Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study

Background General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral. Methods A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. Results Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. Conclusions The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

General practitioners’ experiences with, views of, and attitudes towards, general practice-based pharmacists: a cross-sectional survey

Background There is limited United Kingdom (UK) literature on general practice-based pharmacists’ (PBPs’) role evolution and few studies have explored general practitioners’ (GPs’) experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs’ experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI). Methods A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 general practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descriptive analyses were used and responses to open-ended questions were analysed thematically. Results The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to-face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approximately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts. Conclusion Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs’, community pharmacists’ and patients’ views of this role in general practice is required to corroborate study findings.

Physical examination performed by general practitioners in 5 community health service institutions in Beijing: an observational study

Background Physical examination is a core component of consultation. Little is known about the status quo of physical examinations performed by general practitioners in community health service institutions in China. The aim of this study was to investigate general practitioners’ performance of physical examinations in consultations. Methods An observational study was conducted in 5 community health service institutions in Beijing between November 2019 and January 2020. Eleven general practitioners were observed for one workday. Information of consecutive consultations was recorded including patient characteristics, reasons for encounter, physical examinations performed by general practitioners, length of consultation time and time spent on specific activities in consultations. Results A total of 682 consultations of 11 general practitioners were recorded. Physical examinations were performed in 126 consultations (15.8%). Physical examination was more likely to be performed in patients visiting with symptoms (P < 0.001). Majority of the 126 physical examinations were distributed in “Head, face, and neck examination” (n = 54, 42.9%) and “Cardiovascular examination” (n = 55, 43.7%). No physical examination was performed on skin, male genitalia, female breasts and genitalia, and neurological systems. Total 2823 min of activities were observed and recorded. General practitioners only spent 3.1% of the recorded time on physical examination, which was less than the time spent on taking history (18.2%), test (4.9%), diagnosis (22.7%), therapy (38.4%), and health education (8.6%). The average time spent on physical examinations was 0.8±0.4 min per consultation. Conclusion Physical examination was insufficiently performed by general practitioners in community health service institutions in Beijing. More time and commitment should be advocated for improving the quality of physical examinations in primary care.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England

Background Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians’ decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients. Setting We test our prediction on general practitioners’ antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population. Methods We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs’ prescribing. Results We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure. Conclusions Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians’ work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45 Highlights Many physicians are working under increasing pressure. We test the importance of pressure on physicians’ prescribing of antibiotics. The prescribed rate of broad-spectrum antibiotics increases with pressure. Policy makers should be aware of the societal costs of pressured physicians. [Formula: see text]

The outpatient medical care in patients with chronic diseases under dispensary supervision in the conditions of the COVID-19 pandemic. Temporary guidelines. Version 2

Guidelines were approved at the meeting of the academic council of the National Medical Research Center for Therapy and Preventive Medicine, Moscow (Protocol No. 10 of 19.10.2021).The aim of these guidelines is to provide primary care physicians with scientifically based algorithms for the implementation of dispensary monitoring in patients with chronic non-communicable diseases in the conditions of the new coronavirus infection (COVID-19) pandemic, including the use of telemedicine technologies.The organization and conduct of high-quality medical follow-up are the most important tasks aimed at both reducing the risks of developing complications of chronic non-communicable diseases and reducing overall mortality, especially in the current conditions of the COVID-19 pandemic. The guidelines contain clinical aspects of dispensary follow-up, general principles of tactics for managing patients with various chronic non-communicable diseases in COVID-19 conditions, in addition, brief checklists with options for interviewing patients with various chronic non-communicable diseases are presented, topical aspects of the interaction of drugs used in the treatment of chronic non-communicable diseases with antiviral drugs are considered.The guidelines are intended for general practitioners, district therapists, general practitioners (family doctors), as well as doctors of other specialties providing primary health care.

Integrating Quality of Life in the Care Pathway of Cancer Patients Undergoing Immunotherapy Treatment: Descriptive, Cross-sectional Survey of an Online Patient Community's Experiences and Expectations

Background New cancer treatments, such as immune checkpoint inhibitors (ICIs), can improve survival and health-related quality of life (HRQoL) in patients with cancer. Although long-term monitoring of HRQoL has been shown to improve survival, integration of HRQoL into everyday practice remains poorly documented. Objective This study describes experiences and expectations of patients treated with ICIs regarding a discussion of HRQoL with health care professionals (HCPs) in cancer management. Methods This cross-sectional study was conducted in an online patient community (Carenity) in France. Patients treated with ICIs for cancer, included between September 2018 and January 2019, completed a questionnaire to assess the involvement of HCP in a discussion of HRQoL and when and what was discussed. Results Of 82 patients included (mean age: 56.9 years, 95% CI 54.2-59.6; 46 [56%] male; 34 [41%] with lung cancer), 62 (76%) reported discussing HRQoL at least once with HCPs, mainly general practitioners (54/82, 66%), oncologists (53/82, 65%), and hospital nurses (50/82, 61%). Around half (45/82, 55%) of the patients were satisfied with these discussions. Discussions with the oncologist were at the patient’s initiative (34/53, 64%). Discussions occurred primarily during follow-up visits (40/62, 65%), when adverse events occurred (30/62, 48%), and at treatment initiation (27/62, 32%). The most discussed dimensions were symptoms (48/62, 77%) and physical well-being (43/62, 69%). With respect to expectations, 54/82 (66%) patients considered oncologists as the most important HCPs for discussing HRQoL. These discussions were desirable throughout the care pathway, particularly at diagnosis (63/82, 77%) and when treatment was initiated (75/82, 92%) or changed (68/82, 83%). All HRQoL dimensions were considered important to discuss. Conclusions With only around half of the patients satisfied with HRQoL discussions, impactful HRQoL integration in clinical practice is critical. According to patients, this integration should involve mainly oncologists and general practitioners, should happen at every step of the care pathway, and should be extended to dimensions that are currently rarely addressed.

Using cancer risk algorithms to improve risk estimates and referral decisions

Background Cancer risk algorithms were introduced to clinical practice in the last decade, but they remain underused. We investigated whether General Practitioners (GPs) change their referral decisions in response to an unnamed algorithm, if decisions improve, and if changing decisions depends on having information about the algorithm and on whether GPs overestimated or underestimated risk. Methods 157 UK GPs were presented with 20 vignettes describing patients with possible colorectal cancer symptoms. GPs gave their risk estimates and inclination to refer. They then saw the risk score of an unnamed algorithm and could update their responses. Half of the sample was given information about the algorithm’s derivation, validation, and accuracy. At the end, we measured their algorithm disposition. We analysed the data using multilevel regressions with random intercepts by GP and vignette. Results We find that, after receiving the algorithm’s estimate, GPs’ inclination to refer changes 26% of the time and their decisions switch entirely 3% of the time. Decisions become more consistent with the NICE 3% referral threshold (OR 1.45 [1.27, 1.65], p < .001). The algorithm’s impact is greatest when GPs have underestimated risk. Information about the algorithm does not have a discernible effect on decisions but it results in a more positive GP disposition towards the algorithm. GPs’ risk estimates become better calibrated over time, i.e., move closer to the algorithm. Conclusions Cancer risk algorithms have the potential to improve cancer referral decisions. Their use as learning tools to improve risk estimates is promising and should be further investigated.

Prescription of Physical Activity by General Practitioners in Type 2 Diabetes: Practice and Barriers in French Guiana

BackgroundGeneral practitioners (GPs) are the major primary healthcare players in the management of type 2 diabetes. In addition to a well-balanced diet, physical activity (PA) appears as a necessary non-medicinal therapy in the management of diabetic patients. However, GPs emphasize several obstacles to its prescription. The aim of this study is to evaluate the practices, barriers, and factors favoring the prescription of PA in type 2 diabetic patients by GPs in French Guiana.MethodWe conducted a cross-sectional descriptive study using a questionnaire, designed to interview 152 French Guiana GPs and describe their practice in prescribing PA in type 2 diabetic patients.ResultsOur results revealed that the prescription of PA as a non-medicinal therapeutic choice in the management of type 2 diabetes was practiced by 74% of the French Guiana GPs. However, only 37% of GPs responded that they implemented the recommendations; indeed, only one-third knew about them. The majority of GPs were interested in PA training, but only 11% were actually trained in this practice. The lack of structure adapted to the practice of PA and the lack of awareness of the benefits of PA in metabolic pathology appeared as the main obstacles to PA prescription.ConclusionThis study highlights the importance of improving the training of GPs in the prescription of PA, the development of adapted PA structures, and collaboration between the different actors within the framework of the sport-health system in type 2 diabetes in French Guiana.

Implementation and Evaluation of a Digitally Enabled Precision Public Health Intervention to Reduce Inappropriate Gabapentinoid Prescription: Cluster Randomized Controlled Trial

Background Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale. Objective The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior. Methods This study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention. Results The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02). Conclusions Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.