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Background: Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs. Methods: A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs. Results: Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4–13] to 5 [0–11] vs 8 [3–13] to 7 [3–12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0–3] to 1 [0–2] vs 1 [0–2] to 1 [0–3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of − £229.0 (95% CI − 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI − 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017). Conclusion: The pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner. Trial registration: ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498

MSS1 and MSS2 were supported by grants from the Chief Scientist Office of the Scottish Government (references CZG/2/412 and CZH/4/945). We are grateful to the general practitioners and patients who participated in these studies. ; Peer reviewed ; Postprint

The role of the general practitioner in the care of mentally disturbed non institutionalised persons aged 20 years and older was examined. Data were based on the representative community sample of the Upper Bavarian Field Study with a sample size of 1495 interviewees — aged 20 years and older. The 5-year prevalence of mental illness according to the definition used was 32.8%. 38.5% of all persons, identified as cases, consulted their general practitioner because of psychiatric or emo tional problems. Females and the elderly were most likely to have received treatment by their general practitioner. The majority of treated persons were neurotic and psychosomatic patients. The general practitioner provided care for more psychiatric patients than the psychiatrist and for 25% of all "cases", without additional psychiatric consultation.

Background : Spouse abuse constitutes a real public health issue. Recently highlighted during the " Grenelle des violences conjugales" in 2019, it is currently at the center of several discussions between actors from the political, social, judicial, associative and health professional spheres. Reunion island was the third most affected region by spouse abuse in 2017. The general practitioner, who is often consulted by victims as a first resort, is a key element in the care process. The study's objective was to determine how the general practitioner deals with situations of spouse abuse in Reunion island.Method : Qualitative study with a grounded theorizing approach. The study involved 14 interviews with general practitioners in different Reunion Island's areas.Results : The open analysis and initial tagging led to a one hundred codes' book. The analysis of these codes revealed 5 categories: receiving the revelation of conjugal violence, being able to orientate, having the audacity to approach the subject, practicing in Reunion Island and developing one's practice. The results were modeled in schematic form, thus providing a better understanding of the processes involved and the general practitioner's specific needs.Conclusion : Aware of the subject of domestic violence, the general practitioner possesses good theoretical knowledge, but may sometimes feel isolated. In order to create or enhance links with the other partners of the network, we propose a tool for helping the general practitioners in their practice in Reunion island. ; Introduction : Les violences conjugales constituent un véritable enjeu de santé publique. Récemment mis en avant lors du Grenelle des violences conjugales en 2019, elles sont actuellement au centre de plusieurs discussions entre des acteurs politiques, sociaux, judiciaires, associatifs et professionnels de santé. En 2017, La Réunion se situait à la troisième place des régions les plus touchées par les violences conjugales.Souvent consulté en premier recours par les victimes, le médecin généraliste est un acteur central dans la prise en charge. L'objectif de cette étude était de déterminer comment le médecin généraliste prend en charge des situations de violences conjugales à la Réunion.Méthode : Étude qualitative avec une approche par la théorisation ancrée. Elle a donné lieu à la réalisation de 14 entretiens auprès de médecins généralistes installés dans différents secteurs de l'île de la Réunion. Résultats : L'analyse ouverte et l'étiquetage initial ont permis de réaliser un livre de 100 codes. L'analyse de ces codes a permis de faire émerger 5 catégories : accueillir la révélation de violences conjugales, pouvoir orienter, oser aborder le sujet, exercer à la Réunion et faire évoluer sa pratique. Ces résultats ont été modélisés sous la forme de schéma, ce qui permet de mieux appréhender les processus mis en jeu et les besoins du médecin généraliste. Conclusion : Sensibilisé au sujet des violences conjugales, le médecin généraliste possède de bonnes connaissances théoriques, mais peut parfois se sentir isolé. Afin de créer ou de renforcer des liens avec les partenaires du réseau, nous proposons de fournir aux médecins généralistes un outil d'aide à la pratique spécifique à La Réunion.

Background : Spouse abuse constitutes a real public health issue. Recently highlighted during the " Grenelle des violences conjugales" in 2019, it is currently at the center of several discussions between actors from the political, social, judicial, associative and health professional spheres. Reunion island was the third most affected region by spouse abuse in 2017. The general practitioner, who is often consulted by victims as a first resort, is a key element in the care process. The study's objective was to determine how the general practitioner deals with situations of spouse abuse in Reunion island.Method : Qualitative study with a grounded theorizing approach. The study involved 14 interviews with general practitioners in different Reunion Island's areas.Results : The open analysis and initial tagging led to a one hundred codes' book. The analysis of these codes revealed 5 categories: receiving the revelation of conjugal violence, being able to orientate, having the audacity to approach the subject, practicing in Reunion Island and developing one's practice. The results were modeled in schematic form, thus providing a better understanding of the processes involved and the general practitioner's specific needs.Conclusion : Aware of the subject of domestic violence, the general practitioner possesses good theoretical knowledge, but may sometimes feel isolated. In order to create or enhance links with the other partners of the network, we propose a tool for helping the general practitioners in their practice in Reunion island. ; Introduction : Les violences conjugales constituent un véritable enjeu de santé publique. Récemment mis en avant lors du Grenelle des violences conjugales en 2019, elles sont actuellement au centre de plusieurs discussions entre des acteurs politiques, sociaux, judiciaires, associatifs et professionnels de santé. En 2017, La Réunion se situait à la troisième place des régions les plus touchées par les violences conjugales.Souvent consulté en premier recours par les victimes, le médecin généraliste est un acteur central dans la prise en charge. L'objectif de cette étude était de déterminer comment le médecin généraliste prend en charge des situations de violences conjugales à la Réunion.Méthode : Étude qualitative avec une approche par la théorisation ancrée. Elle a donné lieu à la réalisation de 14 entretiens auprès de médecins généralistes installés dans différents secteurs de l'île de la Réunion. Résultats : L'analyse ouverte et l'étiquetage initial ont permis de réaliser un livre de 100 codes. L'analyse de ces codes a permis de faire émerger 5 catégories : accueillir la révélation de violences conjugales, pouvoir orienter, oser aborder le sujet, exercer à la Réunion et faire évoluer sa pratique. Ces résultats ont été modélisés sous la forme de schéma, ce qui permet de mieux appréhender les processus mis en jeu et les besoins du médecin généraliste. Conclusion : Sensibilisé au sujet des violences conjugales, le médecin généraliste possède de bonnes connaissances théoriques, mais peut parfois se sentir isolé. Afin de créer ou de renforcer des liens avec les partenaires du réseau, nous proposons de fournir aux médecins généralistes un outil d'aide à la pratique spécifique à La Réunion.

Background: Information on self-management, including addressing people?s fears and concerns, are core aspects of managing patients with low back pain (LBP). Web apps with patient information may be used to extend patient-physician consultations and encourage self-management outside of the consultation room. It is, however, important to identify the end users? needs and preferences in order to maximize acceptance. Objective: The aim of this study was to identify preferences for the content, design, and functionality of a Web app with evidence-based information and advice for people with LBP in Denmark. Methods: This is a phenomenological qualitative study. Adults who had consulted their general practitioner because of LBP within the past 14 days were included. Each participated in a semistructured interview, which was audiotaped and transcribed for text condensation. Interviews were conducted at the participant?s home by 2 interviewers. Participants also completed a questionnaire that requested information on age, gender, internet usage, interest in searching new knowledge, LBP-related function, and pain. Results: Fifteen 45-min interviews were conducted. Participants had a median age of 40 years (range 22-68 years) and reported a median disability of 7 points (range 0-18) using the 23-item Roland Morris Disability Questionnaire. Participants reported that Web-based information should be easy to find and read, easily overviewed, and not be overloaded with information. Subjects found existing Web-based information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies or organizations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy and preferred site when searching for information and advice regarding LBP. Conclusions: This study identified important issues to consider when developing and supplementing existing general practice treatment with ...

BACKGROUND: Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs. METHODS: A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs. RESULTS: Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4–13] to 5 [0–11] vs 8 [3–13] to 7 [3–12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0–3] to 1 [0–2] vs 1 [0–2] to 1 [0–3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of − £229.0 (95% CI − 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI − 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017). CONCLUSION: The pharmacist service was effective in reducing MRPs, inappropriateness of ...

BACKGROUND: Information on self-management, including addressing people's fears and concerns, are core aspects of managing patients with low back pain (LBP). Web apps with patient information may be used to extend patient-physician consultations and encourage self-management outside of the consultation room. It is, however, important to identify the end users' needs and preferences in order to maximize acceptance. OBJECTIVE: The aim of this study was to identify preferences for the content, design, and functionality of a Web app with evidence-based information and advice for people with LBP in Denmark. METHODS: This is a phenomenological qualitative study. Adults who had consulted their general practitioner because of LBP within the past 14 days were included. Each participated in a semistructured interview, which was audiotaped and transcribed for text condensation. Interviews were conducted at the participant's home by 2 interviewers. Participants also completed a questionnaire that requested information on age, gender, internet usage, interest in searching new knowledge, LBP-related function, and pain. RESULTS: Fifteen 45-min interviews were conducted. Participants had a median age of 40 years (range 22-68 years) and reported a median disability of 7 points (range 0-18) using the 23-item Roland Morris Disability Questionnaire. Participants reported that Web-based information should be easy to find and read, easily overviewed, and not be overloaded with information. Subjects found existing Web-based information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies or organizations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy and preferred site when searching for information and advice regarding LBP. CONCLUSIONS: This study identified important issues to consider when developing and supplementing existing general practice treatment with Web-based information and advice for patients with LBP. Development of a Web app should consider patient input, and developers should carefully address the following domains: readability, customization, design, credibility, and usability.

IntroductionRegular contact with a general practitioner (GP) has been shown to lower the risk of potentially avoidable hospitalisations (PAHs) independently of continuity of provider and frequency of contact. Multimorbidity affects between 55 and 98% people aged 65+ years and continues to place pressure on healthcare systems globally. However, little is known about its impact on the relationship between continuity of primary care and PAHs.
Objectives and ApproachA retrospective, longitudinal cohort study using survey data linked to routinely-collected administrative health data from the 45 and Up Study conducted in New South Wales, Australia was used to investigate the effect measure modification by multimorbidity on the relationship between regularity of GP contact and PAHs.
Multimorbidity was assessed using the Rx-Risk comorbidity score, which captures the number of condition groups, assigned based on medicine dispensing records, using a 5-year look-back period. PAHs were: (i) any unplanned hospitalisations, (ii) chronic ambulatory care sensitive conditions (ACSC) hospitalisations or (iii) unplanned ACSC hospitalisations. Multivariable logistic regression and population attributable fractions (PAF) were used to examine effect measure modification by multimorbidity.
ResultsHigher GP regularity was significantly associated with a reduction in the probability of each PAH type. This reduction diminished with increasing multimorbidity with the effect measure modification most apparent for chronic ACSC and unplanned chronic ACSC hospitalisations. The PAF of moving to the highest quintile of regularity significantly reduced with increasing multimorbidity. For example, a reduction in the PAF of unplanned ACSC hospitalisations of 31.1% was observed in those with a RX Risk score of >10 (17.8%) compared with those with no multimorbidity (48.9%).
Conclusion / ImplicationsWeakening of the relationship between GP visit regularity and PAHs with increasing levels of multimorbidity suggests a need to focus on improving primary care support to prevent PAHs for patients with multimorbidity.

Background Transthyretin amyloidosis (also known as ATTR amyloidosis) is a systemic, life-threatening disease characterized by transthyretin (TTR) fibril deposition in organs and tissue. A definitive diagnosis of ATTR amyloidosis is often a challenge, in large part because of its heterogeneous presentation. Although ATTR amyloidosis was previously considered untreatable, disease-modifying therapies for the treatment of this disease have recently become available. This article aims to raise awareness of the initial symptoms of ATTR amyloidosis among general practitioners to facilitate identification of a patient with suspicious signs and symptoms. Methods These consensus recommendations for the suspicion and diagnosis of ATTR amyloidosis were developed through a series of development and review cycles by an international working group comprising key amyloidosis specialists. This working group met to discuss the barriers to early and accurate diagnosis of ATTR amyloidosis and develop a consensus recommendation through a thorough search of the literature performed using PubMed Central. Results The cardiac and peripheral nervous systems are most frequently involved in ATTR amyloidosis; however, many patients often also experience gastrointestinal and other systemic manifestations. Given the multisystemic nature of symptoms, ATTR amyloidosis is often misdiagnosed as a more common disorder, leading to significant delays in the initiation of treatment. Although histologic evaluation has been the gold standard to confirm ATTR amyloidosis, a range of tools are available that can facilitate early and accurate diagnosis. Of importance, genetic testing should be considered early in the evaluation of a patient with unexplained peripheral neuropathy. Conclusions A diagnostic algorithm based on initial red flag symptoms and manifestations of cardiac or neurologic involvement will facilitate identification by the general practitioner of a patient with clinically suspicious symptoms, enabling subsequent referral of the patient to a multidisciplinary specialized medical center.

BACKGROUND. The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM. A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD. Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS. The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION. The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of ...