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Objective: To describe trends in the organisational structure, workforce and recorded appointments by role in English general practice., Design: Retrospective longitudinal study., Setting: English general practice., Data Sources and Participants: NHS England, Office for Health Improvement and Disparities and Care Quality Commission national administrative datasets covering between 5 to 10 years from 2013 to 2023., Results: Between 2013 and 2023, the number of general practices fell by 20% from 8044 to 6419; the average practice list size increase by 40% from 6967 to 9724 patients. The total population covered by providers with over 100 000 registered patients reached 2.3 million in 2023 compared to 0.5 million in 2017. The proportion of practices under individual ownership decreased from 13% to 11% between 2018 and 2023; there was little change in the proportion owned by partnerships, incorporated companies or NHS bodies, which respectively averaged around 80.3%, 6.9% and 0.7%. Between 2015 and 2022, there was a 20% rise in the total full-time equivalent (FTE) general practice workforce, including Primary Care Network staff, from 1.97 to 2.37 per 1000 patients because of an increase in multidisciplinary other 'Direct Patient Care' (DPC) and administrative roles. The number of nurses remained stable, and the number of qualified general practitioners (GPs) decreased by 15%. In September 2022, there were 0.45 FTE qualified GPs per 1000 patients; GPs and other DPC roles, excluding nurses, each represented 19% of the FTE per 1000 patients workforce; administrative roles represented 51%. The general practice workforce is predominantly female. A quarter of GPs qualified overseas. Between 2018 and 2023, there was no clear upward or downward trend in total appointments per 1000 patients with, on average, half provided by GPs., Conclusions: Since 2013, there has been a shift in general practice towards larger practices with more multidisciplinary teams, alongside a reduction in the number of FTE qualified GPs per 1000 patients. We recommend that the impacts of these changes on access, quality and costs are closely monitored., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Following major achievements seen with drug therapies for the treatment of advanced melanoma in the last decade, they now also have an ever-increasing role for the treatment of earlier stage disease. This review outlines the current drugs used to treat melanoma, and how general practitioners (GPs) can assist in the management of patients with melanoma and the associated toxicities with treatment., Objective: This review summarises the evolving status of melanoma care, emphasising when to refer patients to medical oncologists as part of the multidisciplinary team. It provides guidance into recognising and managing immune-related adverse events (irAEs) associated with immunotherapy, and provides insights into the future changes in clinical practice., Discussion: Drug therapies are increasingly used for the treatment of many patients with melanoma. Early referral is crucial, and clinical trials remain the best choice for most patients. Recognition and prompt management of irAEs is vital, and collaboration between GPs and oncologists is essential for best care.

Background: Cardiovascular diseases (CVDs) pose significant global health challenges, with genetics increasingly recognised as a key factor alongside traditional risk factors. This presents an opportunity for general practitioners (GPs) to refine their approaches., Objective: This article explores the impact of genetics on CVDs and its implications for GPs. It discusses monogenic disorders like inherited cardiomyopathies and polygenic risks, as well as pharmacogenetics, aiming to enhance risk assessment and personalised care., Discussion: Monogenic disorders, driven by single gene mutations, exhibit predictable inheritance patterns, including inherited cardiomyopathies and channelopathies such as Long QT syndrome. Polygenic risks involve multiple genetic variants influencing CVD susceptibility, addressed through polygenic risk scores for precise risk assessment. Pharmacogenetics tailor drug interventions based on genetic profiles, though challenges like accessibility and ethical considerations persist. Integrating genetics into cardiovascular care holds promise for alleviating the global CVD burden and improving patient outcomes.

Background: Valproate is a teratogenic drug that should be avoided during the preconception period and pregnancy. The aim was to explore general practitioners' (GPs) prescription patterns over time, describe trends, and explore inter-practice variation within primary care., Methods: We identified women of childbearing age (12-46 years old) in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network. We performed repeated cross-sectional analyses from 2004 to 2018 to determine rates of prescription and a retrospective cohort estimated the prevalence of use of valproate during pregnancy., Results: In 2004, 0.31% (95% Confidence Interval (95%CI):0.18 to 0.44%) women were prescribed valproate, decreasing to 0.16% (95%CI:0.07 to 0.24%) by 2018. Among women with epilepsy, the rate fell from 15.2% (95%CI:14.4 to 16.0%) to 8.8% (95% CI:8.2 to 9.7%) over the same period. In 2018, almost two thirds (62.2%) of women who were prescribed valproate had epilepsy only, whereas bipolar disorder and migraine accounted for 15.8% and 7.4% respectively. Contraceptive prescriptions did not increase over time, and only in 2018 was there greater odds of being prescribed contraception (OR 1.41, 95%CI:1.08 to 1.45). Just under a fifth (19.7%) of women were prescribed valproate during their pregnancy; two out of three of these pregnancies were preceded by folic acid prescription (5 mg). While some practices reduced their rate of valproate prescription, others did not., Conclusions: Regulatory guidelines have changed GPs' prescription patterns in women of childbearing potential for valproate but not for contraception. Further research is needed to identify the barriers of GPs and women of childbearing potential to undertaking contraception., (© 2022. The Author(s).)

Background: In 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented., Methods: Data were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as 'inside/integrated', 'inside/parallel', 'outside/onsite' or 'outside/offsite'. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information., Results: An increase of EDs using GPED was observed from 81% to 95% over the study period. 'Inside/parallel' was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of 'inside/integrated' models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served., Conclusion: The majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: This mixed-method feasibility study conducted in New South Wales (NSW), Australia, aimed to explore clinical practices around the identification of patients with refractory epilepsy and referral from primary care to Tertiary Epilepsy Centers. The perceptions of general practitioners, neurologists, and adults living with refractory epilepsy were considered., Methods: Fifty-two data collection events were achieved through 22 semi-structured interviews with six neurologists and 12 adults who currently have, or have had refractory epilepsy, and four family members, 10 clinical observations of patient consultations and 20 surveys with general practitioners. A thematic analysis was conducted on the qualitative data alongside assessment of observational fieldnotes and survey data., Findings: Two main themes emerged: 1) Patient healthcare pathways and care experiences highlighted the complex and deeply contextualized experiences of both patients and healthcare professionals, from first identification of people's seizures, in primary and community care settings, to referral to Tertiary Epilepsy Centers, shedding light on a fragmented, nonstandardized referral process, influenced by both individual and shared-care practices. 2) Factors impacting referrals and patient pathways indicated that onward referral to a Tertiary Epilepsy Center is affected by the knowledge, or the lack thereof, of healthcare professionals regarding treatment options. Barriers include limited person-centered care, shared decision-making, and refractory epilepsy education for healthcare professionals, which can delay patients' disease identification and can hinder speedy referral pathways and processes, in Australia for up to 17 years. In addition, person-centered communication around care pathways is affected by relationships between clinicians, patients, and family members., Conclusion: This study has identified a noticeable lack of standardized care across epilepsy-related healthcare sectors, which recognizes a need for developing and implementing clearer epilepsy-related guidelines and Continuing Professional Development in the primary and community care settings. This, however, requires greater collaboration and commitment in the primary, community, and tertiary care sectors to address the ongoing misconceptions around professional roles and responsibilities to optimize shared-care practices. Ultimately, prioritizing person-centered care on both patients' and professionals' agendas, in order to improve satisfaction with care experiences of people living with complex epilepsy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Medical management is undeniably an important therapeutic intervention for selected sexual dysfunctions, but it does not serve as a stand-alone approach to treat many common sexual dysfunctions such as lack of interest in sex, sexual performance anxiety, inability to reach orgasm or too quick an orgasm., Objective: The aim of this article is to highlight the role of general practitioners (GPs) in recognising sexual problems, encourage initiation of conversation about sexual dysfunction with patients and raise awareness of sex therapy and presentations that may benefit from referral to sex therapists., Discussion: GPs in Australia have a significant role in addressing sexual health concerns despite practice-related and doctor-patient-related barriers, thereby promoting the healthy sexuality of Australians. Sex therapy is a specialty comprised of various medical, cognitive, emotional and behavioural interventions. Sex therapists, who are healthcare professionals with tertiary training in human sexuality, can share care with GPs to help individuals and/or couples understand, improve and resolve their sexual dysfunctions.

Pharmacogenomic biomarker availability of Hungarian Summaries of Product Characteristics (SmPC) was assembled and compared with the information in US Food and Drug Administration (FDA) drug labels of the same active substance (July 2019). The level of action of these biomarkers was assessed from The Pharmacogenomics Knowledgebase database. From the identified 264 FDA approved drugs with pharmacogenomic biomarkers in drug label, 195 are available in Hungary. From them, 165 drugs include pharmacogenomic data disposing 222 biomarkers. Most of them are metabolizing enzymes (46%) and pharmacological targets (41%). The most frequent therapeutic area is oncology (37%), followed by infectious diseases (12%) and psychiatry (9%) (p < 0.00001). Most common biomarkers in Hungarian SmPCs are CYP2D6, CYP2C19, estrogen and progesterone hormone receptor (ESR, PGS). Importantly, US labels present more specific pharmacogenomic subheadings, the level of action has a different prominence, and offer more applicable dose modifications than Hungarians (5% vs 3%). However, Hungarian SmPCs are at 9 oncology drugs stricter than FDA, testing is obligatory before treatment. Out of the biomarkers available in US drug labels, 62 are missing completely from Hungarian SmPCs (p < 0.00001). Most of these belong to oncology (42%) and in case of 11% of missing biomarkers testing is required before treatment. In conclusion, more factual, clear, clinically relevant pharmacogenomic information in Hungarian SmPCs would reinforce implementation of pharmacogenetics. Underpinning future perspective is to support regulatory stakeholders to enhance inclusion of pharmacogenomic biomarkers into Hungarian drug labels and consequently enhance personalized medicine in Hungary.

Objective: In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital admission. We investigated how the number of injury-related emergency department visits and GP contacts evolved over the period 2013-2017., Design: Retrospective observational trend study., Method: To calculate the trend in emergency department visits in the Netherlands, we used data from the injury information system (LIS) for the period 2013-2017. To calculate the trend in GP contacts (GP practices as well as GP centres), we used data from the NivelZorgregistraties (Nivel medical records). In order to compare the trends, we distinguished between minor and major injuries. The numbers from the records were extrapolated to numbers for the whole of the Netherlands., Results: In the period studied, the number of patients with minor injuries who visited the ED dropped by 38.5%, while the number of patients with major injuries (fractures and brain injuries) increased by 4.1%. In the same period, the number of GP contacts for minor injuries at GP practices increased by 25% and at GP centres by 43%; the number of primary care contacts for major injuries increased by 5.1% (GP practices) and 31% (GP centres) respectively., Conclusion: The role of general practitioners in the treatment of patients with minor injuries is increasing. The trend in major injuries is a better indicator for monitoring accidents and violence in the Netherlands. Conflict of interest and financial support: none declared.

Introduction: Approximately 15% of patients treated by anticoagulant for a venous thromboembolic event are also treated with antiplatelet therapy; and this association increases the risk of bleeding. The aim of this survey was to evaluate general practitioner's management of antiplatelet therapy at the initiation of anticoagulation, and at six months compared to French vascular physicians' management., Methods: A questionnaire including 4 clinical situations was established and the physicians were asked to detail antiplatelet and anticoagulant therapy management. From September 2017 to December 2017, an e-mail invitation and a reminder were sent to members of the departmental councils who participated; 218 questionnaires were obtained., Results: Overall, 91.3% of physicians considered that there was an increased risk of bleeding when antiplatelet therapy is associated with anticoagulation. After initiating anticoagulation, 67% of respondents continued antiplatelet therapy, while 30% stopped. Three strategies were used: 49.0% of physicians maintained concomitant antiplatelet therapy with full-dose anticoagulant, both at anticoagulant initiation and at 6 months; 23% of physicians stopped antiplatelet therapy and prescribed full-dose anticoagulant at initiation and at 6 months; 12.4% of physicians prescribed antiplatelet therapy associated with reduced-dose anticoagulation at 6 months regardless of the strategy at anticoagulant initiation., Conclusion: One third of general practitioners stopped antiplatelet therapy at the initiation of an anticoagulation for a venous thromboembolic event. Prospective controlled trials are needed to clarify the best way to treat these patients in this situation., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Over the past 10 years there have been significant developments in general practice regarding diagnostics, differentiation of competences of general practitioners, cooperation within primary care and with secondary care, task delegation and patient information provision. Less progress has been made in other areas: E-health applications are rarely used, and there is no clear guideline for an integrated policy in patients with multimorbidity. General practitioners also continue to suffer from excessive regulatory pressure, excessive protocols and standardization. In the coming decade, GPs will continue to work in accordance with the core values ​​of their profession: 'person-oriented', 'medical-generalist', 'continuous' and 'jointly'. Their function to provide guidance is becoming increasingly important. In addition, more diagnostics and treatment will take place at the interface between general practice and secondary care. Chronic care will focus more on the needs and wishes of the individual patient. GPs retain their important role in terminal palliative care and emergency care.

Background and Objectives: General practice electronic health records (EHRs) are a rich source of primary care data that can be used for important research. The aim of this qualitative study was to analyse the attitudes of Australian general practitioners (GPs) to the use of data extracted from primary care EHRs for clinical research., Method: Semi-structured interviews were conducted with 13 Australian GPs. Interviews were recorded, transcribed and thematically analysed., Results: Two main themes emerged. The data custodian role encompassed GPs' determination to maintain privacy, their trust of organisations involved and benefits of research outcomes. The theme of protecting practice resources included concerns about unrecompensed staff time and potential risks to data and systems., Discussion: This study highlights that while Australian GPs have concerns about the use of data stored on their EHRs, they also recognise the benefits of using this data for research purposes. Addressing these concerns could help to ensure that researchers have access to this valuable and rich data resource.

Background: Shortage of general practitioners (GPs), especially in rural areas, is an increasing problem for the German healthcare system. Different approaches are pursued to counteract this development. The study HaMEdSi (Hausärzte (GPs) for Medical Education in Siegen-Wittgenstein) among other things examines the occupational perspectives of the GPs depending on their surgeries' characteristics and draws a realistic picture of how primary care in the region of Siegen-Wittgenstein, representative for many rural regions, will develop over the next few years., Method: A survey was conducted among GPs in the region of Siegen-Wittgenstein. This area is a representative rural region in Germany. GPs were amongst other assessed regarding their demographic characteristics and working perspectives., Results: A representative number of GPs took part in the study (n = 85, 54%). For instance, 50.6% of the study participants will no longer be working in practice in 10 years from now and 25% of them assume that their practices be closed after the age-related retirement due to a lack of successor., Conclusions: The situation in rural areas in reality looks worse than previously estimated in the assessments of the Statutory Health Insurance. Something must be done here to mitigate the impending GPs' shortage. Measures such as promotion of training, employment or settlement in undersupplied regions as well as cross-border promotion, could on the long term compensate for the shortage that threatens many rural regions in Germany.

Background: Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients., Objective: To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients., Design: We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment., Main Measures: Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (OR adj ) were calculated for GPs' advice to stop., Key Results: Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (OR adj 13.8, 95%CI 12.6-15.1), with side effects compared to without OR adj 1.62 (95%CI 1.5-1.7) and with frailty (OR adj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (OR adj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99)., Conclusions: The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Background: Few studies have specifically assessed the scope, nature and challenges of palliative and end-of-life care in rural general practice. These knowledge gaps limit the development of evidence-based policies and services for patients in the last months of life. This study aimed to explore the perspectives of general practitioners (GPs) and other stakeholders on rural GPs' involvement and challenges in providing palliative and end-of-life care in regional Australia., Methods: A qualitative study involving five focus groups with 26 GPs based in rural/regional Western Australia together with 15 individual telephone interviews with four GPs and 11 other stakeholders involved in end-of-life care across Australia., Results: The rural GPs' central role in end-of-life care was recognized by the majority of participants but multiple challenges were also identified. Some challenges were comparable to those found in urban settings but others were more pronounced, including resource limitations and lack of training. Inappropriate payment models discouraged GPs' involvement in some aspects of end-of-life care, such as case conferences and home visits. Compared to GPs in urban settings, those in rural/regional communities often reported closer doctor-patient relationships and better care integration and collaboration. These positive aspects of care could be further developed to enhance service provision. Our study highlighted the importance of regular interactions with other professionals and patients in providing end-of-life care, but many GPs and other stakeholders found such interactions more challenging than the more "technical" aspects of care., Conclusions: Rural/regional GPs appear to be disproportionately affected by inappropriate payment models and limited resources, but may benefit from closer doctor-patient relationships and better care integration and collaboration relative to urban GPs. Systematic collection of empirical data on GP management at end-of-life is required to build on these strengths and address the challenges.

Objective: The goal of this study was to analyze trends in valproate use in patients followed by neurologists and general practitioners in Germany between 2009 and 2017., Methods: This study included all patients aged ≥15 years followed in 2009, 2013, and 2017 in neurological (N = 99) and general (N = 499) practices in Germany. Trends in valproate use were estimated based on the mean number of patients per practice who were prescribed valproate and the proportion of physicians prescribing it. Covariables included gender, age, and physician. This cross-sectional study uses descriptive statistics only., Results: In total, 1,298,446 patients were followed in general and neurological practices in 2009, 1,358,160 in 2013, and 1,413,286 in 2017. The mean number of patients aged 15-45 years per practice with at least one valproate prescription decreased in neurological (men: 11.07 versus 9.92; women: 9.27 versus 5.88) and general practices (men: 0.82 versus 0.75; women: 0.60 versus 0.37) between 2009 and 2017. Moreover, the proportion of neurologists prescribing valproate in women between 15 and 45 years of age decreased over time (94% in 2009 versus 86% in 2017), and there was also a substantial decrease in the share of general practitioners prescribing valproate in men (47% versus 41%) and women between 15 and 45 years of age (37% versus 22%)., Conclusion: The proportion of men and women between 15 and 45 years of age receiving valproate decreased in neurological and general practices in Germany between 2009 and 2017., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: General practitioners (GPs) provide advice to women and couples before and during pregnancy to optimise the health and wellbeing of couples and their child. Genetic carrier screening can identify the chance of couples having children with recessively inherited genetic conditions. The 2018 federal budget announced Mackenzie's Mission, a $20 million Medical Research Future Fund project investigating how such screening could be offered to all couples who wish to access it., Objective: The aim of this paper is to discuss historical and current screening methodologies, options for individuals and couples identified as having a high chance of having a child with a genetic condition, screening guidelines, Mackenzie's Mission and the implications of carrier screening in general practice., Discussion: GPs are crucial to any population-wide genetic carrier screening program and are often the first health professional that women and couples see for preconception and early pregnancy care. Knowledge of genetic screening will be increasingly important as such programs are developed.

Background: Undescended testis (UDT) is a common condition, and parents often primarily present to general practitioners. Management in a timely fashion may reduce the risk of malignancy and infertility, Objectives: The aim of this article is to summarise the key points of assessment and management of UDT in the primary care setting. By reviewing key definitions, such as undescended, retractile, ectopic and ascending testes, we aim to provide updated information for the ongoing management of these conditions., Discussion: The exact pathophysiology of UDT is still an area of ongoing research, and there remains much controversy regarding the exact mechanisms leading to congenital and acquired UDT. Current evidence does not support the use of ultrasonography prior to referral. Hormone therapy has shown no significant benefit, and surgery remains the treatment of choice.

Background: Medication safety is an important health issue for nursing home residents (NHR). They usually experience polypharmacy and often take potentially inappropriate medications (PIM) and antipsychotics. This, coupled with a frail health state, makes NHR particularly vulnerable to adverse drug events (ADE). The value of systematic medication reviews and interprofessional co-operation for improving medication quality in NHR has been recognized. Yet the evidence of a positive effect on NHR' health and wellbeing is inconclusive at this stage. This study investigates the effects of pharmacists' medication reviews linked with measures to strengthen interprofessional co-operation on NHR' medication quality, health status and health care use., Methods: Pragmatic cluster randomised controlled trial in nursing homes in four regions of Germany. A total of 760 NHR will be recruited. Inclusion: NHR aged 65 years and over with an estimated life expectancy of at least six months. Intervention with four elements: i) introduction of a pharmacist's medication review combined with a communication pathway to the prescribing general practitioners (GPs) and nursing home staff, ii) facilitation of change in the interprofessional cooperation, iii) educational training and iv) a "toolbox" to facilitate implementation in daily practice., Analysis: primary outcome - proportion of residents receiving PIM and ≥ 2 antipsychotics at six months follow-up. Secondary outcomes - cognitive function, falls, quality of life, medical emergency contacts, hospital admissions, and health care costs., Discussion: The trial assesses the effects of a structured interprofessional medication management for NHR in Germany. It follows the participatory action research approach and closely involves the three professional groups (nursing staff, GPs, pharmacists) engaged in the medication management. A handbook based on the experiences of the trial in nursing homes will be produced for a rollout into routine practice in Germany., Trial Registration: Registered in the German register of clinical studies (DRKS, study ID DRKS00013588 , primary register) and in the WHO International Clinical Trials Registry Platform (secondary register), both on 25th January 2018.

Background: Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults., Methods: A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement., Results: A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study., Conclusions: There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated., Trial Registration: PROSPERO number CRD42017075315.

Background and Objectives: General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars., Method: Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data., Results: Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, and supervising medical students and interns., Discussion: Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

Competing Interests: Competing interests: None declared.

Introduction: Inadequate smoking cessation interventions by physicians have been attributed to lack of training, and it is generally thought that additional education will improve patient care. However, interventions aimed at increasing knowledge and practical skills only address one determinant of behavior (capability). This prospective study assessed how much a teaching session for general practitioner (GP) trainees enrolled in Vocational Training Schemes in England also affected two other determinants (motivation and opportunity) specified by the COM-B theory of behavior., Methods: Between October and December 2015, GP trainees were given a 3.5-h training session in the theory and practice of smoking cessation. Questionnaires addressed motivation, capability, and opportunities to provide evidence-based brief advice to smokers at the beginning and end of the session, and 3 months later. They also looked at the recollection of previous teaching as well as knowledge, skills, intervention frequency, and perceived barriers against providing interventions., Results: Participants (n = 123) remembered little previous training on the subject and self-reported presession knowledge was minimal. Motivation was high throughout while capability and opportunity increased considerably during the session. No further change in these parameters was noted at 3 months. The proportion of participants stating they provided evidence-based brief advice to >50% of smokers increased from 25.2% before the session to 57.7% at follow-up. Lack of time remained a commonly cited barrier., Conclusions: Training elicited an immediate and sustained effect on capability, perceived opportunity, and behavior itself. While perceived barriers referring to capability were greatly reduced, barriers referring to opportunity (eg, lack of time) persisted., Implications: This is the first study evaluating a GP training session on smoking cessation with regard to the COM-B model. In a pre-post design with 3-month follow-up, we observed substantial and sustained changes in GP trainees' perceived capability and opportunity to provide evidence-based very brief advice, and these increases were paralleled by favorable changes in practice behavior.

Introduction: General practitioners (GPs) require the necessary skills to identify potentially malignant skin lesions and refer patients in an appropriate and timely manner. We examined the impact of a single consultant delivered education session to GP trainees on their diagnosis of common skin lesions., Methods: A prospective analysis of baseline knowledge was assessed using a photographic questionnaire. A dedicated education session was delivered by a consultant plastic surgeon. Their knowledge was re-assessed after 3 months., Results: There were 23 participants. Baseline ability to correctly diagnose skin lesions improved significantly at 3 months following dedicated teaching (baseline mean 30.2%, 3-month mean 65.9%, p = 0.001). All trainees recommended that dedicated skin education should be incorporated into GP training curricula., Conclusion: Dedicated education sessions on skin lesions can improve the diagnostic accuracy of GP trainees, and we suggest that they are incorporated into the GP training curriculum.

Objective: Effective management of patients diagnosed with ototoxicity is needed to reduce hearing and balance damage which affects communication and life quality. Despite widespread recommendations to monitor and manage ototoxicity in an early and effective manner, there is limited evidence to support the actual implementation of these recommendations for affected patient groups in healthcare services across the UK with limited publications available. In this study, an online questionnaire analysed the current practice of ototoxicity management and patient pathways across the UK once the diagnosis of ototoxicity was confirmed, targeting Audiologists, ENTs/AVPs and GPs., Design: Qualitative Survey Study., Study Sample: A randomised sample of hearing services in the UK, including audiology departments; GP practices and local health settings were targeted with a total of 134 completed surveys., Results: About 72% reported the absence of ototoxicity management protocols within their centre. Results depicted great inconsistency and variation across the UK in ototoxicity management services provided, treatment modification, monitoring and referral pathways., Conclusion: Developing and advocating national guidelines are intended not only to inform clinical decision making but to provide minimum standards of care in ototoxicity management and offer greater awareness and education to improve patients' quality of life.

Background: The World Health Organization (WHO) aims to promote strategies that ensure efficacy, safety, suitability, and cost-effectiveness of medicine prescription. Health systems should design effective mechanisms to monitor prescription and rational use of medicines at all healthcare settings. This study aimed to determine and analyze prescription patterns of general practitioners and specialists in Kerman/Iran from 2005 to 2015., Methods: This is an explanatory mixed method study. Data were gathered during two phases. At the first phase, prescriptions issued by physicians during 2005-2015 were reviewed to extract information required to develop eight main prescription indicators. In the second phase, the indicators trends were presented to experts participating in expert panel to have their opinions and analyses on the data obtained in the first phase. Experts were selected based on their experience and expertise in medicine and/or health policy and/or experience in implementation of polices to promote rational use of medicines. Some experts attending the panel were a sample of physicians whose prescriptions were included in the first phase., Results: Findings revealed that two indicators of the average price of prescriptions and the maximum number of medicines in each prescription had an increasing trend over the study period. Reasons including unprecedented devaluation of the Iranian Rial and willingness of young physicians to prescribe more medications were proposed as the primary contributors to the observed increasing trends. However, other indicators including types of prescribed medicines, average number of medicines per prescription, the percentage of prescriptions with more than four medications, a percentage of encounters with a corticosteroid prescribed, a percentage of encounters with an antibiotic prescribed, and a percentage of encounters with an injection prescribed decreased in the study period. Reasons of controlling initiatives adopted by the Ministry of Health, the higher responsibility of physicians, adoption of continued medical education (CME) programs, and improved knowledge of pharmacists, physicians, and patients about irrational use of medicines were proposed by participants as the main reasons for the decreasing trend., Conclusion: Findings indicated that prescription indicators were better in Kerman than those of country average over the study period based on comparing the results of this study and others in Iran. However, they were non-desirable when compared to the international average. The number of factors contributes to the irrational use of medicines, including lack of knowledge among healthcare providers and patients, patients' misunderstanding about the efficacy of some particular medicines, the high cost of drug development and manufacturing, and unavailability of effective medicines., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Introduction: Epilepsy represents a major health problem in low- and middle-income countries where treatment gap (TG) levels are high. The reduction of epilepsy TG in the rural area of the Chaco region, Plurinational State of Bolivia, has been the aim of many projects based on the reinforcement of the primary care setting. To plan educational campaigns directed to the healthcare professionals, it is necessary to establish their baseline knowledge level. The objective of our study was to assess the baseline level of knowledge, attitudes, and practices (KAP) towards epilepsy among general practitioners (GPs) of the rural communities of the Chaco region., Methods: The study was conducted in three departments of Bolivia. All the GPs living in these areas were invited to participate in the study consisting of two training modules six months apart from each other, each with two-day duration. They answered a validated questionnaire to evaluate the KAP towards epilepsy before and after the courses., Results: Fifty GPs [30 men (60%); mean age: 32.1±5.8years] participated in the first training course. After six months, 31 GPs (62%) [19 men (61.3%); mean age: 33±5.0years] participated in the second module. Before the training, the majority of GPs declared a low level of satisfaction about their epilepsy knowledge, which improved after the courses. A change in practices was recorded after the training, with an increased confidence to manage antiepileptic treatment., Conclusion: Our study showed the significant impact of specific training programs on epilepsy among GPs., (Copyright © 2018 Elsevier Inc. All rights reserved.)

General practice has an important role within the Australian healthcare system to provide access to care and effective management of chronic health conditions. However, people with serious mental illness experience challenges associated with service access. The current paper seeks to examine drivers of access to general practice for people with common and serious mental disorders, compared with people who access care for type II diabetes, a common physical health problem managed in general practice. The Bettering the Evaluation and Care of Health (BEACH) programme provides the most comprehensive and objective measurement of general practitioner activity in Australia. Using BEACH data, this study compared general practice encounters for depression, anxiety, bipolar disorder, schizophrenia, and type II diabetes during a 10-year period between 2006 and 2016. Analysis revealed more frequent encounters for depression compared to anxiety, and a higher representation of women in encounters for bipolar disorder compared to men. The relationship between number of encounters and patient age was strongly associated with the life course and mortality characteristics associated with each disorder. The findings highlight specific challenges associated with access to primary care for people with serious mental illness, and suggest areas of focus to improve the ability of these patients to access and navigate the health system., Competing Interests: The authors have declared that no competing interests exist.

Background: The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies., Methods: General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment., Results: GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%)., Discussion: Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial's scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment., Conclusion: Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice., Trial Registration: Dutch Trial Registration NTR6089, registered September 14th 2016.

Background: There are growing calls for elder abuse screening to be conducted by a range of community-based service providers, including general practitioners (GPs), practice nurses, home care workers and lawyers. Improved screening may be a valuable first step towards improving elder abuse detection and response; however, practitioners need evidence-based strategies for screening and follow-up., Objective: This article summarises several brief screening tools for various forms of elder abuse. Screening tool properties and evidence gaps are noted. As elder abuse often requires multidisciplinary responses, initiatives to connect health, legal and other service providers are highlighted., Discussion: GPs are trusted professionals who are well placed to identify older patients at risk of, or experiencing, various forms of abuse. They should be aware of available screening tools and consider how best to incorporate them into their own practice. They also play an important role in multidisciplinary action to address elder abuse.

Background: Depression reduces individuals' function and work ability and is associated with both frequent and long-term sickness absence., Objective: Investigate if monitoring of depression course using a self-assessment instrument in recurrent general practitioner (GP) consultations leads to improved work ability, decreased job strain, and quality of life among primary care patients., Methods: Primary care patients n = 183, who worked. In addition to regular treatment (control group), intervention patients received evaluation and monitoring and used the MADRS-S depression scale during GP visit at baseline and at visits 4, 8, and 12 weeks. Work ability, quality of life and job strain were outcome measures., Results: Depression symptoms decreased in all patients. Significantly steeper increase of WAI at 3 months in the intervention group. Social support was perceived high in a significantly higher frequency in intervention group compared to control group., Conclusions: Monitoring of depression course using a self-assessment instrument in recurrent GP consultations seems to lead to improved self-assessed work ability and increased high social support, but not to reduced job strain or increased quality of life compared to TAU. Future studies concerning rehabilitative efforts that seek to influence work ability probably also should include more active interventions at the workplace.

Psoriasis affects 0.5-2% of children. Severe forms required use of systemic treatments. Few studies are published on efficiency and tolerance of systemic treatments in children. We conducted a survey in France to better understand management of children with psoriasis. A survey on childhood psoriasis management was sent by e-mail to GPs, pediatricians, and dermatologists. The survey included 384 physicians. Respectively 53.1%, 49.8%, and 83.3% of GPs, pediatricians, and dermatologists declare to have seen at least one child with psoriasis during the 3 previous months. Less than 5% of GPs and pediatricians used severity score versus 23.7% of dermatologists. If most of physicians declare to use local treatments, less than 5% of GPs and pediatricians used systemic treatments. 32.4% of dermatologists declared to use at least one systemic treatment, but only 2.9% to use the 4 systemic treatments available in France. This survey shows that only half of GPs and pediatricians see children with psoriasis, but most of dermatologists. However, the management of severe forms seems limited by the underuse of severity scores and systemic treatments. These results should stimulate dermatology societies to promote prospective studies and guidelines in young populations with psoriasis., (© 2017 Wiley Periodicals, Inc.)

Background: Active attitude toward treatment and health (ATH) leads to improved cooperation and better health outcomes in patients. Supporting it in the population of older adults is a growing need in primary care. Recognising the role of gender, health and other sociodemographic factors can help to distinguish patients who need the most assistance in activation from general practitioners (GPs). The objective of the study was to investigate gender differences in ATH as well as the moderating role of self-assessed health (SAH) and selected sociodemographic factors (age, education, financial status, marital status)., Methods: A cross-sectional, multicentre study among 4936 primary care older patients (aged 50+) was conducted. The PRACTA-Attitude toward Treatment and Health questionnaire (PRACTA-ATH) was used to measure the cognitive, emotional (positive and negative affect), and motivational dimensions of ATH. Patients were approached before and after their visits in the primary health-care facilities randomly selected in Central Poland., Results: Generalised linear models (GENLIN) revealed the main effects of gender, SAH, and sociodemographic characteristics, such as financial status, marital status and education. Interaction effects of gender and age (Wald's χ 2  = 24.767, p < 0.001 for ATH Global), as well as gender and SAH (Wald's χ 2  = 16.712, p < 0.002 for ATH Global) on ATH were found. The most assistance in regard to ATH was required by men aged 50-74 and men declaring good self-assessed health. Generally, women declared a more active attitude than men, showing more knowledge (M = 5.40, SD = 0.07 and M = 5.21, SD = 0.07, for women and men, respectively, p = 0.046), positive emotion (M = 5.55, SD = 0.06 and M = 5.33, SD =0.06, for women and men, respectively, p = 0.015) and motivation to be involved in their health issues (M = 5.71, SD = 0.07 and M = 5.39, SD = 0.07, for women and men, respectively, p = 0.001). The level of negative emotions related to health was not significantly different between genders (p = 0.971)., Conclusions: The need to create health promoting programmes taking account of particular gender differences in older adults emerges. In regard to clinical practice, building a sense of efficacy and individual responsibility for health, providing information about the means of health promotion and prevention, and recognising health-related cognitions, is recommended especially for men who feel well and are less advanced in age (50-74).

Aims: The aims of the present study were to examine the prevalence of high-risk prescribing (HRP) in community-dwelling adults in Ireland from 2011-2015 using consensus-validated indicators, factors associated with HRP, and the variation in HRP between general practitioners (GPs) and in the dispensing of high-risk prescriptions between pharmacies., Methods: A repeated cross-sectional national pharmacy claims database study was conducted. Prescribing indicators were based on those developed in formal consensus studies and applicable to pharmacy claims data. Multilevel logistic regression was used to examine factors associated with HRP and dispensing., Results: There were significant reductions in the rates of most indicators over time (P < 0.001). A total of 66 022 of 300 906 patients at risk in 2011 [21.9%, 95% confidence interval (CI) 21.8, 22.1%], and 42 109 of 278 469 in 2015 (15.1%, 95% CI 15.0, 15.3%), received ≥1 high-risk prescription (P < 0.001). In 2015, indicators with the highest rates of HRP were prescription of a nonsteroidal anti-inflammatory drug (NSAID) without gastroprotection in those ≥75 years (37.2% of those on NSAIDs), coprescription of warfarin and an antiplatelet agent or high-risk antibiotic (19.5% and 16.2% of those on warfarin, respectively) and prescription of digoxin ≥250 μg day -1 in those ≥65 years (14.0% of those on digoxin). Any HRP increased significantly with age and number of chronic medications (P < 0.001). a) After controlling for patient variables, the variation in the rate of HRP between GPs was significant (P < 0.05); and b) after controlling for patient variables and the prescribing GP, the variation in the rate of dispensing of high-risk prescriptions between pharmacies was significant (P < 0.05)., Conclusions: HRP in Ireland has declined over time, although some indicators persist. The variation between GPs and pharmacies suggests the potential for improvement in safe medicines use in community care, particularly in vulnerable older populations., (© 2017 The British Pharmacological Society.)

Background: Practice-based research networks (PBRNs) are collaborations between clinical practitioners and academics. PBRNs aim to foster research in general practice through opportunities to learn more about how to undertake and participate in research, and assist in translating new knowledge into practice. Critically, PBRNs also offer clinicians the chance to contribute to research by posing questions of importance to quality clinical care., Objective: The objectives of this article are to describe why PRBNs are needed, the current situation regarding PBRNs in Australia, and why Australian general practice and patient outcomes could benefit from further investment in PBRNs., Discussion: PBRNs may assist by engaging more general practitioners (GPs) in the research process, thereby increasing the relevance of the research questions posed to the outcomes of the population GPs work within. Unlike similar countries (eg UK and The Netherlands), Australia no longer has any funding to support the activities of primary-care based PBRNs.

Background: Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations - specifically GP cooperatives and walk-in clinics., Methods: Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline., Results: Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices., Conclusion: GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Erectile dysfunction is a common but often neglected condition. Prevalence increases with age, but is not insignificant in younger men., Objective: This article will broadly describe the epidemiology, classification and risk factors of erectile dysfunction. It will also discuss assessment and current treatment modalities, with a particular focus on the unique role of the general practitioner (GP)., Discussion: Erectile dysfunction may be classified as vasculogenic, neurogenic, endocrinological, drug-related, psychogenic or mixed. Commonly, erectile dysfunction is a cause of anxiety and even depression. Risk factors, such as smoking and hypertension, and reversible causes, such as hypogonadism or offending medications, should be addressed. At present, oral pharmacotherapy represents the first-line option for most patients with erectile dysfunction. It is of utmost importance to evaluate and treat comorbidities, such as depression, metabolic syndrome and cardiovascular disease, that often accompany erectile dysfunction. Patients will undoubtedly benefit from comprehensive management by a dedicated GP. Occasionally, referral to a urologist, psychologist or sexual health physician may be required.

Background: Peyronie's disease is a relatively common condition in urological practice, but is still poorly identified and understood in the wider medical community and by most of the public. Identifying the condition and appropriate referral for expert opinion can significantly lessen the physical and psychological effect on patients., Objective: The objective of this article is to provide general practitioners with a concise and updated review of Peyronie's disease, with the aim of helping them to provide appropriate advice to their patients., Discussion: Peyronie's disease is an aberrant wound healing process culminating in excess scar formation in the penis, which may cause penile pain, shortening and curvature. It is often accompanied by erectile dysfunction, and can result in progressive and severe impairment of penetrative intercourse. The course of the disorder is divided into active inflammatory and chronic stable phases. Oral therapy is usually of limited efficacy, while penile traction may only be beneficial in motivated patients. Intralesional injections of collagenase were recently introduced as a non-surgical measure to decrease penile curvature. Surgery remains the most effective treatment for Peyronie's disease and is considered the gold standard.

Background: Upper urinary tract stones are a common problem in Australia, with an incidence of 0.13% per year, and a lifetime prevalence of up to 15% in males and 8% in females. Many of these patients first present to general practitioners (GPs), so a thorough understanding of the diagnosis, treatment and prevention of stone disease is an important part of any GP's arsenal., Objective: In this article, we present evidence-based guidelines regarding urolithiasis, from diagnosis, through to conservative and operative management, and prevention, as a reference for GPs and other primary care physicians., Discussion: The majority of urolithiasis cases can be conservatively managed. However, prior to conservative management, adequate imaging must be obtained and emergent conditions must be excluded. Conservative management should not be initiated without a plan in the event the management fails, and adequate analgesia and medical expulsive therapy should be prescribed. Should surgery be necessary, the majority of operations can be performed as minimally invasive day procedures.

Background For the past several years pharmacists' responsibilities have expanded globally from traditional tasks of dispensing medications to collaborating with other health care professionals in patient care. Similar developments have not occurred in outpatient settings in Iceland. Objective The aim of this study was to explore Icelandic general practitioners' views on the current status of primary care, their perceptions of pharmacists as a health care profession, and their attitudes towards future GP-pharmacist collaboration in primary care in Iceland. Setting Twelve primary care clinics in Iceland. Methods Semi-structured in-depth interviews were conducted with general practitioners from different primary care clinics in Iceland. A purposive and snowball sampling technique was used to select participants. All interviews were recorded and transcribed verbatim. The transcripts were categorized by themes and then analyzed using conventional content analysis. Main outcome measure General practitioners' attitudes towards pharmacists. Results Twenty general practitioners from twelve different primary care clinics in Iceland were interviewed. There are several unmet needs regarding medicines and patient monitoring in the Icelandic health care system. General practitioners suggested ways in which these gaps may be addressed and pharmacist-led clinical service was one of the suggestions. Currently, their communication with pharmacists in the primary sector solely surrounds practical non-clinical issues. Due to increasing polypharmacy and multimorbidity, they suggested that pharmacists should be more involved in patient care. Conclusions General practitioners believe that pharmacist-led clinical service can increase the quality of patient therapy. To improve communication between these health care providers, pharmacists must also re-professionalize (strengthening the profession´s status through new responsibilities and tasks), not having a conflict of interest and showing that they have expertise in patient care.