Research Posters 2014 – 2020
2014 The long-term effects of a weight loss intervention and of oral glucosamine sulphate on incident knee OA in primary care
Bastiaan de Vos
Obesity as a risk factor for knee OA and weight loss as a treatment for knee OA have been extensively described. More recently, weight loss has been suggested as a strategy to prevent the development of knee OA in a high risk population. Few studies have been designed specifically to investigate this preventive relationship. In the present study, the long-term effects of a tailor-made diet and exercise intervention aimed to reduce body weight and of oral glucosamine sulphate (2 x 2 factorial design) on the incidence of knee OA were studied in a population of middle-aged, overweight women, without knee OA at baseline, 6-7 years after randomisation. 477 knees from 245 participants (60%) were available for analysis after 6.6 years of follow-up.
19% of all knees showed incident knee OA according to clinical and radiographic ACR criteria (18% in the intervention group and 19% in the control group). Despite significant intervention effects found earlier on body weight changes and physical activity, no significant intervention effects on incident knee OA were found. A moderate amount of weight loss in the first year of the study (5 kg/5%) was associated with a significant decrease in incident knee OA (7% versus 21%).
This trial provides important insights for future studies on the prevention of knee OA, which are currently lacking. Weight loss remains challenging in the present population, but this study provides proof that the concept of preventing knee OA through weight loss is viable.
2015 Factors influencing self-efficacy and self-management in patients with depression and multi-morbidity
The prevalence of physical-mental multi-morbidity is increasing in all age groups, posing multiple challenges to clinicians. Self-management is a key aspect in the management of these patients. Complex interventions like collaborative care are proving beneficial in improving self-management and outcomes in these patients.
Aim The aim of this study is to identify patient level characteristics associated with increased self-efficacy and self-management behaviours in people with physical-mental multi-morbidity. This will help clinicians in identifying and targeting patients who will benefit most from complex interventions such as collaborative care.
Methods In this study, secondary analysis of baseline data collected from the COINCIDE cluster randomized controlled trial was performed. Validated scales were used to measure severity of depression, anxiety, quality of life, self-management and self-efficacy. Fifteen dependent variables were evaluated using univariate analysis; multiple regression models were used to identify factors associated with self-efficacy and self-management.
Results An increase in the number of Long-term-conditions (LTCs), severity of depression and anxiety were negatively associated with self-efficacy and self-management. Global quality of life, measured using the WHOQoL BREF scale, was consistently shown to be significantly associated with self-efficacy and self-management behaviours.
Discussion This study confirms that patients with higher number of LTCs, severe depression and severe anxiety have lower levels of self-efficacy and self-management. Global quality of life is strongly associated with patient’s self-efficacy and self-management. These findings could inform clinicians about which patients with common mental health problems are most likely to benefit from collaborative care.
2016 A systematic review comparing hbA1c to fasting plasma glucose and the oral glucose tolerance test in the diagnosis of type 2 diabetes mellitus in adults
Aim: The World Health Organisation recommended the addition of the HbA1c ≥ 6.5% as part of the diagnostic criteria for type 2 diabetes mellitus (T2DM) in 2011. This systematic review compares the HbA1c ≥ 6.5% (48mmol/l) criteria with the fasting plasma glucose (FPG) and the oral glucose tolerance test (OGTT) in the diagnosis of T2DM in adults.
Methods: Ovid Medline, EMBASE, Cochrane databases of systematic reviews, Database of reviews of abstracts and extracts, PubMed and CINAHL Plus were searched. A total of 1977 studies were eligible of which 24 studies were included in this systematic review following the review of full articles.
Result: Ten studies reported a higher prevalence and six studies reported a lower prevalence based on HbA1c ≥ 6.5% in comparison to the FPG criterion. For all the studies, prevalence was lower using the HbA1c criteria in comparison to the OGTT criteria apart from one study where the prevalence was comparable. The degrees of agreement between the tests ranged from poor to good. The HbA1c criterion was more specific than sensitive for the diagnosis of T2DM.
Conclusion: The prevalence of T2DM varies depending on the diagnostic criteria and the characteristics of the population being studied. The HbA1c ≥ 6.5% criterion has lower, higher or comparable prevalence when compared to FPG. The prevalence was lower by HbA1c criteria in comparison to the OGTT criteria in nearly all the studies. The appropriate use of the HbA1c ≥ 6.5% recommendation is able to differentiate between individuals with or without T2DM.
2017 Tackling obesity in early childhood: Improving recognition of childhood obesity and developing communication tools for primary care
Aim & Objectives This pilot project aims to reduce the incidence of cancer by changing weight trajectories of preschool children through; (i) assisting GPs to initiate conversations with parents about their child’s weight, (ii) improving recognition of overweight and obese children, and (iii) increasing healthy behaviours within families with overweight and obese children.
Content of presentation GPs and other primary healthcare professionals struggle to identify overweight and obesity in young children, and there are a number of barriers to addressing the issue with parents. This presentation will outline three potential tools to address this.
Relevance/Impact Evidence suggests that weight trajectories remain stable from early childhood to adulthood. Obesity is the 2nd biggest modifiable risk factor for cancer after smoking. Addressing obesity in children may reduce adult obesity levels, thus reducing the incidence of weight-related illnesses.The RCGP childhood obesity e-learning module is currently being revised, and one or more of these interventions could be integrated for dissemination to GPs.
Outcomes A language toolbox for GPs and other health professionals to use in their consultations, a visual patient information tool, and an adapted lifestyle, habit-based leaflet are being piloted. These interventions will be iteratively refined for piloting with health professionals and parents through an in-depth literature review, input from a steering committee of topic experts, and focus groups and interviews with GPs, health visitors, practice nurses and parents.
Discussion Demonstrations of the interventions, and preliminary results from the interviews and focus groups will be presented at the RCGP conference.
2018 “Just a gp”: active denigration (badmouthing) of general practice as a career choice
The problem There is currently a national General Practitioner (GP) recruitment crisis. Anecdotal evidence suggests that negative comments from clinical teachers about a career choice of General Practice may influence trainee application to GP.
Approach Six focus groups were undertaken involving GPST1 trainees from two Northern training programmes, using a semi-structured question format. Trainees were asked about any positive or negative comments made to them relating to their career choice. Focus group transcripts were thematically analysed.
Findings Active denigration of General Practice as a career was evident. Recurrent negative comment themes included general practice being regarded as a ‘second class career’, questioning of trainees’ career choice, and GPs being regarded as lesser quality doctors. The majority of these comments were from doctors in secondary care. Some participants described positive comments regarding GP as a good career choice from hospital clinical supervisors and consultants. Comments from GPs were mixed. Participants perceived that negative comments had not influenced their own career choice but may have influenced their colleagues. Positivity about GP was identified as a driving force for recruitment.
Consequences Our findings support the anecdotal evidence that active denigration of General Practice as a career choice exists. We recommend that further work is undertaken to explore the extent to which these findings are confirmed, and to what extent they are discouraging individuals in applying to GP.
2019 ‘It’s quite a tightrope that we walk’. Why GPs are doing more blood tests: a qualitative study
Aims/objectives: To explore reasons for rising rates of blood testing in UK primary care.
Content of presentation: We conducted 26 in-depth, semi-structured interviews with GPs and nurse practitioners. Interviews were transcribed verbatim and analysed using a grounded theory approach by two researchers. In this presentation we describe themes using illustrative quotes and discuss potential implications for clinical practice.
Relevance/impact: Rates of pathology testing are rising at around 10% each year, with the Carter Review estimating that around 25% of tests are unnecessary. There is increasing recognition of the risks of overdiagnosis, yet at the same time GPs are under pressure to avoid underdiagnosis particularly for cancers.
Understanding the reasons for rising pathology testing rates is important for clinicians and commissioners wishing to ensure appropriate testing.
Outcomes: Reasons for increasing rates of pathology testing were categorised into four groups. 1. ‘Doctors’ characteristics included their training and experience, their risk management and their fear of litigation. 2. ‘Patient’ factors, for example doctors’ perceptions that patients find normal tests reassuring. 3. ‘Organisational factors’ included continuity of care, time pressures and workload. Here clinicians perceived that blood tests could be a time-saving tool to manage complex symptoms during a consultation, but they also generated increasing workloads dealing with results. 4. ‘Societal’ factors. Perceptions of increasing risk aversion, which was considered potentially harmful: ‘we medicalise too much because we search a lot’.
Discussion:A wide range of non-clinical factors influence decisions to perform blood tests in primary care, some of which may be modifiable.
2020 Improving early-detection of cirrhosis in Non-alcoholic Fatty Liver Disease in Primary Care: Results of a risk-stratification pathway in two London boroughs
Aims/Objectives We present the initial findings of a 24 month evaluation of a NAFLD primary care risk-stratification pathway using non-invasive tests. The aim was to increase detection of high-risk liver disease.Relevance/ImpactLiver Disease is a GP clinical priory. NAFLD presents a particular challenge, with a high prevalence (15-40%), but only few high-risk individuals progressing to cirrhosis. Ahead of similar NICE NAFLD guidance due this year, the practical application of non-invasive risk-stratification in primary care is an important new area of focus.
Content Patients diagnosed with NAFLD by their GP in the first 24m of the pathway (March 2014 – February 2016) were eligible (n=3012). Those on the pathway were risk-stratified into low or high-risk of significant fibrosis, with referral recommended for high-risk patients. A hospital case note review was conducted on all patients with NAFLD referred to Hepatology for this period. Comparison was made between outcomes in pathway and non-pathway referrals.
Outcomes 1434 (47.6%) of 3012 eligible patients were risk-stratified using the pathway. 50/70 (71.4%) of practices used the pathway. Preliminary results show detection rates of significant liver fibrosis were 7.7% in those with NAFLD referred without reference to the pathway, compared to 50.0% with pathway use.
Discussion Pathway uptake is improving. Early findings demonstrate potential for NAFLD risk-stratification in primary care to increase the proportion of high-risk NAFLD referred to Hepatology, with a concurrent relative reduction in referrals of low-risk patients. Collaboration between academic GPs, Hepatologists and Commissioners has allowed the development of a pathway showing promising early results.