perception of the coronavirus disease 2019 risk reduces.

On challenges to respect for autonomous decision making in primary care

2021 ◽  
pp. 147775092110699
Author(s):  
John Spicer ◽  
Sanjiv Ahluwalia ◽  
Rupal Shah
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Decision Making ◽  
Health Care Access ◽  
Clinical Work ◽  
Community Practice ◽  
Full Account ◽  
Autonomous Decision ◽  
Comprehensive Service ◽  
The Impact

Primary health care is characterised by timely and appropriate health care access, delivered continuously over time to a specific population, providing a comprehensive service, with coordination of care for those that need it. Practitioners deal with a multiplicity of clinical issues within longitudinal relationships, embedded in the context of families and communities. We propose that these aspects of primary care have a bearing on how matters of decision making are considered and implemented. Further, the standard account of autonomous decision making is not wholly adequate when applied to clinician–patient encounters in primary care. We add considerations of the impact of illness (however defined) and self-identity as also relevant to a more measured and full account. The context of primary care is quite different from that of secondary care. Although there are generalists who work in hospitals, we argue that this aspect and the other attributes of primary care generate special ethical considerations. One of these is how autonomy, or more fully, how respect for the principle of autonomy is considered and operationalised in community practice. In this study, we describe some theoretical aspects of autonomy and seek to apply, and challenge, these aspects in the context of clinical work in primary care. In doing so we will review the descriptors of primary care: why in essence it is different from other contexts of clinical work.

scholarly journals Hospital climate actions and assessment tools: a scoping review protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e032561
Author(s):  
Connie Cai Ru Gan ◽  
Nicola Banwell ◽  
Ramon San Pascual ◽  
Cordia Chu ◽  
Ying Wei Wang
Keyword(s):  
Climate Change ◽  
Scoping Review ◽  
Grey Literature ◽  
Assessment Tools ◽  
Annual Conference ◽  
Mitigation And Adaptation ◽  
Smart Healthcare ◽  
Study Results ◽  
Climate Action ◽  
The Impact

IntroductionHealth and climate change are inexorably linked through the exacerbation of health risks and the contribution of the health sector to greenhouse gas emissions. Climate action in healthcare settings is critical to reduce risks and impacts of climate change through the smarter use of energy, minimising waste and enhancing disaster preparedness. Globally, hospital climate action is growing; however, the potential for further progress and impacts remains. The literature on this topic lacks synthesis, and this poses challenges for hospital leadership in tracking the impact of climate action. This scoping review will summarise the current knowledge about hospital climate action and existing tools to measure progress in this area.Methods and analysisThis scoping review will be conducted applying the six-stage protocol proposed by Arksey and O’Malley. The study includes literature of how hospitals have addressed climate change (mitigation and adaptation) since the Kyoto Protocol was signed in 1997. All identified studies indexed in Medline, Scopus, Embase and CINAHL will be examined. The search strategy will also include Google Scholar to capture relevant grey literature. Quantitative and thematic analysis will be used to evaluate and categorise the study results.Ethics and disseminationThis scoping review is part of the climate-smart healthcare initiative which will provide a valuable synthesis to aid understanding of hospitals’ climate actions, and tools used to measure its implementation. As such it will contribute to mobilising and accelerating the implementation of climate action in hospitals. The findings will be disseminated with all members of the International Health Promoting Hospital and Health Services (HPH) and the Global Green and Healthy Hospital network. Dissemination will occur through peer-reviewed publications; and with the HPH and GGHH members through its annual conference and newsletter.

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