bluuebunny/crossref_metadata_2025_split huggingface dataset:
A primary care network analysis: natural communities of general practices in London
Authors: Beaney Thomas , Clarke Jonathan , Barahona Mauricio , Majeed Azeem 
Published: June 2020

BackgroundPrimary care networks (PCNs) are a new organisational hierarchy introduced in the NHS Long Term Plan with wide-ranging responsibilities. The vision is that they represent ‘natural’ communities of general practices with boundaries that make sense to practices, other healthcare providers, and local communities.AimOur study aims to identify natural communities of general practices based on patient registration patterns, using network analysis methods and unsupervised clustering to create catchments for these communities.MethodPatients resident in and attending GP practices in London were identified from Hospital Episode Statistics from 2017 to 2018. We used a series of novel methods for unsupervised graph clustering. A cosine similarity matrix was constructed representing similarities between each general practice to each other, based on registration of patients in each Lower Super Output Area (LSOA). Unsupervised graph partitioning using Markov Multiscale Community Detection was conducted to identify communities of general practices. Catchments were assigned to each PCN based on the majority attendance from an LSOA.ResultsIn total 3 428 322 unique patients attended 1334 GPs in general practices LSOAs in London. The model grouped 1291 general practices (96.8%) and 4721 LSOAs (97.6%), into 165 mutually exclusive PCNs. The median PCN list size was 53 490 and a median of 70.1% of patients attended a general practice within their allocated PCN, ranging from 44.6% to 91.4%.ConclusionWith PCNs expected to take a role in population health management and with community providers expected to reconfigure around them, it is vital we recognise how PCNs represent their communities. This method may be used by policymakers to understand the populations and geography shared between networks.
Anticipatory care planning for older adults: a trans-jurisdictional feasibility study
Authors: Corry Dagmar , Doherty Julie , McCann Adrienne , Doyle Frank , Cardwell Christopher , Carter Gillian , Clarke Mike , Fahey Tom , Gillespie Paddy , McGlade Kieran , O’Halloran Peter , Wallace Emma , Brazil Kevin 
Published: June 2020

BackgroundAs the population of older adults’ increases, the complexity of care required to support those who choose to remain in the community has also increased. Anticipatory Care Planning (ACP) through earlier identification of healthcare needs is evidenced to improve quality of life, decrease the number of aggressive futile interventions, and even to prolong life.AimTo determine the feasibility of a cluster randomised trial to evaluate the implementation and outcomes of Anticipatory Care Planning (ACP) in primary care to assist older adults identified as at risk for functional decline by developing a personalised support plan.MethodGP practices were randomised into control/intervention groups stratified by jurisdiction [Northern Ireland (UK) and the Republic of Ireland (RoI)], and by setting (urban and rural). Participants were included if they were a) aged ≥70 years, b) 2 or more chronic medical conditions, c) 4 or more prescribed medications. The Anticipatory Care Plan consisted of home visits where the study nurse discussed patients’ goals and plans. An action plan was put in place following consultation with patient’s GPs and study Pharmacist.ResultsEight primary care practices participated; four in the UK and four in the RoI. Sample n = 64. Data was collected pertaining to patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and the use of potentially inappropriate medication.ConclusionUnique insights relating to the trans-jurisdictional delivery of healthcare services in the UK and RoI were observed which has implications on service delivery for older adults.
How can referrals of patients who are obese to the local exercise referral scheme be increased? A UK based primary care quality improvement study
Authors: Zaver Vasudev , Wormall Stephen , Prasad Vibhore , Perera Keshara 
Published: June 2020

BackgroundObesity is classified as a body mass index (BMI) >30kg/m2 and contributes to poor health outcomes in the UK. In 2017–18, obesity resulted in 711,000 hospital admissions. The National Institute for Health and Care Excellence (NICE) recommends GPs educate patients who are obese and refer them to exercise programmes. Our practice, Brierley Park Medical Centre, (NHS Mansfield and Ashfield CCG) is in a 4th decile most deprived region of North Nottinghamshire (UK) and serves a population of 9,288. The local exercise referral scheme (ERS) allows clinicians to refer patients to the local gym for a reduced fee at the point of access.AimTo calculate and increase the number of adult patients who are obese in our practice who are referred to the local ERS.MethodThe number of adult obese patients who were referred to the local ERS scheme from October 2018 to September 2019 was calculated. An intervention comprising internal system alerts, GP education utilising Making Every Contact Count framework and targeted patient group text alerts was designed and delivered. Pre (cycle 1) and post (cycle 2) intervention data from November to February were generated and compared.ResultsIn total, 2766 adult obese patients (29.8% of practice population) were identified: 16 (0.2%) patients were referred to ERS during cycle 1.96 (1%) patients were referred during cycle 2.ConclusionThe interventions that we have designed and implemented have increased the number of referrals to ERS and may be applied to similar primary care settings.
MULTIPAP Study: Improving healthcare for patients with multimorbidity
Authors: Prados-Torres Alexandra , Cura-González Isabel del , Prados-Torres Juan Daniel , Muth Christiane , Leiva-Fernández Francisca , Lopez-Rodriguez Juan A , González-Rubio Francisca 
Published: June 2020

BackgroundThe steady rise in multimorbidity entails serious consequences for our populations, challenges healthcare systems, and calls for specific clinical approaches of proven effectiveness. The MULTIPAP Study comprises three sequential projects (MULTIPAP and MULTIPAP Plus RCTs, and the MULTIPAP Cohort). Results of MULTIPAP RCT are presented.AimTo evaluate the effectiveness of a complex, patient-centred intervention in young-old patients with multimorbidity and polypharmacy.MethodPragmatic cluster-randomised clinical trial in a primary healthcare setting. GPs were randomly allocated to either conventional care or the MULTIPAP intervention based on the Ariadne Principles with two components: GPs e-training (that is, eMULTIPAP addresses specific, key concepts on multimorbidity, polypharmacy and shared decision-making) and GP–patient-centred interview. Young-old patients aged 65–74 years with multimorbidity and polypharmacy were included. Main outcome: difference in the Medication Appropriateness Index (MAI) after 6-month follow-up between groups. Secondary outcomes: MAI, quality of life, patient perception, health services use, treatment adherence and cost-effectiveness after 12-month follow-up.Results117 GPs from 38 Spanish primary health care recruited 593 patients randomly assigned to the intervention/control groups. Difference in MAI scores between groups in the intention-to-treat analysis after 6 months’ follow-up: −2.42 (−4.27 to −0.59), P = 0.009 (adjusted difference in mean MAI score −1.81(−3.35 to −0.27), P = 0.021). Secondary outcomes: not significant, including quality of life (adjusted difference in mean EQ-5D-5L (VAS) 2.94 (−1.39 to 7.28), P = 0.183, EQ-5D-5L (index) −0.006(−0.034 to 0.022), P = 0.689).ConclusionThe intervention significantly improved medication appropriateness. The observed quality of life improvement was not significant. GPs e-training in multimorbidity has shown to be feasible and well accepted by the professionals. Future studies may test whether this format facilitates implementation.
Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations
Authors: Wouters Loes , Zwart Dorien , Erkelens Carmen , de Groot Esther , Damoiseaux Roger , Hoes Arno , Rutten Frans 
Published: June 2020

BackgroundDuring telephone triage it is difficult to assign the adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.AimTo assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.MethodCross-sectional study of 1,655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient’s general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 am to 9 am) was calculated by comparing to the risk at other hours, and was adjusted for gender and age.ResultsThe mean age of callers was 58.9 (SD ± 19.5) years, 55.5% were women and in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (CI = 1.39 to 2.34, P<0.001); 2.33 (1.68 to 3.22, P<0.001) for men, and 1.29 (0.83 to 1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07 to 3.10, P = 0.039).ConclusionPatients calling the OHS-PC for chest discomfort between 0–9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more ‘straightaway’ could be considered for these patients with chest discomfort.
The Moving Healthcare Professionals Programme
Authors: Brannan Michael , Hughes-Short Matt 
Published: June 2020

BackgroundHealthcare professionals (HCPs) are estimated to see nearly 500 000 patients during their career. Evidence demonstrates that one in four patients would be more active if advised by their GP. However, there is a lack of engagement between HCPs and patients regarding the benefits of physical activity (PA). PA is not discussed with 80% of patients, with 75% of GPs feeling they lack knowledge to advise their patients.AimMoving Healthcare Professionals Programme (MHPP) aims include increasing awareness and skills in PA for prevention and management of ill health; changing clinical practice in the promotion of activity; and evaluating impact to identify ‘what works’.MethodGPs were recruited as Physical Activity Clinical Champions (PACCs) to deliver peer-to-peer training to HCPs nationally. Additionally, relationships were developed with undergraduate medical schools to embed PA into curriculum. A PA advice pad was developed as a local GP pilot, while the ‘Moving Medicine’ online resource was created.ResultsOver 22 000 HCPs were trained to date, with evaluation demonstrating an increase in knowledge, skills and confidence, and over 18 000 completions of our eLearning modules. PA coverage was expanded across the undergraduate curriculum at multiple medical schools, while feedback on the e-advice pad pilot has informed a further digital pilot. Additionally, there were >3000 monthly users of ‘Moving Medicine’.ConclusionThis work demonstrated scope for significant improvements in HCP engagement in multiple clinical settings. Working with GPs has proved crucial to this success across various workstreams, with their participation a continued focus moving into Phase 2.
Awareness and use of online appointment booking in general practice: analysis of GP Patient Survey data
Authors: Gomez-Cano Mayam , Atherton Helen , Campbell John , Eccles Abi , Dale Jeremy , Poltawski Leon , Abel Gary 
Published: June 2020

BackgroundGeneral practices are required to provide online booking to patients in line with policy to digitise access. However, uptake of online booking by patients is currently low and there is little evidence about awareness and use by different patient groups.AimTo examine variability in awareness and use of online appointment booking in general practice.MethodSecondary analysis of two questions from the GP Practice Survey data (2018) asking about awareness and use of online booking of appointments. Multivariable logistic regression was used to examine associations with age, gender, ethnicity, deprivation, the presence of a long-term condition, long-term sickness and being deaf.ResultsIn total, 43.3% (277 278/647 064) of responders reported being aware of being able to book appointments online, while only 15% (93 671/641 073) reported doing so. There was evidence of variation by all factors considered, with strong deprivation gradients in both awareness and use (for example, most versus least deprived quintile OR for use: 0.63 (95% CI = 0.61 to 0.65). There was a reduction in awareness and use in patients >75 years of age. Patients with long-term conditions were more aware and more likely to use online booking.ConclusionWhile over 40% of patients know that they can book appointment online, the number that actually do so is far lower. With the constant push for online services within the NHS and the roll out of the NHS app, practices should be aware that not all patient groups will book appointments online and that other routes of access need to be maintained to avoid widening health inequalities.
Determinants of primary care workforce variation in England
Authors: Gibson Jon , Spooner Sharon , Sutton Matt 
Published: June 2020

BackgroundThe General Practice Forward View (GPFV) outlined how the government plans to attain a strengthened model of general practice. A key component of this proposal is an expansion of the workforce by employing a varied range of practitioners, in other words ‘skill mix’. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.AimThe aim of this study is to examine what practice characteristics are associated with the current employment of these ‘new’ roles.MethodThe study uses practice level workforce data (2015–2019), publicly available from NHS Digital. The authors model FTE of specific workforce groups (for example, advanced nurse) as a function of deprivation, practice rurality, patient demographics (total list size and percentage of patients aged >65 years) and FTEs from other staff groups.ResultsAlthough analysis is ongoing, initial estimation suggests that the employment of ‘new’ roles has occurred in larger practices (in terms of list size), in practices with a higher proportion of patients living in deprived areas and practices with a larger proportion of patients aged >65 years. FTE for advanced nurses is negatively associated with GP FTE.ConclusionA negative correlation between advanced nurse FTE and GP FTE is potentially suggestive of substitution between roles, deliberate or otherwise. For example, practices may employ ‘new’ roles if they are unable to recruit GPs or they may recruit staff to free up GP time. Further work is needed to confirm these findings and to explore the reasons behind practice employment decisions.
Exploring patient preference regarding interpreter use in primary care
Authors: Steele Heather , Lehane David , Walton Elizabeth , Mitchell Caroline 
Published: June 2020

BackgroundEffective communication is considered an essential component of delivering health care. Trained, professional interpreters are the gold standard for overcoming language barriers with those with limited English proficiency (LEP). However, LEP patients often use unqualified interpreters such as family members and friends. Existing literature explores the rationale behind choosing different interpreters, but rarely from the patient perspective.AimTo explore the patient perspective on the type of interpreter best suited for primary care consultations.MethodParticipants self-identified as having LEP were recruited from four GP practices in areas of Sheffield with high proportions of black and minority ethnic (BME) residents. The participants were from Urdu-, Arabic-, or Romani-speaking ethnic groups. Semi-structured interpreted interviews were recorded, transcribed, and analysed thematically with independent verification of emergent themes. Interviews continued to data saturation.ResultsAll participants expressed a preference for face-to-face interpreters. Urdu and Arabic participants highlighted the importance of using an interpreter with the same dialect; Roma participants were passionate about the need for qualified Roma interpreters. Most participants also identified trust and sex as important factors. However, interpreter preference varied between participants: some valued the continuity of family members, whereas others favoured the professionalism and linguistic accuracy associated with qualified interpreters.ConclusionThis study identified conflicts between patient preferences and guidance for healthcare professionals; all of the participants disliked telephone interpreting, and many recognised the benefits of untrained interpreters. The study highlights the complexities of interpreter preference in primary care and suggests that the decision should be flexible, and patient centred.
Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice
Authors: Greene Charlotte , Pearson Alice 
Published: June 2020

BackgroundOpioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.AimAn audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.MethodA search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.ResultsDemographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.ConclusionOpioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.
Blood tests in general practice: the use of routine data to characterise venous blood testing in North West London, 2016–2018
Authors: Bakhet Marize , Ul-Haq Zia , Kamalati Tahereh , Lucas Amanda , Majeed Azeem , El-Osta Austen 
Published: June 2020

BackgroundLaboratory testing is an integral diagnostic tool, contributing to 70% of diagnoses in the NHS today. Its use has been steadily increasing despite estimates that ≤40% of blood tests ordered are unnecessary. Understanding blood-testing patterns is a fundamental step to tackling overuse.AimTo characterise the volume, type, and per patient frequency (PPF) of venous blood testing reported in general practice in North West London, 2016–2018.MethodFollowing ethics clearance, aggregate data of blood tests reported in general practice in North West London between 2016 and 2018 were extracted from the Discover database. Non-venous blood test codes and codes not used within the designated time period were excluded. Codes reporting the same analyte were aggregated. Overall volume and PPF were calculated per analyte.ResultsThree hundred and thirty-six individual analytes were reported and grouped into 35 recognised panels or groupings. Blood testing increased by 16.5% over the 3-year period. Full blood count, urea and electrolytes, liver function tests, and lipid profile accounted for 80.4% of all venous blood tests. Requests for HbA1c increased by 52.8% and non-HDL cholesterol by 148.7%, whereas glucose decreased by 13.3% and urea by 15.7%. The PPF remained unchanged over the 3-year period at 1.29 blood tests per person per year. The coagulation assay had the highest PPF at 3.0.ConclusionRoutine general practice data revealed important trends in blood testing. Trends uncovered can inform innovative and targeted solutions to reduce unnecessary blood testing.
Appropriate secondary prevention of stroke and transient ischaemic attack with antithrombotics: an audit in general practice
Authors: Williams Isabelle , Smith William , Nash Edward , Patel Ajay 
Published: June 2020

BackgroundStroke is a major cause of death and disability worldwide. Major advances have occurred in secondary prevention of stroke/transient ischaemic attack (TIA) during the past three decades. Primary care is a critical point of contact with patients in the implementation of secondary prevention, with the majority of patients with past stroke/TIA being managed in the community.AimTo assess current practice at the New Queen Street and Stanground Surgeries, Peterborough, in reference to the National Institute for Health and Care Excellence guidelines on secondary prevention of stroke/TIA.MethodAn audit at the above practices was undertaken by searching the SystmOne computer system for adult patients with previous stroke/TIA (311), excluding those with haemorrhagic stroke and those on aspirin. The patient records of the remaining group (37) were investigated to find whether they were on appropriate antithrombotic therapy and, if not, why.ResultsOf post-stroke/TIA patients, 234/236 were receiving antithrombotic therapy unless contraindicated. For those not on antithrombotics, risk of bleeding was the reason given in 10/13 of cases, though many of these patients did not have active bleeding (exact number unclear due to poor documentation). In 2/13 cases there was no documented reason given and informed dissent in one of the 13 cases.ConclusionIt was found that both practices implemented the guidelines to a satisfactory degree. However, to further improve secondary prevention outreach, bleeding risk should be assessed using a tool such as S2TOP-BLEED before withholding antithrombotic therapy, as, on balance, antithrombotic therapy may still be preferable. In addition, accurate and detailed documentation of the indications/contraindications to anticoagulation is paramount for such assessment.