Adults with intellectual disabilities and mental health disorders in primary care: A scoping review

Background: General practitioners (GPs) are increasingly confronted with patients with both intellectual disabilities (ID) and mental health disorders (MHD). Currently, the care provided to these patients is found to be insufficient, putting them at risk of developing more severe MHD. Improving the quality of GP care will improve the whole of mental healthcare for this patient group. Therefore, an overview of the content and quality of care provided to them by the GP might be helpful. Aim: To provide an up-to-date literature overview of the care provided by GPs to patients with ID and MHD, identify knowledge gaps, and inform research, practice, and policy about opportunities to improve care. Design: Scoping review. Method: Pubmed, PsychINFO, Embase, and grey literature were searched for publications concerning patients with ID, MHD, and primary care. Selected publications were analysed qualitatively. Results: One hundred publications met the inclusion criteria. Five overarching themes were identified: GP roles, knowledge and experience, caregiver roles, collaboration, and a standardized approach. The results show GPs’ vital, diverse, and demanding roles in caring for patients with both ID and MHD. GPs experience problems in fulfilling their roles, and gaps are identified regarding effective GP training programmes, applicable guidelines and tools, optimal collaborative mental healthcare, and corresponding payment models. Conclusion: The improvement required in the current quality of GP care to patients with ID and MHD can be achieved by bridging the identified gaps and initiating close collaborations between care professionals, policymakers, and organizational managers.

Association of Continuity of General Practitioner Care with Utilisation of General Practitioner and Specialist Services in China: A Mixed-Method Study

Background: Continuity of general practitioner (GP) care, widely known as the core value of high-quality patient care, has a positive association with health outcomes. Evidence about the relationship between continuity and health service utilisation has so far been lacking in China. This study aimed to analyse the association of continuity of GP care with utilisation of general practitioner and specialist services in China. Method: A cross-sectional mixed methods study was conducted in 10 urban communities in Hangzhou. Quantitative data were collected from a random sample of 624 residents adopting the self-developed questionnaire. Measurement of continuity of GP care included informational continuity (IC), managerial continuity (MC) and relational continuity (RC). With adjustment for characteristics of residents, multivariate regression models were established to examine the association of continuity of GP care with the intention to visit GP, frequency of GP and specialist visitations. Qualitative data were collected from 26 respondents using an in-depth interview, and thematic content analysis for qualitative data was conducted. Results: Quantitative analysis showed that the IC was positively associated with the intention to visit GP and frequency of GP visitations. Those people who gave a high rating for RC also used GP services more frequently than their counterparts. MC was negatively associated with frequency of specialist visitations. Qualitative analysis indicated that service capabilities, doctor–patient interaction and time provision were regarded as three important reasons why patients chose GPs or specialists. Conclusions: Overall, high IC and RC are independently associated with more GP service utilisation, but a high MC might reduce specialist visitations. Continuity of GP care should be highlighted in designing a Chinese GP system.

Hoe universeel en billijk is de Belgische ziekteverzekering?

How equitable and universal is the Belgian health insurance? Accessibility to and delivery of effective, high-quality and affordable healthcare are fundamental objectives that have shaped health policy and the universal healthcare coverage in Belgium. To what extent are access to and financing of healthcare in Belgium equitable? In general, the use of hospital care is in proportion to healthcare needs, and access can be considered equitable. However, inequity in the use of outpatient specialist care is important and increasing over time. When accounting for healthcare needs, we find that care use among high-income groups and individuals with a high educational attainment is substantially higher compared to financially vulnerable groups (individuals at risk of poverty, people with severe material deprivation, unemployed, singles). Also individuals who are entitled to an increased reimbursement, show a lower use of specialist care than expected based on their care needs. On the other hand, increased reimbursement is effective in improving the accessibility to GP care, while for other financially vulnerable individuals we find a lower use of GP care. The ability of a health system to realize an equitable access to care depends, among other things, on the user charges and the advance payments borne by the patient. In 2018, almost 4% of the households experienced catastrophic out‑of‑pocket payments, strongly concentrated among low-income households. Protection measures, such as the increased reimbursement, the mandatory third‑party payer arrangement and the system of maximum billing, reduce inequities, but there is room to improve and strengthen the financial protection against co-payments and supplements.

WORK–LIFE BALANCE OF GENERAL PRACTITIONERS IN GERMANY CONSIDERING RECENT REGULATIONS

Background: In the light of demographic changes in the population and among the doctors, the German government has in the last two decades taken several regulatory steps to address work–life balance and related issues. Objective: This article seeks to identify crucial pieces of legislation that may increase the attractiveness for the GP profession in Germany. Method: The article summarizes important regulatory steps and their results in terms of increasing the attractiveness of the GP profession. Results: Some regulations in Germany including the “Vertragsarztrechtsänderungsgesetz” led to more flexibilization in terms of the location and the internal structure of GP practices, while others addressed the further digitalization. A central element for creating attractive working conditions for GPs is the possibility of selective and direct contracting between the insurance companies and the GPs, parallel to the more general collective contracting. Discussion: While some of these regulations helped to make the GP profession more attractive, they have failed to increase the number of GPs especially in rural socially deprived areas. Conclusion: The government will need to invest more resources in scientific studies (e.g. international comparison) to identifying regulatory measures that help address the growing gap between the amount of GP care needed by the aging population and the level of care provided with the current human resources.

Experiences of general practice care for self-harm: a qualitative study of young people's perspectives

Background: Self-harm is a growing concern and rates of self-harm in young people presenting to general practice are rising. There is however an absence of evidence on young people’s experiences of GP care and on accessing general practice. Aim: To explore the help-seeking behaviours, experiences of GP care, and access to general practice for young people who self-harm. Design and setting: Semi-structured interviews were conducted with young people aged 16-25 from England with previous self-harm behaviour. Method: Interviews with 13 young people occurred between April and November 2019. Young people were recruited from the community, third-sector organisation, and Twitter. Data were analysed using reflexive thematic analysis with principles of constant comparison. A patient and public involvement advisory group informed recruitment strategies and supported interpretation of findings. Results: Young people described avenues of help-seeking they employ and reflected on mixed experiences of seeing GPs which can influence future help-seeking. Preconceptions and a lack of knowledge on accessing general practice were found to be barriers to help-seeking. GPs who attempted to understand the young person and establishing relationship-based care can facilitate young people accessing general practice care for self-harm. Conclusion: It is therefore important young people are aware how to access general practice care and that GPs listen, understand, and proactively follow-up young people who self-harm. Supporting young people with self-harm behaviour requires continuity of care.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters

Background Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits. Aims We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR. Methods We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018–07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED. Results A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%). Discussion Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary. Conclusion Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

An exploration of GP care in outreach settings for people experiencing homelessness: a qualitative study

Background: Although people experiencing homelessness (PEH) have the worst health outcomes in society, they have a low uptake of primary care services. GP outreach has developed as a way of increasing access into primary care but little is known about the experience of patients receiving care in this way. Aims: 1) To explore homeless patients’ experiences of GP care in community outreach settings in UK; 2) To seek staff/volunteer views on the strengths and weaknesses of the GP community outreach services. Design and setting: A qualitative study with PEH and staff/volunteers working in 3 different community outreach settings in the UK. Method: Individual semi-structured interviews with 22 PEH and two focus groups with key staff/volunteers. Data was analysed thematically using framework analysis. Findings: GP outreach services better enabled PEH to access medical care and staff/volunteers valued GP support to promote, and facilitate access to, health care services. In particular, findings illuminate the high value that PEH placed on the organisational environment of the GP outreach service. Valued aspects of GP outreach were identified as: 1) comfortable, safe and engendered a sense of belonging; 2) convenient, opportunistic and a one stop shop; and, 3) being heard, having more time and breaking down barriers. Conclusion: Organisational environment is important in enabling PEH to engage with GP services. The physical and organisational environment of the outreach settings were the most important factors: they created a space between the GP and patients where professional barriers were flattened and facilitated a therapeutic relationship.

Discovery of predictors of sudden cardiac arrest in diabetes: rationale and outline of the RESCUED (REcognition of Sudden Cardiac arrest vUlnErability in Diabetes) project

IntroductionEarly recognition of individuals with increased risk of sudden cardiac arrest (SCA) remains challenging. SCA research so far has used data from cardiologist care, but missed most SCA victims, since they were only in general practitioner (GP) care prior to SCA. Studying individuals with type 2 diabetes (T2D) in GP care may help solve this problem, as they have increased risk for SCA, and rich clinical datasets, since they regularly visit their GP for check-up measurements. This information can be further enriched with extensive genetic and metabolic information.AimTo describe the study protocol of the REcognition of Sudden Cardiac arrest vUlnErability in Diabetes (RESCUED) project, which aims at identifying clinical, genetic and metabolic factors contributing to SCA risk in individuals with T2D, and to develop a prognostic model for the risk of SCA.MethodsThe RESCUED project combines data from dedicated SCA and T2D cohorts, and GP data, from the same region in the Netherlands. Clinical data, genetic data (common and rare variant analysis) and metabolic data (metabolomics) will be analysed (using classical analysis techniques and machine learning methods) and combined into a prognostic model for risk of SCA.ConclusionThe RESCUED project is designed to increase our ability at early recognition of elevated SCA risk through an innovative strategy of focusing on GP data and a multidimensional methodology including clinical, genetic and metabolic analyses.