Research Posters 2007 – 2013
2007 Experiences and views of recently qualified GPs on training in a GP practice serving a deprived population and the impact on career choice
Introduction There is an increasing need to recruit and retain GPs in the UK. Deprived areas often struggle to recruit GPs, with this set to worsen as proportionally more GPs in these areas are due to retire within the next five to ten years.AimExamine the training experiences of recently qualified GPs who trained in deprived areas in more depth than the information gained from the national GMC training survey. This will help us understand the factors that influence GPs to train and work in deprived areas and the impact of this training on a GPs choice of current and future workplace.
Method A qualitative research approach was undertaken. Recently qualified GPs who trained in deprived areas across Scotland were invited to participate in focus groups.
Outcome GPs were able to share their wide range of experiences of training in deprived areas. Although the overall quality of training in deprived areas was viewed as very good, several themes emerged identifying areas of potential improvement. These included; the choice of training in a deprived practice, exposure to deprived practices during training and more focused teaching topics relevant to deprived practices for all trainees.
Discussion It is hoped that an enhanced training experience, targeting the themes raised above, would encourage recruitment to deprived areas and we plan to use this research to develop GP training in Scotland. This follows previous research which has strongly suggested that where a GP trains has a significant influence on their future career choice.
2008 Serious infection in the elderly primary care population: a GP interview study exploring the factors which influence diagnosis and decision to admit
Background: Serious infection is both common and a cause of significant morbidity, mortality, and hospital expense, in the growing elderly population. Diagnosing serious infection in the elderly is challenging in primary care because presentation is often not classical, diagnostic tests are less reliable and clinical scores are not well validated. To improve diagnosis of serious infection and reduce unnecessary admissions we first need to understand how GPs approach this diagnostic challenge and the influences on their decision to admit.
Methods: Semi-structured qualitative interviews were conducted with 28 GPs working in differing primary care roles, practice types and geographical locations. Recent clinical cases were used as a starting point to explore decisions regarding diagnosis of serious infection and admission.
Findings: GPs feel that diagnosing infection in the elderly is challenging, due to non-specific symptoms and signs and the confounders of multimorbidity. A change from baseline is important, as is gut instinct, with certain features acting as ‘dealbreakers’ for continuing community based care, including clinical signs (e.g. hypoxia) and safety in the home. A range of perspectives were revealed regarding the value of point of care diagnostics and scoring systems, and the benefits and disadvantages of new models of community based care.
Implications: GPs rely on a variety of social and clinical factors when making complex decisions regarding diagnosis and admission in elderly patients with suspected serious infection. The implications of our findings for diagnostic research and the design of improved models of acute community based care for elderly will be highlighted.
2009 Patient perspectives on case-finding for anxiety and depression in patients with rheumatoid arthritis
Dr Annabelle Machin
Aims/ objectives Co-morbid mood disorders in rheumatoid arthritis (RA) are often under-recognised and treated, which may impact on response to treatment. NICE recommends that mood should be assessed within an annual review. A pilot nurse-led annual review clinic was established in a community hospital. This study aimed to explore patients’ views of the review appointments, perspectives of anxiety and depression in RA and preferences for management.
Content of presentation Results of analysis of data generated from semi-structured interviews with patients who scored positively on case-finding questions for anxiety and depression (GAD-2 and PHQ-2), utilising thematic analysis with constant comparison.
Relevance/ Impact Understanding patients’ perceptions of co-morbid mood disorders, and preferences for care, are vital to improve management.
Outcomes Participants recognised their distress, some seeing it directly linked to their RA, others to external stressors. Participants anticipated that their rheumatologist or GP would be too busy to deal with psychological symptoms, whilst GPs were also perceived to normalise symptoms. Whereas some patients reported being too embarrassed to disclose mood symptoms to their GP, the clinic nurse was perceived to be approachable and understanding and the case-finding questions acceptable
Discussion Participants reported the nurse-led clinic as an ideal setting to discuss their mood. More widespread commissioning of such a service could assist early recognition and management of co-morbid anxiety and depression in people with RA. In primary care GPs should consider utilising the case-finding questions during annual reviews to encourage patients to disclose mood problems and to improve patient outcomes.
2010 New Migrants in Primary Care: A Formative Study of Innovation and Adaptation
Aim: To explore and explain innovations in primary health care for new migrants in the UK.
Content: We will present the findings of a formative project, which has explored innovation in primary care when caring for new migrant groups. We used a novel approach of embedding an initial survey (respondents = 74) within an online blog followed by a short telephone interview (n=11); the findings of a subsequent documentary analysis drawn from in-depth interviews and a focus group from eight primary care organisations will be presented from Glasgow, Sheffield and London, in the form of case studies.
Relevance/Impact: 86% of survey respondents (n=64) reported migration had increased rapidly or steadily in their area in the past 5 years. There were a variety of modifications to services but 1 in 5 respondents did not identify any adaptations or innovation for new migrants. Drivers for adapting services included, practitioner, organisational and wider contextual factors. Critical drivers for innovation included an organisational and practitioner commitment to equity. Barriers to innovation were funding limitations, staff skills, training & ‘burn out’.
Discussion:The logic of adapting services was to enhance access, identify complex need, address the social determinants of health and improve patient-practitioner trust and communication.
2011 A THIN database investigation into how cardiovascular risk scoring influences the prescribing of statins in primary care
Aims/Objectives To understand how calculating QRISK2 score influences the prescribing of statins in primary care and describe current statin use in the UK.
Content We will report on the results of a matched cohort study utilising The Health Improvement Network (THIN) database. Patients from the database will be identified when they have their first QRISK2 score coded and matched to patients who have not had a QRISK2 score recorded and investigate the subsequent prescribing of statins. This will allow modelling of the impact of QRISK2 scoring on the decision to prescribe. We will also describe which patients are, and which patients are not, being prescribed statins based on their sociodemographic variables, risk score and clinical status and how prescribing patterns are changing over time.
Relevance/Impact The primary prevention of CVD is an important part general practice and one aspect of this is the use of statins to lower cholesterol. However, who should be offered statins is a subject of much debate. We will shed light on which patients are receiving statins currently and what factors are influencing prescribing.
Outcomes This research will inform the debate on the use of statins. We will be able to compare current practice to national guidelines and start to unpick the interaction between guidance, clinical judgement and patient preference.
Discussion Primary prevention is important, but if we treat the wrong patients then we run the risk of causing harm. By understanding current practice we can inform interventions to rationalise prescribing and maximise benefit for patients.
2012 How is drug safety monitored in UK primary care? Can we be sure that new drugs are safe to prescribe?
It has long been recognised that all potential hazards of a drug cannot be known before it is marketed. This led to the introduction of the Yellow Card system in 1964, in which doctors report suspected adverse drug reactions (ADRs) to the medicines regulator. While the Yellow Card was a good start, it is a passive system that relies on prescribers suspecting that an ADR has occurred. Our Unit proactively monitors the safety of drugs once they are prescribed in the real world by GPs in England, using an observational method called Modified Prescription-Event Monitoring (MPEM). This method relies on GPs completing and returning forms sent to them.
A topical example of our monitoring is the MPEM study of rivaroxaban, a new oral anticoagulant. This study is ongoing, so results of a planned interim analysis will be presented. The interim evaluable cohort of 8372 patients was identified from rivaroxaban prescriptions dispensed between December 2011 and July 2015. MPEM questionnaires were sent to prescribing GPs at ≥3 months and ≥12 months after the first rivaroxaban prescription issued for each patient. Interim analysis revealed that rivaroxaban is largely prescribed in line with the approved indications: atrial fibrillation, AF (60.2% of reported indications) and venous thromboembolism (37.4%). Of AF patients, 88.0% were aged >65 years, 13.9% had stroke history and 2.4% had bleeding history.
Over 120 PEM/MPEM studies have been completed since 1981. We are grateful to the thousands of GPs who have completed MPEM questionnaires and contributed to protecting public health.
2013 Long-term effects of a randomised, controlled, tailor-made weight loss intervention in primary care on the health and lifestyle of overweight and obese women
Bastiaan de Vos
Maintenance of weight loss after a diet and exercise intervention is often low. Moreover, short follow-up periods and high attrition rates often impede translation of study results to clinical practice. The present study evaluated the long-term effectivity of a randomised, tailor-made lifestyle intervention, consisting of diet and exercise, on the health and lifestyle of overweight, middle-aged women in primary care.
The intervention was part of a randomised controlled trial on the prevention of knee osteoarthritis. The intervention consisted of visits to the dietician and participation in physical activity classes, supervised by a physiotherapist. Frequency of dietician visits and specific goals were determined in dialogue with the participants individually. Primary outcome measure was weight change in kilograms.
The adjusted intervention effect over the total follow-up period of 6.6 years showed a significant difference of 1.56 kg (95% CI: 0.81-2.32, -0.79 kg for the intervention group versus 0.78 kg for the control group) with a standardised effect size of 0.40 (95% CI: 0.21-0.60). For the per protocol analyses, these results are 2.85 kg and 0.71, respectively. There was a significant intervention effect found on change in physical activity (adjusted difference of 14.16%, 95% CI: 1.64 – 26.69). The present study provides important recommendations for future research.
Results show that a tailor-made weight loss intervention can, in fact, induce lifestyle changes which endure over a long period of time. In future research, greater intervention effects are expected when higher compliance rates can be reached.