GPs’ understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care

BackgroundSafety netting is a diagnostic strategy used in UK primary care to ensure patients are monitored until their symptoms or signs are explained. Despite being recommended in cancer diagnosis guidelines, little evidence exists about which components are effective and feasible in modern-day primary care.AimTo understand the reality of safety netting for cancer in contemporary primary care.Design and settingA qualitative study of GPs in Oxfordshire primary care.MethodIn-depth interviews with a purposive sample of 25 qualified GPs were undertaken. Interviews were recorded and transcribed verbatim, and analysed thematically using constant comparison.ResultsGPs revealed uncertainty about which aspects of clinical practice are considered safety netting. They use bespoke personal strategies, often developed from past mistakes, without knowledge of their colleagues’ practice. Safety netting varied according to the perceived risk of cancer, the perceived reliability of each patient to follow advice, GP working patterns, and time pressures. Increasing workload, short appointments, and a reluctance to overburden hospital systems or create unnecessary patient anxiety have together led to a strategy of selective active follow-up of patients perceived to be at higher risk of cancer or less able to act autonomously. This left patients with low-risk-but-not-no-risk symptoms of cancer with less robust or absent safety netting.ConclusionGPs would benefit from clearer guidance on which aspects of clinical practice contribute to effective safety netting for cancer. Practice systems that enable active follow-up of patients with low-risk-but-not-no-risk symptoms, which could represent malignancy, could reduce delays in cancer diagnosis without increasing GP workload.

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Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study

British Journal of General Practice ◽

10.3399/bjgp18x695741 ◽

2018 ◽

Vol 68 (670) ◽

pp. e333-e341 ◽

Cited By ~ 6

Author(s):

Yasemin Hirst ◽

Anita Wey Wey Lim

Keyword(s):

Primary Care ◽

Text Messaging ◽

Text Message ◽

Safety Net ◽

Text Messages ◽

Low Risk ◽

Diagnostic Strategy ◽

Cancer Symptoms ◽

Additional Tool ◽

Safety Netting

BackgroundSafety netting is an important diagnostic strategy for patients presenting to primary care with potential (low-risk) cancer symptoms. Typically, this involves asking patients to return if symptoms persist. However, this relies on patients re-appraising their symptoms and making follow-up appointments, which could contribute to delays in diagnosis. Text messaging is increasingly used in primary care to communicate with patients, and could be used to improve safety netting.AimTo explore the acceptability and feasibility of using text messages to safety net patients presenting with low-risk cancer symptoms in GP primary care (txt-netting).Design and settingQualitative focus group and interview study with London-based GPs.MethodParticipants were identified using convenience sampling methods. Five focus groups and two interviews were conducted with 22 GPs between August and December 2016. Sessions were audiorecorded, transcribed verbatim, and analysed using thematic analysis.ResultsGPs were amenable to the concept of using text messages in cancer safety netting, identifying it as an additional tool that could help manage patients and promote symptom awareness. There was wide variation in GP preferences for text message content, and a number of important potential barriers to txt-netting were identified. Concerns were raised about the difficulties of conveying complex safety netting advice within the constraints of a text message, and about confidentiality, widening inequalities, and workload implications.ConclusionText messages were perceived to be an acceptable potential strategy for safety netting patients with low-risk cancer symptoms. Further work is needed to ensure it is cost-effective, user friendly, confidential, and acceptable to patients.

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Screening and management of cardiovascular disease in Australian adults with HIV infection

Sexual Health ◽

10.1071/sh13009 ◽

2013 ◽

Vol 10 (6) ◽

pp. 495 ◽

Cited By ~ 7

Author(s):

Derek Chan ◽

David Gracey ◽

Michael Bailey ◽

Deborah Richards ◽

Brad Dalton

Keyword(s):

Cardiovascular Disease ◽

Primary Care ◽

Clinical Practice ◽

Hiv Infection ◽

Primary Care Physicians ◽

Management Practices ◽

Cvd Risk ◽

Online Forms ◽

Current Screening

Background Cardiovascular disease (CVD) is common in HIV infection. With no specific Australian guidelines for the screening and management of CVD in HIV-infected patients, best clinical practice is based on data from the general population. We evaluated adherence to these recommendations by primary care physicians who treat HIV-infected patients. Methods: Primary care physicians with a special interest in HIV infection were asked to complete details for at least 10 consecutive patient encounters using structured online forms. This included management practices pertaining to blood pressure (BP), blood glucose, electrocardiogram, lipid profile and CVD risk calculations. We assessed overall adherence to screening and follow-up recommendations as suggested by national and international guidelines. Results: Between May 2009 and March 2010, 43 physicians from 25 centres completed reporting for 530 HIV-infected patients, of whom 93% were male, 25% were aged 41–50 years and 83% were treated with antiretrovirals. Risk factors for CVD were common and included smoking (38%), hyperlipidaemia (16%) and hypertension (28%). In men aged >40 years and women aged >50 years without evidence of ischaemic heart disease, only 14% received a CVD risk assessment. Lipid and BP assessments were performed in 87% and 88% of patients, respectively. Conclusions: This Australian audit provides unique information on the characteristics and management of HIV and CVD in clinical practice. We have found a high burden of risk for CVD in HIV-infected Australians, but current screening and management practices in these patients fall short of contemporary guidelines.

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Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data

British Journal of General Practice ◽

10.3399/bjgp18x695813 ◽

2018 ◽

Vol 68 (670) ◽

pp. e323-e332 ◽

Cited By ~ 9

Author(s):

Brian D Nicholson ◽

Clare R Goyder ◽

Clare R Bankhead ◽

Berit S Toftegaard ◽

Peter W Rose ◽

...

Keyword(s):

Primary Care ◽

Secondary Analysis ◽

Diagnostic Process ◽

Free Text ◽

Theory Approach ◽

Test Results ◽

Primary Care Practitioners ◽

Grounded Theory Approach ◽

Safety Netting

BackgroundIt is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained.AimTo explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions.Design and settingA secondary analysis of survey data from the International Cancer Benchmarking Partnership.MethodThe authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach.ResultsPCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, ‘double safety netting’ is described, where both patient and PCP retain responsibility.ConclusionThe degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system’s properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.

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Outpatient management of pediatric oncology patients with low-risk fever and neutropenia: Implementation of new clinical practice guideline at Texas Children's Hospital.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.8_suppl.26 ◽

2017 ◽

Vol 35 (8_suppl) ◽

pp. 26-26

Author(s):

Abhishek Amar Bavle ◽

Amanda Bell Grimes ◽

Sibo Zhao ◽

Daniel Joseph Zinn ◽

Andrea Jackson ◽

...

Keyword(s):

Clinical Practice ◽

Pediatric Oncology ◽

Clinical Practice Guideline ◽

Practice Guideline ◽

Outpatient Care ◽

Blood Cultures ◽

Low Risk ◽

Outpatient Management ◽

Oncology Patients

26 Background: Traditionally, pediatric oncology patients with fever and severe neutropenia (absolute neutrophil count [ANC] <500) are admitted on empiric intravenous (IV) antibiotics pending blood cultures, fever resolution, and a rising ANC. Based on significant evidence that risk-stratification of these patients with fever and neutropenia (FN) and outpatient management of “low-risk” FN (LRFN) patients with oral antibiotics can be safe and effective, we implemented an institutional clinical practice guideline (CPG) to provide outpatient care for children with LRFN. Methods: A validated “Alexander” clinical decision rule was adopted to risk stratify pediatric oncology patients with FN. A new CPG was formulated for the outpatient management of LRFN patients, with either discharge on presentation or at 24-48 hours after admission, with levofloxacin and close follow-up. All stakeholders were educated regarding the new guidelines and process prior to implementation, and the guidelines were approved by the institutional Evidence Based Outcomes Center. Results: In 9 months since guideline implementation, 10/11 (91%) of the eligible patients have been managed outpatient for LRFN (mean ANC 160, range 0 - 480). Seven patients were discharged home from the ER or oncology clinic. Three patients were discharged early at 24 – 48 hours after admission. Outpatient management was safe, and all but one patient had resolution of fever within 48 hours and negative blood cultures. One patient had a positive blood culture with Staphylococcus epidermidis and was admitted for IV antibiotics with no complications. Parents of 9/10 patients responded to surveys. All 9 families found outpatient management to be a good experience, follow-up easy, and reported no adverse effects with levofloxacin. One family preferred inpatient care due to anxiety, while importantly 8/9 (89%) parents said they preferred outpatient care compared to inpatient observation. Conclusions: Pediatric oncology patients with low-risk fever and neutropenia were successfully idenitified and managed in the outpatient setting without adverse events with a high level of parent satisfaction.

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Evidence of disparities in the provision of the maternal postpartum 6-week check in primary care in England, 2015–2018: an observational study using the Clinical Practice Research Datalink (CPRD)

Journal of Epidemiology & Community Health ◽

10.1136/jech-2021-216640 ◽

2021 ◽

pp. jech-2021-216640

Author(s):

Yangmei Li ◽

Jennifer J Kurinczuk ◽

Christopher Gale ◽

Dimitrios Siassakos ◽

Claire Carson

Keyword(s):

Primary Care ◽

Clinical Practice ◽

Policy Change ◽

Post Partum ◽

Practice Research ◽

Clinical Practice Research Datalink ◽

Younger Women ◽

Preterm Babies ◽

Deprived Areas

BackgroundA maternal postpartum 6-week check (SWC) with a general practitioner (GP) is now considered an essential service in England, a recent policy change intended to improve women’s health. We aimed to provide an up-to-date snapshot of the prevalence of SWC prior to the policy change as a baseline, and to explore factors associated with having a late or no check.MethodsWe conducted a cohort study using primary care records in England (Clinical Practice Research Datalink (CPRD)). 34 337 women who gave birth between 1 July 2015 and 30 June 2018 and had ≥12 weeks of follow-up post partum were identified in the CPRD Pregnancy Register. The proportion who had evidence of an SWC with a GP was calculated, and regression analysis was used to assess the association between women’s characteristics and risks of a late or no check.ResultsSixty-two per cent (95% CI 58% to 67%) of women had an SWC recorded at their GP practice within 12 weeks post partum, another 27% had other consultations. Forty per cent had an SWC at the recommended 6–8 weeks, 2% earlier and 20% later. A late or no check was more common among younger women, mothers of preterm babies or those registered in more deprived areas.ConclusionsNearly 40% of women did not have a postpartum SWC recorded. Provision or uptake was not equitable; younger women and those in more deprived areas were less likely to have a record of such check, suggesting postpartum care in general practice may be missing some women who need it most.

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Peripheral arterial disease diagnosis and management in primary care: a qualitative study

BJGP Open ◽

10.3399/bjgpopen19x101659 ◽

2019 ◽

Vol 3 (3) ◽

pp. bjgpopen19X101659 ◽

Cited By ~ 1

Author(s):

Jan Lecouturier ◽

Jason Scott ◽

Nikki Rousseau ◽

Gerard Stansby ◽

Andrew Sims ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Disease Diagnosis ◽

Diagnosis And Management ◽

Increased Risk ◽

Peripheral Arterial ◽

The Impact

BackgroundPatients diagnosed with peripheral arterial disease (PAD) are at an increased risk of coronary heart disease, stroke, heart attack, and PAD progression. If diagnosed early, cardiovascular risk factors can be treated and the risk of other cardiovascular diseases can be reduced. There are clear guidelines on PAD diagnosis and management, but little is known about the issues faced in primary care with regards adherence to these, and about the impact of these issues on patients.AimTo identify the issues for primary care health professionals (HPs) and patients in PAD diagnosis and management, and to explore the impact of these on HPs and PAD patients.Design & settingQualitative study conducted in a primary care setting in the North East of England. Data was collected between December 2014 and July 2017.MethodSemi-structured interviews and focus groups were conducted with PAD register patients (n = 17), practice nurses ([PNs], n = 17), district nurses (DNs], n = 20), tissue viability nurses (n = 21), and GPs (n = 21).ResultsHPs’ attitudes to PAD, difficulty accessing tests, and patient delays impacted upon diagnosis. Some HPs had a reactive approach to PAD identification. Patients lacked understanding about PAD and some reported a delay consulting their GP after the onset of PAD symptoms. After diagnosis, few were attending for regular GP follow-up.ConclusionPatient education about PAD symptoms and risks, and questioning about exercise tolerance, could address the problem of under-reporting. Annual reviews could provide an opportunity to probe for PAD symptoms and highlight those requiring further investigation. Improved information when PAD is diagnosed and, considering the propensity for patients to tolerate worsening symptoms, the introduction of annual follow-up (at minimum) is warranted.

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Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

BJGP Open ◽

10.3399/bjgpo.2021.0104 ◽

2021 ◽

pp. BJGPO.2021.0104

Author(s):

Johanne Holm Toft ◽

Inger Økland ◽

Christina Furskog Risa

Keyword(s):

Diabetes Mellitus ◽

Primary Care ◽

Qualitative Study ◽

Gestational Diabetes ◽

Gestational Diabetes Mellitus ◽

Healthy Lifestyle ◽

Women's Experiences ◽

Tailored Information ◽

In Pregnancy

BackgroundWomen with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. AimTo elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & settingQualitative study in primary care in the region of Stavanger, Norway. MethodSemi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. ResultsMost women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. ConclusionWomen experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support.

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6-Month Follow Up Among Participants from the Healthy Eating and Active Living for Diabetes in Primary Care Networks Trial: A Qualitative Study

Canadian Journal of Diabetes ◽

10.1016/j.jcjd.2013.08.057 ◽

2013 ◽

Vol 37 ◽

pp. S19 ◽

Cited By ~ 1

Author(s):

Lisa Wozniak ◽

Jenelle Pederson ◽

Clark Mundt ◽

Allison Soprovich ◽

Ron Plotnikoff ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Healthy Eating ◽

Active Living

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Effectiveness of a conversational chatbot in the smartphone to cease smoking in the adult population: pragmatic, controlled, randomized clinical trial in primary care (Dejal@). (Preprint)

10.2196/preprints.34273 ◽

2021 ◽

Author(s):

EDUARDO OLANO-ESPINOSA ◽

Jose Francisco Avila-Tomas ◽

Cesar Minue-Lorenzo ◽

Blanca Matilla Pardo ◽

Encarnación Serrano-Serrano ◽

...

Keyword(s):

Primary Care ◽

Clinical Trial ◽

Clinical Practice ◽

Randomized Clinical Trial ◽

Control Group ◽

Evidence Based ◽

Intention To Treat ◽

Usual Clinical Practice ◽

Treat Analysis

BACKGROUND The magnitude and severity of smoking, the benefits of quitting, and the existence of effective and efficient interventions make it a priority problem. Health professionals intervene less than they should, and the most effective interventions are more expensive, require specific training and more time, which is a disadvantage for the service provider and for the accessibility of the services. Information and communication technologies avoid these problems thanks to their accessibility, privacy, customization possibilities, access to social support, and scalability. OBJECTIVE To assess the effectiveness of an evidence-based intervention to cease smoking via a chatbot in the smartphone compared to usual clinical practice in primary care. METHODS Pragmatic randomized clinical trial in 34 primary healthcare centers within the Madrid Health Service (Spain). Smokers over 18 years of age who attended on-site consultation and accepted help to quit tobacco were recruited by their doctor or nurse and randomly allocated to receive usual care (control group, CG) or an evidence-based chatbot intervention (intervention group, IG). The interventions in both arms were based on the 5A´s by the US clinical practice guideline, which combines behavioral and pharmacological treatments and is structured in several follow-up appointments. The primary outcome was continuous abstinence from smoking that was biochemically validated after 6 months by the collaborators. The outcome analysis was blinded to allocation of subjects although participants were unblinded to group assignment. An intention-to-treat analysis, entering the basal observation carried forward in cases of missing data, and logistic regression models with robust estimators were employed for assessing the primary outcomes. RESULTS The trial was conducted between October 1st of 2018 and March 31st of 2019. The sample comprised 513 patients (242 in the IG and 271 in the CG), with an average age of 49.8 years (SD 10.82) and gender ratio of 59.3% women and 40.7% men. Of them, 232 patients (45.2%) completed the follow-up, 104 (42.9%) in the IG and 128 (47.2%) in the CG. Main outcome: In the intention-to-treat analysis, the biochemically-validated abstinence rate at 6 months was higher in the IG with 26.03% (63/242) versus 18.82% (51/271) in the CG (odds ratio (OR)=1.52, 95% CI: 1.00–2.31, P=.05). After adjusting for basal CO-oxymetry and bupropion intake, no substantial changes were observed (OR=1.52, 95% CI 0.99–2.33 P= .053; pseudo R2=0.045). In the IG, 61.16% (148/242) of users accessed the chatbot, average bot-patient interaction time was 121 minutes (CI 95% 121.1–140.0), and average number of contacts was 45.56 (SD 36.32). CONCLUSIONS A treatment including a chatbot for helping in tobacco cessation was more effective than usual clinical practice in primary care. CLINICALTRIAL ClinicalTrials.gov, reference number NCT 03445507.

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