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BackgroundHealth services in many countries are promoting digital-first models of access to general practice based on offering online, video, or telephone consultations before a face-to-face consultation. It is claimed that this will improve access for patients and moderate the workload of doctors. However, improved access could also potentially increase doctors’ workload. ObjectiveThe aim of this study was to explore whether and under what circumstances digital-first access to general practice is likely to decrease or increase general practice workload. MethodsA process map to delineate primary care access pathways was developed and a model to estimate general practice workload constructed in Microsoft Excel (Microsoft Corp). The model was populated using estimates of key variables obtained from a systematic review of published studies. A MEDLINE search was conducted for studies published in English between January 1, 2000, and September 30, 2019. Included papers provided quantitative data about online, telephone, or video consultations for unselected patients requesting a general practice in-hours consultation for any problem. We excluded studies of general practitioners consulting specialists, consultations not conducted by doctors, and consultations conducted after hours, in secondary care, in specialist services, or for a specific health care problem. Data about the following variables were extracted from the included papers to form the model inputs: the proportion of consultations managed digitally, the proportion of digital consultations completed without a subsequent consultation, the proportion of subsequent consultations conducted by telephone rather than face-to-face, consultation duration, and the proportion of digital consultations that represent new demand. The outcome was general practice workload. The model was used to test the likely impact of different digital-first scenarios, based on the best available evidence and the plausible range of estimates from the published studies. The model allows others to test the impact on workload of varying assumptions about model inputs. ResultsDigital-first approaches are likely to increase general practice workload unless they are shorter, and a higher proportion of patients are managed without a subsequent consultation than observed in most published studies. In our base-case scenarios (based on the best available evidence), digital-first access models using online, telephone, or video consultations are likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. An important determinant of workload is whether the availability of digital-first approaches changes the demand for general practice consultations, but there is little robust evidence to answer this question. ConclusionsDigital-first approaches to primary care could increase general practice workload unless stringent conditions are met. Justification for these approaches should be based on evidence about the benefits in relation to the costs, rather than assumptions about reductions in workload. Given the potential increase in workload, which in due course could worsen problems of access, these initiatives should be implemented in a staged way alongside careful evaluation.

Background Multimorbidity is a growing problem. The number and complexity of (non-)pharmaceutical treatments create a great burden for patients. Treatment burden refers to the perception of the weight of these treatments, and is associated with multimorbidity. Measurement of treatment burden is of great value for optimizing treatment and health-related outcomes. Objective We aim to translate and validate the Multimorbidity Treatment Burden Questionnaire (MTBQ) for use in the Dutch population with multimorbidity and explore the level of treatment burden. Methods Translating the MTBQ into Dutch included forward–backward translation, piloting, and cognitive interviewing (n = 8). Psychometric properties of the questionnaire were assessed in a cross-sectional study of patients with multimorbidity recruited from a panel in the Netherlands (n = 959). We examined item properties, dimensionality, internal consistency reliability, and construct validity. The level of treatment burden in the population was assessed. Results The mean age among 959 participants with multimorbidity was 69.9 (17–96) years. Median global NL-MTBQ score was 3.85 (interquartile range 0–9.62), representing low treatment burden. Significant floor effects were found for all 13 items of the instrument. Factor analysis supported a single-factor structure. The NL-MTBQ had high internal consistency (α = 0.845), and provided good evidence on the construct validity of the scale. Conclusion The Dutch version of the 13-item MTBQ is a single-structured, valid, and compact patient-reported outcome measure to assess treatment burden in primary care patients with multimorbidity. It could identify patients experiencing high treatment burden, with great potential to enhance shared decision-making and offer additional support. [ABSTRACT FROM AUTHOR]

Background: Rates of blood testing have increased over the past two decades. Reasons for testing cannot easily be extracted from electronic health record databases. Aim: To explore who requests blood tests and why, and what the outcomes of testing are in UK primary care. Design and setting: A retrospective audit of electronic health records in general practices in England, Wales, Scotland, and Northern Ireland was undertaken. Method: Fifty-seven clinicians from the Primary care Academic CollaboraTive (PACT) each reviewed the electronic health records of 50 patients who had blood tests in April 2021. Anonymised data were extracted including patient characteristics, who requested the tests, reasons for testing, test results, and outcomes of testing. Results: Data were collected from 2572 patients across 57 GP practices. The commonest reasons for testing in primary care were investigation of symptoms (43.2%), monitoring of existing disease (30.1%), monitoring of existing medications (10.1%), and follow up of previous abnormalities (6.8%); patient requested testing was rare in this study (1.5%). Abnormal and borderline results were common, with 26.6% of patients having completely normal test results. Around one-quarter of tests were thought to be partially or fully unnecessary when reviewed retrospectively by a clinical colleague. Overall, 6.2% of tests in primary care led to a new diagnosis or confirmation of a diagnosis. Conclusion: The utilisation of a national collaborative model (PACT) has enabled a unique exploration of the rationale and outcomes of blood testing in primary care, highlighting areas for future research and optimisation. [ABSTRACT FROM AUTHOR]

Background: Treatment burden is the effort required of patients to look after their health, and the impact this has on their wellbeing. Quantitative data on treatment burden for patients with multimorbidity are sparse, and no single-item treatment burden measure exists.Aim: To determine the extent of, and associations with, high treatment burden among older adults with multimorbidity, and to explore the performance of a novel single-item treatment burden measure.Design and Setting: Cross-sectional postal survey via general practices in Dorset, UK.Method: Patients ≥55 years, living at home, with three or more long-term conditions (LTCs) were identified by practices. Treatment burden was measured using the Multimorbidity Treatment Burden Questionnaire. Data collected were sociodemographics, LTCs, medications, and characteristics including health literacy and financial resource. Associations with high treatment burden were investigated via logistic regression. Performance of a novel single-item measure of treatment burden was also evaluated.Results: A total of 835 responses were received (response rate 42%) across eight practices. Patients' mean age was 75 years, 55% were female (n = 453), and 99% were white (n = 822). Notably, 39% of patients self-reported fewer than three LTCs (n = 325). Almost one-fifth (18%) of responders reported high treatment burden (n = 150); making lifestyle changes and arranging appointments were particular sources of difficulty. After adjustment, limited health literacy and financial difficulty displayed strong associations with high treatment burden; more LTCs and more prescribed regular medications were also independently associated. The single-item measure discriminated moderately between high and non-high burden with a sensitivity of 89%, but a specificity of 58%.Conclusion: High treatment burden was relatively common, underlining the importance of minimising avoidable burden. More vulnerable patients, with less capacity to manage, are at greater risk of being overburdened. Further development of a single-item treatment burden measure is required. [ABSTRACT FROM AUTHOR]

Background People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. Methods The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. Results Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73–4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32–2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15–2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17–0.87); P = 0.021]. Conclusions Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to identify factors associated with being overweight or obese, and perceptions of weight by hypertensive patients living in rural South Africa. Design: This was a nested cross-sectional study. Setting: The setting was primary healthcare clinics close to Manguzi Hospital, KwaZulu-Natal. Subjects: Subjects were 109 males and 391 females, prescribed at least one antihypertensive medication aged ≥ 18 years. Outcome measures: The primary outcome measure was body mass index (BMI) ≥ 25 kg/m2. The secondary outcome measure was recognition of being overweight by those with a BMI ≥ 25 kg/m2. Results: The mean age was 58 years. Three hundred and ninety-one (78%) participants were female, and the majority had never been to school or had attended primary school only. Three hundred and eleven (62%) participants were overweight or obese, with a BMI ≥ 25 kg/m2. Factors associated with being overweight or obese included having high cholesterol [adjusted odds ratio (OR) 10.62, 95% confidence interval (CI): 1.22-92.4, p-value 0.032], and having never smoked (adjusted OR 3.22, 95% CI: 1.38-7.52, p-value 0.007. Human immunodeficiency virus (HIV) was associated with a lower risk of being overweight or obese (adjusted OR 0.52 for BMI ≥ 25, 95% CI: 0.31-0.89, p-value < 0.0001). Only 12% of participants who were overweight or obese perceived that they were overweight. Participants with a BMI ≥ 25 kg/m2 were most likely to recognise they were overweight if they had high cholesterol, diabetes or HIV. Conclusion: Almost two thirds of participants were overweight or obese, and of these, only 12% perceived that they were overweight. Educating patients about obesity, particularly when they have other cardiovascular risk factors such as hypertension, is of public health importance. [ABSTRACT FROM AUTHOR]

Background: The true burden of acute lower respiratory tract disease (aLRTD; includes acute lower respiratory tract infection [aLRTI] and presumed non-infective exacerbations of chronic lung disease and heart failure) among adults presenting to primary care, and the proportion that are potentially vaccine preventable is unknown., Aim: To describe aLRTD incidence in adults presenting to primary care; estimate proportions caused by respiratory syncytial virus (RSV), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and Streptococcus pneumoniae (SP); and investigate disease burden from patient and NHS perspectives., Design & Setting: Primary care prospective cohort study conducted in six representative general practices (total ∼86 000 registered adults) in Bristol, UK., Method: Adults (aged ≥18 years) registered at participating general practices and presenting to primary care (in-hours or out-of-hours) or emergency department (if not admitted) with aLRTD will be eligible. They will be identified by real-time primary care record searches. Researchers will screen electronic GP records, including free text, contact patients to assess eligibility, and offer enrolment in a surveillance study and an enhanced diagnostic study (urine, saliva, and respiratory samples; physical examination; and symptom diaries). Data will be collected for all aLRTD episodes, with patients assigned to one of three arms: surveillance; embedded diagnostic; and descriptive dataset. Outcome measures will include clinical and pathogen-defined aLRTD incidence rates, symptom severity and duration, NHS contacts and costs, health-related quality-of-life changes, and mortality (≤30 days post-identification)., Conclusion: This comprehensive surveillance study of adults presenting to primary care with aLRTD, with embedded detailed data and sample collection, will provide an accurate assessment of aLRTD burden due to vaccine-preventable infections., (Copyright © 2024, The Authors.)