Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

National Trends and Policy Impacts on Provision of Home Medicines Reviews and Residential Medication Management Reviews in Older Australians, 2009–2019

Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians.

Effects of a disposable home electro-stimulation device (Pelviva) for the treatment of female urinary incontinence: a randomised controlled trial

Aims To compare current General Medical Practitioner treatment as usual (TAU) for the treatment of female urinary incontinence with a novel disposable home electro-stimulation device (Pelviva). Methods Open label, Primary Care post-market evaluation. 86 women with urinary incontinence were randomly assigned to one of two 12-week treatments: TAU or Pelviva for 30 min every other day plus TAU. Outcome measures included ICIQ-UI (primary), PISQ-IR, PGI-S / PGI-I and FSFI (secondary) at recruitment and immediately after intervention, 1-h pad test at recruitment and usage diaries throughout. Results Pelviva plus TAU produced significantly better outcome than TAU alone: 3 versus 1 point for ICIQ-UI (Difference − 1.8 95% CI: − 3.5 to − 0.1, P = 0.033). Significant differences were also observed for PGI-I at both 6 weeks (P = 0.001) and 12 weeks (P < 0.001). In the Pelviva group, 17% of women described themselves as feeling very much better and 54% a little or much better compared to 0% and 15% in the TAU. Overall PISQ-IR score reached statistical significance (P = 0.032) seemingly related to impact (P = 0.027). No other outcome measures reached statistical significance. Premature termination due to COVID-19 meant only 86 women were recruited from a sample size of 264. TAU did not reflect NICE guidelines. Conclusions This study suggests Pelviva is more successful than TAU in treating urinary incontinence in Primary Care. The study had reduced power due to early termination due to COVID-19 and suggests TAU does not follow NICE guidelines.

General Practitioner Experiences Using a Low Back Pain Management Booklet Aiming to Decrease Non-indicated Imaging for Low Back Pain

Background Imaging is overused in the management of low back pain and effective interventions to decrease use have not been developed. An intervention, incorporating a low back pain management booklet and practitioner training session, to reduce non-indicated imaging for low back pain has been developed based on theories of behaviour change. This study aimed to explore general medical practitioner experiences using the low back pain management booklet in clinical practice to 1) determine the adoption, feasibility of use, and appropriateness of the booklet; and 2) identify implementation strategies to address barriers to use.Methods Fourteen general medical practitioners were recruited and trained to use the booklet with low back pain patients over a minimum five-month period. Quantitative data on use of the booklet were collected and analysed descriptively. Qualitative data were collected in general medical practitioner interviews and thematically analysed. Barriers to use were identified and mapped to suitable implementation strategies using the Behaviour Change Wheel. Results The 14 general medical practitioners used the booklet with 73 patients. General medical practitioners thought using the booklet helped improve patient management and helped reduce pressure to refer for non-indicated imaging. Facilitators for using the booklet included patient’s requesting imaging and lower practitioner confidence in managing low back pain. Barriers included accessible storage and remembering to use the booklet. Implementation strategies were identified to increase adoption and feasibility of use, including development of a digital version of the booklet.Conclusions General medical practitioners reported that the low back pain management booklet was useful for clinical practice, particularly with patients requesting imaging. Barriers to use were identified and implementation strategies to address these barriers will be incorporated into future effectiveness studies. This study forms one of a series of studies to develop and test an intervention to reduce non-indicated imaging for low back pain; a successful intervention would decrease healthcare costs and improve patient management.

General practitioner experiences using a low back pain management booklet aiming to decrease non-indicated imaging for low back pain

Background Imaging is overused in the management of low back pain and effective interventions to decrease use have not been developed. An intervention, incorporating a low back pain management booklet and practitioner training session, to reduce non-indicated imaging for low back pain has been developed based on theories of behaviour change. This study aimed to explore general medical practitioner experiences using the low back pain management booklet in clinical practice to 1) determine the adoption, feasibility of use, and appropriateness of the booklet; and 2) identify implementation strategies to address barriers to use.Methods Fourteen general medical practitioners were recruited and trained to use the booklet with low back pain patients over a minimum five-month period. Quantitative data on use of the booklet were collected and analysed descriptively. Qualitative data were collected in general medical practitioner interviews and thematically analysed. Barriers to use were identified and mapped to suitable implementation strategies using the Behaviour Change Wheel. Results The 14 general medical practitioners used the booklet with 73 patients. General medical practitioners thought using the booklet helped improve patient management and helped reduce pressure to refer for non-indicated imaging. Facilitators for using the booklet included patient’s requesting imaging and lower practitioner confidence in managing low back pain. Barriers included accessible storage and remembering to use the booklet. Implementation strategies were identified to increase adoption and feasibility of use, including development of a digital version of the booklet.Conclusions General medical practitioners reported that the low back pain management booklet was useful for clinical practice, particularly with patients requesting imaging. Barriers to use were identified and implementation strategies to address these barriers will be incorporated into future effectiveness studies. This study forms one of a series of studies to develop and test an intervention to reduce non-indicated imaging for low back pain; a successful intervention would decrease healthcare costs and improve patient management.

The Prevalence and Severity of External Auditory Exostosis in Young to Quadragenarian-Aged Warm-Water Surfers: A Preliminary Study

External auditory exostosis (EAE) has previously only been shown to occur in cold water surfers. We assessed young surfers living and surfing in Queensland, Australia, for EAE in water temp ranges from 20.6 °C (69.1 °F, Winter) to 28.2 °C (82.8 °F, Summer). All participants underwent a bilateral otoscopic examination to assess the presence and severity of EAE. A total of 23 surfers participated with a mean age of 35.4 years (8.3 years) and a mean surfing experience of 20.0 years (9.9 years). Nearly two-thirds of participants (n = 14, 60.9%) had regular otological symptoms, most commonly water trapping (n = 13, 56.5%), pain (n = 8, 34.8%), and hearing loss (n = 6, 26.1%). Only 8.7% (n = 2) of all surfers reported regular use of protective equipment (e.g., earplugs) on a regular basis. The overall prevalence of exostosis was 69.6% (n = 16), and the majority (n = 12, 80.0%) demonstrated bilateral lesions of a mild grade (<33% obstruction of the external auditory canal). This is the first study assessing EAE in young surfers exposed to only warm waters (above 20.6 °C). The prevalence of EAE in this study highlights that EAE is not restricted to cold water conditions, as previously believed. Warm water surfing enthusiasts should be screened on a regular basis by their general medical practitioner and utilize prevention strategies such as earplugs to minimize exposure to EAE development.

Hypertension − an update for the dental (sedation) team

Hypertension is the commonest risk factor contributing to the global burden of disease. Public Health England estimates that, in England, 24% of the population are hypertensive, with 40% possibly undiagnosed. With this in mind, dentists, in particular those undertaking sedation, are in a perfect position to screen for high blood pressure and refer on for further detailed assessment. This paper outlines when a referral to the General Medical Practitioner (GP) should be considered, when sedation should be deferred and how hypertension is diagnosed and managed in primary care based on the National Institute for Health and Care Excellence (NICE)/British Hypertension Society (BHS) guidelines.CPD/Clinical Relevance: The purpose of this article is to update General Dental Practitioners (GDPs), including those who practise IV Midazolam sedation, on how patients who present with suspected hypertension are managed by their GP. Consideration is given to what blood pressures are deemed safe to sedate and what blood pressures should be referred for further assessment, even if considered safe to sedate.

REVISITING THE MAXIM IMPERITIA CULPAE ADNUMERATUR IN CONTEXT OF MEDICAL NEGLIGENCE – CAN THE MAXIM BE EXTENDED TO INCLUDE THE APPLICATION OF LUXURIA?

In any given context, negligence means that the defendant or the accused failed to foresee the possibility of harm (bodily/mental injury or death) occurring to another in circumstances where the reasonable person (diligens paterfamilias) in the defendant’s or accused position would have foreseen the possibility of harm occurring to another and would have taken steps to avoid or prevent it. The generic test for negligence is thus one of foreseeability and preventability. Although the test for negligence is fundamentally objective, it does contain subjective elements when the negligence of an expert is assessed. Where the defendant or accused is an expert, the standard of negligence is upgraded from the reasonable layperson to the reasonable expert. Where the expert is a medical practitioner, the standard is that of the reasonable medical practitioner in the same circumstances. It is to be noted that the standard of care and skill, in context of medical negligence, required of a general practitioner is to be distinguished from the standard and care and skill required of a medical specialist. Simply stated, if the physician is a general medical practitioner, the test is that of the reasonable general practitioner. If the physician is a specialist, the test is that of the reasonable specialist with reference to the specific field of medical specialisation. This principle is of particular significance as it has definite implications for the practice of medicine in a developing country as South Africa. Due to the shortages of medical services and qualified health care practitioners and/or compromised medical services, particularly in rural areas, health care practitioners (inclusive of doctors, nurses and paramedics) are often called upon to perform medical services for which they are, strictly speaking, not qualified to undertake – for example, a general practitioner in a small rural hospital may be required to administer anaesthesia to a patient despite not being a qualified anaesthetist; a nurse might be required to assist with the extraction of a tooth without being a dentist. The question arises, according to which yardstick they should be judged in instances of alleged negligence? The locality of practice and the imperitia culpae adnumeratur – rule are clearly also relevant factors in answering this question.In view of the aforesaid, it is the aim of this note to revisit the meaning and application of the maxim imperitia culpae adnumeratur and its possible link with conscious negligence (luxuria) in context of medical negligence. It is to be noted, for purposes of this discussion, that the test for medical negligence is exactly the same in civil law as it is in the criminal law – it makes no difference whether a medical practitioner is sued civilly for damages or by a patient who alleges that he has been negligently treated or is prosecuted by the state. The burden of proof in criminal cases though, is heavier than in civil cases since in the latter the plaintiff must only prove his case on a balance of probability, whereas in the former negligence must be proven beyond reasonable doubt.