Patients repeatedly removed from GP lists: a mixed methods study of "revolving door" patients in general practice

Introduction: Patients who have been repeatedly removed from General Practice (GP) lists, so-called “revolving door” patients in general practice have not been examined in the literature. This mixed methods study sought to define and characterise “revolving door” patients in general practice in Scotland. It investigated the impact they had on the NHS and the impact this status may have on “revolving door” patients themselves. Methods: Thirteen semi-structured interviews with Practitioner Services and GP professional key informants and one “ex-revolving door” patient were conducted and analysed using a Charmazian grounded theory approach. Patient removal data from the Community Health Index were used to construct cohorts of “revolving door” patients and link them with routine NHS data on hospital admissions, outpatient attendances and drug misuse treatment episodes. These data were analysed quantitatively and qualitatively and all the data were integrated dialectically. Results: “Revolving door” patients were removed four or more times from GP lists in six years. There was a dramatic decline in the number of “revolving door” patients in Scotland whilst the study was conducted. It appeared this was because the NHS response altered due to changes in approaches to treating problem drug use and pressure to reduce removal activity from professional bodies. The final influence was the positive, ethical, regulatory, and financial climate of the 2004 General Medical Services contract. “Revolving door” patients had three necessary characteristics: unreasonable expectations of what the National Health Service had to offer, inappropriate behaviour and unmet health needs. Problem substance use and psychiatric health problems were important. Professionals who came into contact with “revolving door” patients found it a difficult experience and they generated a lot of work. Being a “revolving door” patient impacted on the quality of care that patients received in general practice in terms of relational, informational and management continuity of care. “Revolving door” patients were more likely to be admitted to hospital after they have been removed from a GP list and more likely to be referred for addiction care after they were re-registered. Conclusions: It was the status of being repeatedly removed from GP lists that set “revolving door” patients apart from the usual general practice population. I suggest that GPs were able to suspend their core values and remove “revolving door” patients because the legitimate work of general practice was challenged. There were two ways in which this may happen. The first was that “revolving door” patient’s dominant health needs were not viewed as biomedical because they contained aspects of a moral schema of understanding. The second was that their behaviour or expectations threatened the doctor-patient relationship. These were features common to other patients reviewed in the literature on problem doctor-patient relationships. “Revolving door” patients did not understand the unwritten rules of the doctor-patient relationship; so removing them from GP lists did not change their behaviour. Current theories about personality disorder and adult attachment should be integrated into the work of general practice and further researched in this context. This might help GPs and patients to improve problem doctor-patient relationships

A systematic review of interventions by healthcare professionals to improve management of non-communicable diseases and communicable diseases requiring long-term care in adults who are homeless

Objective: Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults. Design: Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before–after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria. Data sources: Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors. Setting: Community. Participants: Adults (≥18 years) fulfilling European Typology of Homelessness criteria. Intervention: Delivered by healthcare professionals managing NCD and LT-CDs. Outcomes: Primary outcome: unscheduled healthcare utilisation. Secondary outcomes: mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, self-efficacy, quality of life and cost-effectiveness. Results: 11 studies were included (8 RCTs, 2 quasi-experimental and 1 feasibility) involving 9–520 participants (67%–94% male, median age 37–49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality. Conclusions: Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational case-management interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness

Interventions by healthcare professionals to improve management of physical long-term conditions in adults who are homeless: a systematic review protocol

Introduction People experiencing homelessness are at increased risk of, and have poorer outcomes from, a range of physical long-term conditions (LTCs). It is increasingly recognised that interventions targeting people who are homeless should be tailored to the specific needs of this population. This systematic review aims to identify, describe and appraise trials of interventions that aim to manage physical LTCs in homeless adults and are delivered by healthcare professionals. Methods and analysis Seven electronic databases (Medline, EMBASE, Cochrane Central Register of Controlled Trials, Assia, Scopus, PsycINFO and CINAHL) will be searched from 1960 (or inception) to October 2016 and supplemented by forward citation searching, handsearching of reference lists and searching grey literature. Two reviewers will independently review titles, abstract and full-texts using DistillerSR software. Inclusion criteria include (1) homeless adults with any physical LTC, (2) interventions delivered by a healthcare professional (any professional trained to provide any form of healthcare, but excluding social workers and professionals without health-related training), (3) comparison with usual care or an alternative intervention, (4) report outcomes such as healthcare usage, physical and psychological health or well-being or cost-effectiveness, (5) randomised controlled trials, non-randomised controlled trials, controlled before-after studies. Quality will be assessed using the Cochrane EPOC Risk of Bias Tool. A meta-analysis will be performed if sufficient data are identified; however, we anticipate a narrative synthesis will be performed. Ethics and dissemination This review will synthesise existing evidence for interventions delivered by healthcare professionals to manage physical LTCs in adults who are homeless. The findings will inform the development of future interventions and research aiming to improve the management of LTCs for people experiencing homelessness. Ethical approval will not be required for this systematic review as it does not contain individual patient data. We will disseminate the results of this systematic review via conference presentations, healthcare professional networks, social media and peer-reviewed publication

The effects of model resolution on the South Asian and West African monsoons in the Pliocene

The Pliocene Epoch (5.33 – 2.58 Million years ago) is currently being used as a future climate change analogue due to CO2 levels during this time which are close to those of the present day, similar continental configuration between the two and a wealth of paleoenvironmental proxy data available. However, most model simulations involving the Pliocene are run at coarse resolution and include many boundary condition changes from the present day. This thesis examines the effects of increased model resolution on the Pliocene climate using an atmosphere-only, spectral global climate model (the IGCM4) with the sea surface temperature field as the only boundary condition change between Pliocene and present day. Using the present day as a control experiment, basic state differences between the Pliocene and present day are explored. Then, a step-change approach is utilised: first, the dynamical resolution of the model is increased while the topography field remains constant (at low resolution). A further step follows to additionally increase the resolution of topography (to high resolution), in order to separate these two effects of increased resolution. Two monsoon systems are examined - the South Asian monsoon (SAM) and the West African monsoon (WAM). Dynamical differences are found between Pliocene and present day for the SAM region, affecting monsoonal circulation. A northward shift in climatic features is observed with increased dynamical resolution, while the effects of topographic resolution are confined to the immediate area surrounding certain topographic features. Resolution effects are found to have varying effects regionally, with dynamical resolution generally being more important than topography

Core intended learning outcomes for tackling health inequalities in undergraduate medicine Curriculum development

© 2015 Williamson et al.; licensee BioMed Central. Background: Despite there being a concerted effort in recent years to influence what doctors can do to tackle health inequalities in the UK, there has been limited policy focus on what undergraduate students need to learn at medical school in preparation for this. This project led by members of the Health Inequalities Group of the Royal College of General Practitioners in collaboration with the Institute of Health Equity, University College London sought to fill this gap. Discussion: We conducted a Delphi poll using our teaching and stakeholder networks. We identified 5 areas for learning focusing on key knowledge and skills. These were population concepts, health systems, marginalised patient groups, cultural diversity and ethics. Summary: These intended learning outcomes about health inequalities represent the best available evidence to date for colleagues seeking to develop core undergraduate medical curricula on the topic

Health-care resource use among patients who use illicit opioids in England, 2010–20: A descriptive matched cohort study

Background and aims: People who use illicit opioids have higher mortality and morbidity than the general population. Limited quantitative research has investigated how this population engages with health-care, particularly regarding planned and primary care. We aimed to measure health-care use among patients with a history of illicit opioid use in England across five settings: general practice (GP), hospital outpatient care, emergency departments, emergency hospital admissions and elective hospital admissions. // Design: This was a matched cohort study using Clinical Practice Research Datalink and Hospital Episode Statistics. // Setting: Primary and secondary care practices in England took part in the study. // Participants: A total of 57 421 patients with a history of illicit opioid use were identified by GPs between 2010 and 2020, and 172 263 patients with no recorded history of illicit opioid use matched by age, sex and practice. // Measurements: We estimated the rate (events per unit of time) of attendance and used quasi-Poisson regression (unadjusted and adjusted) to estimate rate ratios between groups. We also compared rates of planned and unplanned hospital admissions for diagnoses and calculated excess admissions and rate ratios between groups. // Findings: A history of using illicit opioids was associated with higher rates of health-care use in all settings. Rate ratios for those with a history of using illicit opioids relative to those without were 2.38 [95% confidence interval (CI) = 2.36–2.41] for GP; 1.99 (95% CI = 1.94–2.03) for hospital outpatient visits; 2.80 (95% CI = 2.73–2.87) for emergency department visits; 4.98 (95% CI = 4.82–5.14) for emergency hospital admissions; and 1.76 (95% CI = 1.60–1.94) for elective hospital admissions. For emergency hospital admissions, diagnoses with the most excess admissions were drug-related and respiratory conditions, and those with the highest rate ratios were personality and behaviour (25.5, 95% CI = 23.5–27.6), drug-related (21.2, 95% CI = 20.1–21.6) and chronic obstructive pulmonary disease (19.4, 95% CI = 18.7–20.2). // Conclusions: Patients who use illicit opioids in England appear to access health services more often than people of the same age and sex who do not use illicit opioids among a wide range of health-care settings. The difference is especially large for emergency care, which probably reflects both episodic illness and decompensation of long-term conditions

Non-attending patients in general practice

Non peer reviewedPublisher PD

Prescribing patterns for medical treatment of suspected prostatic obstruction:a longitudinal register-based study of the Scottish Health and Social Care Open Data

Background: The diagnosis of lower urinary tract symptoms related to suspected bladder outflow obstruction from benign prostate hyperplasia/enlargement in men is increasing. This is leading to high demand on healthcare services; however, there is limited knowledge of differences in pharmacotherapy prescribing for this condition based on geography. Objective: To investigate potential variation in drug prescribing for suspected bladder outflow obstruction in Scotland, based on analysis of publicly available data, to identify trends and inform future prescribing. Study design: A longitudinal register-based data study of prescribing and patient data publicly available from Scottish registries. All information is available as monthly aggregates at the level of single general practices. Setting and participants: 903 (97%) general practices in Scotland, over a 50-month period (October 2015 to November 2019). Outcome measurements and statistical analysis: We analysed numbers of daily doses of drugs for suspected bladder outflow obstruction prescribed per month using a Bayesian Poisson regression analysis, incorporating random effects to account for spatial and temporal elements. Results: Prescriptions for suspected bladder outflow obstruction medications increased during the observation period (overall average rate of change 1.24±0.28, ranging from 0.893 in Orkney to 1.95 in Lanarkshire). While some determinants of health inequality regarding prescribing practices across health boards are consistent with those known from the literature, other inequalities remain unexplained after accounting for practice-specific and patient-specific characteristics such as deprivation and rurality. Conclusions: Inequalities in prescribing for suspected bladder outflow obstruction medications exist in Scotland, partially ascribable to accepted sociodemographic and geographic factors

A change model for GPs serving deprived areas

No abstract available

The complex network of global cargo ship movements

Transportation networks play a crucial role in human mobility, the exchange of goods, and the spread of invasive species. With 90% of world trade carried by sea, the global network of merchant ships provides one of the most important modes of transportation. Here we use information about the itineraries of 16,363 cargo ships during the year 2007 to construct a network of links between ports. We show that the network has several features which set it apart from other transportation networks. In particular, most ships can be classified in three categories: bulk dry carriers, container ships and oil tankers. These three categories do not only differ in the ships' physical characteristics, but also in their mobility patterns and networks. Container ships follow regularly repeating paths whereas bulk dry carriers and oil tankers move less predictably between ports. The network of all ship movements possesses a heavy-tailed distribution for the connectivity of ports and for the loads transported on the links with systematic differences between ship types. The data analyzed in this paper improve current assumptions based on gravity models of ship movements, an important step towards understanding patterns of global trade and bioinvasion.Comment: 7 figures Accepted for publication by Journal of the Royal Society Interface (2010) For supplementary information, see http://www.icbm.de/~blasius/publications.htm