Consultation contexts and the acceptability of alcohol enquiry from general practitioners - a survey experiment

Background: General practitioners have a crucial role in detecting risky drinking in patients. However, little is known about how the context of the consultation affect patient acceptability of these discussions. Methods: During one week in May 2014, adult patients seen at a community general practice in Sydney were randomised to receive one of two postal questionnaires. Participants rated the acceptability of alcohol enquiry in 20 vignettes of general practice consultations, either within a SNAP (smoking, nutrition, alcohol, physical activity) framework (intervention) or alone (control). Results: Of the 441 patients who received the questionnaires, 144 returned completed and returned it. The intervention group rated an additional 2.1 (95% CI = 0.38-3.7, P = 0.016) vignettes as acceptable compared to the control group. Alcohol enquiry acceptability varied greatly between individual scenarios. Discussion: Alcohol-use assessment may be more acceptable to patients when it is framed within the SNAP framework, especially in certain presentations (eg diabetes management)

Online training in evidence-based medicine and research methods for GP registrars: a mixed-methods evaluation of engagement and impact

Abstract Background Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients’ care. Online EBM education could improve clinicians’ skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars (trainees in specialist general practice). We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods). Methods Mixed-method data collection was conducted after individual registrars’ completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016–2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews. Results The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen’s d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences. Conclusions This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor’s role on GP registrars’ ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Patients\u27 acceptance of SNAP assessment: An exploration

We previously described in Australian Family Physician a survey experiment that demonstrated patients\u27 acceptance of alcohol enquiry from their general practitioners (GPs) varied markedly depending on the reason for the initial presentation.1 A further qualitative study identified that the acceptability of these discussions was influenced by their perceived relevance. For many patients, this \u27was determined by whether the presenting complaint was seen to be an issue affected by alcohol drinking\u27.2 Is this finding isolated to assessment of drinking, or does it apply to other SNAP (smoking, nutrition, alcohol, physical activity) risk factors?3 Methods We re-analysed data from the 66 questionnaire respondents from the intervention arm of the original survey experiment.1 In brief, the participants were adult patients who attended a general practice in Sydney, Australia in 2014. Two-thirds of the participants were female and the mean age was 53.6 years. Full demographics are available in the original paper.1 These participants rated the acceptability of GP enquiry (\u27unacceptable\u27, \u27ambivalent\u27 or \u27acceptable\u27) of each of the four SNAP factors to 20 clinical vignettes. The vignettes were simple, written to a fifth grade student reading level,1 and based on the most frequent reasons for encounter and problems managed in Australian general practice.4 We ranked the vignette acceptability data and reported them descriptively. We used Friedman\u27s two-way analysis of variance (ANOVA) by ranks to analyse the differences in SNAP factor acceptability within the vignettes, and Wilcoxon signed rank test between specific factors (IBM SPSS Statistics 23). This study was approved by the University of New South Wales\u27s (UNSW\u27s) Human Research Ethics Committee (reference number HC14074). Results The variation in the acceptance of GP enquiry to all four SNAP factors was substantial, ranging from half of participants (least acceptable vignettes) to all (most acceptable; Table 1). There were variations in SNAP factor acceptability within the vignettes. The vignettes where these differences were statistically significant (P ≤ 0.05) were: cough, sore throat, back pain, skin rash, depression, diabetes, arthritis, high lipids, gastro-oesophageal reflux disease (GORD), bronchitis, asthma and urinary tract infection. For example, while all participants reported smoking enquiry was acceptable in the asthma vignette, 85%, 81% and 92% did so for nutrition, alcohol and physical activity enquiry respectively (P \u3c 0.0001). Discussion Patients\u27 acceptance of GP enquiry for all four SNAP factors seems to vary depending on the reason for presentation. Ensuring that patients understand why we are interested in these issues may be a useful strategy; for instance, explicitly linking SNAP assessment to the presenting complaint.1,

Australian general practitioner perceptions of the detection and screening of at-risk drinking, and the role of the AUDIT-C: a qualitative study

Background: At-risk drinking is common in Australia. Validated screening tools such as the AUDIT-C have been promoted to general practitioners (GPs), but appear rarely used and detection of at-risk drinking in primary care remains low. We sought to describe Australian GP perceptions of the detection and screening of at-risk drinking; to understand their low uptake of alcohol screening questionnaires, and in particular, their attitude to the adoption of the AUDIT-C. Methods. Semi-structured focus group interviews of four groups of GPs and GP trainees were conducted in metropolitan Sydney between August and October 2011. Audio recordings were transcribed and analysed using grounded theory methodology. Results: We identified four main themes: there was consensus that detecting at-risk drinking is important but difficult to do, social and cultural attitudes to alcohol consumption affect willingness to ask questions about its use, the dynamics of patient-doctor interactions are important, and alcohol screening questionnaires lack practical utility. Analysis suggests that the conceptual barriers to detecting at-risk drinking were: community stigma and stereotypes of problem drinking , GP perceptions of unreliable patient alcohol use histories, and the perceived threat to the patient-doctor relationship. Conclusion: This small exploratory study found that the practice of, and barriers to, detecting at-risk drinking appear to be inextricably linked to the sociocultural beliefs surrounding alcohol use. Screening questionnaires such as the AUDIT-C are not designed to address these issues. In the current context, it is unlikely that approaches that focus on the use of these tools will be effective at improving detection of at-risk drinking by GPs. 2013 Tam et al.; licensee BioMed Central Ltd

Let\u27s listen to patients\u27 and GPs\u27 perspectives on alcohol-screening research

Alcohol-screening questionnaires have been found to be effective in the early detection of risky drinking but are rarely used by clinicians in primary care. As research agenda tend not to seek the perspectives of patients and general practitioners (GPs), the best way to address the barriers to implementation is unclear. Contemporary research to explore patient beliefs and attitudes towards alcohol enquiry by GPs is needed

Alcohol enquiry by GPs - Understanding patients\u27 perspectives: A qualitative study

Background Patients\u27 beliefs and attitudes toward receiving alcohol enquiry from general practitioners (GPs) are unclear. These need to be understood to implement pragmatic, early detection and brief intervention strategies. Methods We purposively sampled 23 participants from respondents of an earlier survey conducted in a general practice clinic in Sydney, Australia. Semi-structured interviews were conducted between June and August 2014, recorded, transcribed and analysed using grounded theory method to develop an explanatory model. Results There were three factors that influenced patients\u27 acceptability of alcohol enquiry by GPs: ¿ perceived relevance of the alcohol enquiry dialogue to the consultation ¿ approach and language used in the patient-doctor interaction ¿ unease regarding the moral and stigmatising dimension of alcohol consumption. Discussion Patients are positive towards the role of GPs in health promotion, but nonetheless have reservations towards engaging in alcohol discussions. Setting the context for alcohol dialogue, linking it to patients\u27 agendas, collaborative consultation styles and respecting patients\u27 sensitivity may improve acceptability

Can research that is not intended or unlikely to be published be considered ethical?

Background For research to be ethically acceptable, the potential benefits must justify any risks involved for participants. Dissemination of research findings through publication is one way of creating benefit, but not all researchers intend to publish their research. Other factors, such as lack of size or representativeness, generalisability or innovativeness, or negative findings mean the research is unlikely to be published in a peer-reviewed medical journal. Objectives This paper discusses ethical considerations in research where peer-reviewed publication is not intended or unlikely. Discussion Proposing research that is not intended or unlikely to be published in a peer-reviewed journal does not preclude it from being considered ethical. Additional benefits of such projects may include professional development of investigators, pilot data collection leading to more definitive studies, or developing collaborations with research users that increase relevance and improve utility of finding

The role of quality improvement collaboratives in general practice: a qualitative systematic review

Background This systematic review used qualitative methodologies to examine the role of quality improvement collaboratives (QICs) in general practice. The aim was to inform implementers and participants about the utility of using or participating in QICs in general practice. Methods Included studies were published in English, used a QIC intervention, reported primary research, used qualitative or mixed methods, and were conducted in general practice. A Medline search between January 1995 and February 2020 was developed and extended to include Embase, CINAHL and PsycInfo databases. Articles were sought through chaining of references and grey literature searches. Qualitative outcome data were extracted using a framework analysis. Data were analysed using thematic synthesis. Articles were assessed for quality using a threshold approach based on the criteria described by Dixon-Woods. Results 15 qualitative and 18 mixed-methods studies of QICs in general practice were included. Data were grouped into four analytical themes which describe the role of a collaborative in general practice: improving the target topic, developing practices and providers, developing the health system and building quality improvement capacity. Discussion General practice collaboratives are reported to be useful for improving target topics. They can also develop knowledge and motivation in providers, build systems and team work in local practice organisations, and improve support at a system level. Collaboratives can build quality improvement capacity in the primary care system. These roles suggest that QICs are well matched to the improvement needs of general practice. General practice participants in collaboratives reported positive effects from effective peer interaction, high-quality local support, real engagement with data and well-designed training in quality improvement.Strengths of this study were an inclusive search and explicit qualitative methodology. It is possible some studies were missed. Qualitative studies of collaboratives may be affected by selection bias and confirmation bias