The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient’s priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman’s concept of ‘frames’ to present an examination of how doctors’ and patients’ sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients’ understanding of the goal-setting consultation, GPs actively aligning with patients’ framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided “telling cases” of goal-setting interactions, where doctors and patients need to negotiate each other’s perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations

Correlation between prescribing quality and pharmaceutical costs in English primary care: national cross-sectional analysis

Background Both pharmaceutical costs and quality-indicator performance vary substantially between general practices, but little is known about the relationship between prescribing costs and quality Aim To measure the association between prescribing quality and pharmaceutical costs among English general practices Design and setting Cross-sectional observational study using data from the Quality and Outcomes Framework and the Prescribing Analysis and Cost database from all 8409 general practices in England in 2005-2006 Method Correlation between practice achievement of 26 prescribing quality indicators in eight prescribing areas and related pharmaceutical costs was examined. Results There was no significant association between the overall achievement of quality indicators and related pharmaceutical costs (P= 0.399). Mean achievement of quality indicators across all eight prescribing areas was 79.0% (standard deviation 4.4%). There were small positive correlations in five prescribing areas: influenza vaccination, beta blockers, angiotensin converting enzyme inhibitors, lipid lowering, and antiplatelet treatment (all

Survival prospects after acute myocardial infarction in the UK: a matched cohort study 1987–2011

Objectives: Estimate survival after acute myocardial infarction (AMI) in the general population aged 60 and over, and the effect of recommended treatments. Design: Cohort study in the United Kingdom with routinely collected data between January 1987 and March 2011. Setting: 310 general practices that contributed to The Health Improvement Network (THIN) database. Participants: Four cohorts who reached the age of 60, 65, 70, or 75 years between 1987 and 2011 included 16,744, 43,528, 73,728, and 76,392 participants, respectively. Participants with a history of AMI were matched on sex, year of birth, and general practice to three controls each. Outcome measures: The hazard of all-cause mortality associated with AMI was calculated by a multilevel Cox’s proportional hazards regression, adjusted for sex, year of birth, socioeconomic status, angina, heart failure, other cardiovascular conditions, chronic kidney disease, diabetes, hypertension, hypercholesterolaemia, alcohol consumption, body mass index, smoking status, coronary revascularisation, prescription of beta blockers, ACE inhibitors, calcium-channel blockers, aspirin, or statins, and general practice. Results: Compared to no history of AMI by age 60, 65, 70, or 75, having had one AMI was associated with an adjusted hazard of mortality of 1.80 (95% CI 1.60-2.02), 1.71 (1.59-1.84), 1.50 (1.42-1.59), or 1.45 (1.38-1.53), respectively, and having had multiple AMIs with a hazard of 1.92 (1.60-2.29), 1.87 (1.68-2.07), 1.66 (1.53-1.80), or 1.63 (1.51-1.76), respectively. Survival was better after statins (hazard ratio range across the four cohorts 0.74-0.81), beta blockers (0.79-0.85), or coronary revascularisation (in first five years) (0.72-0.80); unchanged after calcium-channel blockers (1.00-1.07); and worse after aspirin (1.05-1.10) or ACE inhibitors (1.10-1.25). Conclusions: The hazard of death after AMI is less than reported by previous studies, and standard treatments of aspirin or ACE inhibitors prescription may be of little benefit or even cause harm

Eye-Movement does not reduce ratings of vividness and emotionality or the number of intrusive thoughts of unpleasant memories: Implications for Eye-Movement Desensitisation and Reprocessing (EMDR)

Eye-Movement Desensitisation and Reprocessing (EMDR) is a psychotherapy that incorporates the use of saccadic Eye-Movements (EM) to alleviate distress caused by traumatic memories. Although EMDR is recognised as a front-line treatment for individuals suffering from Posttraumatic Stress Disorder (PTSD), the mechanisms underlying the efficacy of the EM component remain a point of contention. The aim of the current research was to investigate first, whether EM reduced ratings of memory vividness and emotionality by taxing Working Memory (WM) capacity, and second, to examine whether EM lowered the number of intrusive thoughts under two opposing suppression conditions. In two experiments, 244 non-clinical participants were asked to recall an unpleasant memory while simultaneously engaging in fast-EM, slow-EM or a no-EM control. Participants then received an instruction to intentionally avoid thinking about the memory, or to think about whatever came to mind. Relative to no-EM, fast-EM and slow-EM had no significant effect on vividness and emotionality ratings, nor did they influence the number of intrusive thoughts. In addition, the level of suppression intent had no impact on memory outcomes. Overall, the results from these two experiments oppose earlier findings in support of WM theory, and a significant body of research that has demonstrated the efficacy of the EM component. Implications for the EM component in EMDR are discussed, and an alternative explanation for EM is offered

Outcomes of blood pressure targets in clinical trial versus primary care setting

Objective: The primary objective was to compare outcomes of different systolic blood pressure (SBP) targets in the US clinical setting and the UK primary care setting. / Methods: Data from the SPRINT randomised control trial and The Health Improvement Network (THIN) primary care database were used to develop survival models for longevity and adverse renal outcome (ARO, main adverse effect) at different SBP targets given treatment in people without diabetes and chronic kidney disease. The hazard of all-cause mortality or ARO associated with SBP targets was calculated by a multilevel Cox’s proportional hazards regression, adjusted for sex, age, race, smoking, BMI, SBP, cardiovascular disease, number of antihypertensive agents at baseline, additional medication after trial entry, their interaction, and clinical site. / Results: Compared to SBP target of ≤120 mmHg, SBP target of ≤140 mmHg was associated with increased hazard of mortality of 1.42 (1.06-1.90) in SPRINT, but with decreased hazard of 0.70 (0.65-0.76) in THIN. Both in SPRINT and THIN, SBP target of ≤140 mmHg was associated with decreased hazard of ARO of 0.32 (0.22-0.46) and 0.87 (0.80-0.95), respectively. Additional antihypertensive agents (3+) were associated with increased hazards of both outcomes, with HRs of 1.71-1.74 in SPRINT and 1.43-2.23 in THIN, yet being on 2 agents had survival benefits in SPRINT (HRs 0.70-0.79). / Conclusions: Lower SBP target was associated with survival benefits in the clinical setting, but with increased hazard of mortality in the primary care setting. In both settings, polypharmacy patients tended to be worse off. An intensive control of SBP may benefit a selected subgroup of patients, but it appears harmful for the broader population

Are patients in heart failure trials representative of primary care populations? A systematic review.

BACKGROUND: Guidelines recommend drug treatment for patients with heart failure with a reduced ejection fraction (HFrEF), however the evidence for benefit in patients with mild disease, such as most in primary care, is uncertain. Importantly, drugs commonly used in heart failure account for one in seven of emergency admissions for adverse drug reactions. AIM: To determine to what extent patients included in studies of heart failure treatment with beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and aldosterone antagonists were representative of a typical primary care population with HFrEF in England. DESIGN & SETTING: Systematic review of randomised controlled trials (RCTs) of drug treatment in patients with HFrEF. METHOD: MEDLINE, MEDLINE In-Process, EMBASE, and CENTRAL were searched from inception to March 2015. The characteristics of the patient's New York Heart Association (NYHA) classification were compared with a primary care reference population with HFrEF. RESULTS: Of the 30 studies included, two had incomplete data. None had a close match (defined as ≤10% deviation from reference study) for NYHA class I disease; 5/28 were a close match for NYHA class II; 5/28 for NYHA class III; and 18/28 for NYHA class IV. In general, pre-existing cardiovascular conditions, risk factors, and comorbidities were representative of the reference population. CONCLUSION: Patients recruited to studies typically had more severe heart failure than the reference primary care population. When evidence from sicker patients is generalised to less sick people, there is increased uncertainty about benefit and also a risk of harm from overtreatment. More evidence is needed on the effectiveness of treatment of heart failure in asymptomatic patients with NYHA class I