Northamptonshire Primary Care
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Social prescribing by students: the design and delivery of a social prescribing scheme by medical students in general practiceBackground Social prescribing is a means of enabling primary care professionals to refer people to a range of local, non-clinical services. Medical students at a large GP surgery in Corby designed, implemented and led a social prescribing service for the practice’s patients. Through the project students gained an understanding of social prescribing in an authentic setting. Methods During a 12 week GP placement students collated information on local organisations, charities and schemes into a social prescribing directory. A clinic was set up and a social prescribing protocol created to enable suitable patients to be referred to the service. Students educated staff and collected feedback on how the service should run. Patients referred to the service were seen by medical students, who identified suitable social prescribing opportunities. Follow up was arranged to encourage patient engagement with services. The student-led service has been successfully integrated with the work of the new PCN link worker. Outcome Medical students were able successfully identify social prescribing opportunities for patients referred to them in primary care. Experiential learning enabled them to develop an understanding of social prescribing and its place in healthcare. Discussion Medical students successfully designed and delivered a social prescribing intervention providing authentic educational experience in real-life clinical practice. The introduction of a Primary Care Network link worker enhanced this work and student input has continued in the ongoing service. It is hoped the scheme will be rolled out across the Primary Care curriculum in Leicester
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Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendationsBackground ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need. Methods Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions. Results The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a ‘specialist’ in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources. Conclusions The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.
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Seeing double: expanding GP capacity through teamwork and redesignLike many practices, we’ve felt the pinch from a shrinking GP workforce. Over a period of some years we’ve suffered from GP turnover: younger GPs emigrating to Australia or Canada, with the more senior among us contemplating approaching retirements. Recruitment has faltered and failed. We responded with some radical ideas and embraced change. This year we merged with a ‘super practice’ to ensure our future viability and we also decided to recruit two advanced nurse practitioners to spread our workload. But we also came up with a novel idea to redesign the GP consultation involving our practice nurses, effectively expanding GP capacity.
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Responses to provision of personalised cancer risk information: a qualitative interview study with members of the publicBackground It is estimated that nearly 600,000 cancer cases in the UK could have been avoided in the past five years if people had healthier lifestyles. A number of theories of behaviour change suggest that before people will change health behaviours, they must accept that a risk applies to them. This study aimed to explore the views of the public on receiving personalised cancer risk information and the potential for that information to motivate behaviour change. Methods We conducted 27 interviews with members of the public (mean age 49 ± 23 years). Each participant completed a questionnaire to allow calculation of their risk of developing the most common cancers (10 for women, 8 for men). During the interviews we presented their risk using a web-based tool developed for the study and discussions covered their views on receiving that information. Each interview was audio-recorded and then analysed using thematic analysis. Results Participants generally viewed the concept of personalised cancer risk positively. The first reaction of almost all when presented with their 10-year risk of an individual cancer without any further context was that it was low and not concerning. Views on what constituted a high risk ranged widely, from 0.5 to 60%. All felt seeing the impact of changes in lifestyle was helpful. For some this led to intentions to change behaviour, but reductions in risk were not always motivating as the risks were considered low and differences small. Conclusions Provision of personalised cancer risk was well received and may be a useful addition to other cancer prevention initiatives. Further work is needed in particular to develop ways to present cancer risk that reflect the general perception of what constitutes a risk high enough to motivate behaviour change and help patients contextualise a less well known health risk by providing a frame of reference.
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Incorporating cancer risk information into general practice: a qualitative study using focus groups with health professionalsBackground It is estimated that approximately 40% of all cases of cancer are attributable to lifestyle factors. Providing people with personalised information about their future risk of cancer may help promote behaviour change. Aim To explore the views of health professionals on incorporating personalised cancer risk information, based on lifestyle factors, into general practice. Design and setting Qualitative study using data from six focus groups with a total of 24 general practice health professionals from the NHS Nene Clinical Commissioning Group in England. Method The focus groups were guided by a schedule covering current provision of lifestyle advice relating to cancer and views on incorporating personalised cancer risk information. Data were audiotaped, transcribed verbatim, and then analysed using thematic analysis. Results Providing lifestyle advice was viewed as a core activity within general practice but the influence of lifestyle on cancer risk was rarely discussed. The word ‘cancer’ was seen as a potentially powerful motivator for lifestyle change but the fact that it could generate health anxiety was also recognised. Most focus group participants felt that a numerical risk estimate was more likely to influence behaviour than generic advice. All felt that general practice should provide this information, but there was a clear need for additional resources for it to be offered widely. Conclusion Study participants were in support of providing personalised cancer risk information in general practice. The findings highlight a number of potential benefits and challenges that will inform the future development of interventions in general practice to promote behaviour change for cancer prevention.
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Development of a Cancer Risk Prediction Tool for Use in the UK Primary Care and Community SettingsSeveral multivariable risk prediction models have been developed to asses an individual's risk of developing specific cancers. Such models can be used in a variety of settings for prevention, screening, and guiding investigations and treatments. Models aimed at predicting future disease risk that contains lifestyle factors may be of particular use for targeting health promotion activities at an individual level. This type of cancer risk prediction is not yet available in the UK. We have adopted the approach used by the well-established U.S.-derived "YourCancerRisk" model for use in the UK population, which allow users to quantify their individual risk of developing individual cancers relative to the population average risk. The UK version of “YourCancerRisk" computes 10-year cancer risk estimates for 11 cancers utilizing UK figures for prevalence of risk factors and cancer incidence. Because the prevalence of risk factors and the incidence rates for cancer are different between the U.S. and the UK population, this UK model provides more accurate estimates of risks for a UK population. Using an example of breast cancer and data from UK Biobank cohort, we demonstrate that the individual risk factor estimates are similar for the U.S. and UK populations. Assessment of the performance and validation of the multivariate model predictions based on a binary score confirm the model's applicability. The model can be used to estimate absolute and relative cancer risk for use in Primary Care and community settings and is being used in the community to guide lifestyle change.
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“Flow” Transcranial Direct Current Stimulation (tDCS) for Depression Treatment in a Primary Healthcare General Practice — An Open-Label Cohort Study Measuring Montgomery-Åsberg Depression Rating Scale (MADRS-S) OutcomesBackground: Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application delivered wellbeing behaviour therapy training. tDCS has evidence of effectiveness in treating symptoms of depression. Purpose/Aim: This post marketing study evaluated the effect of Flow on depression for primary care general practice patients with depression symptoms. Methods: Open-label patient cohort design with no control group. Inclusion criteria were aged 18 years or over and reporting depression symptoms. Participants self-administered five 30 minute tDCS sessions per week for the first three weeks, and then 3 sessions per week following this. Three, six and ten week assessment with participant self-report measure: Montgomery- Åsberg Depression Rating Scale (MADRS-S). Results: MADRS-S remission rates were between 29% - 30% at three weeks, 33% - 34% at six-weeks and 50% at 10-weeks treatment. There was a significant improvement in MADRS-S with large effect sizes at all time points. Conclusions: Flow tDCS can be delivered through a primary healthcare general practice service and patients will choose to use. Flow tDCS provides an effective depression treatment in addition and as an alternative to antidepressants and psychotherapy. tDCS has evidence as an effective depression treatment, and the widespread availability of tDCS in primary care general practice should be considered.
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The management of acute venous thromboembolism in clinical practice – study rationale and protocol of the European PREFER in VTE RegistryBackground Venous thromboembolism (VTE) is a major health problem, with over one million events every year in Europe. However, there is a paucity of data on the current management in real life, including factors influencing treatment pathways, patient satisfaction, quality of life (QoL), and utilization of health care resources and the corresponding costs. The PREFER in VTE registry has been designed to address this and to understand medical care and needs as well as potential gaps for improvement. Methods/design The PREFER in VTE registry was a prospective, observational, multicenter study conducted in seven European countries including Austria, France Germany, Italy, Spain, Switzerland, and the UK to assess the characteristics and the management of patients with VTE, the use of health care resources, and to provide data to estimate the costs for 12 months treatment following a first-time and/or recurrent VTE diagnosed in hospitals or specialized or primary care centers. In addition, existing anticoagulant treatment patterns, patient pathways, clinical outcomes, treatment satisfaction, and health related QoL were documented. The centres were chosen to reflect the care environment in which patients with VTE are managed in each of the participating countries. Patients were eligible to be enrolled into the registry if they were at least 18 years old, had a symptomatic, objectively confirmed first time or recurrent acute VTE defined as either distal or proximal deep vein thrombosis, pulmonary embolism or both. After the baseline visit at the time of the acute VTE event, further follow-up documentations occurred at 1, 3, 6 and 12 months. Follow-up data was collected by either routinely scheduled visits or by telephone calls. Results Overall, 381 centres participated, which enrolled 3,545 patients during an observational period of 1 year. Conclusion The PREFER in VTE registry will provide valuable insights into the characteristics of patients with VTE and their acute and mid-term management, as well as into drug utilization and the use of health care resources in acute first-time and/or recurrent VTE across Europe in clinical practice.
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“Flow” Transcranial Direct Current Stimulation (tDCS) for Depression Treatment in a Primary Healthcare General Practice — Depression, Functioning, and Health-Related Quality of Life OutcomesBackground: Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application that delivers wellbeing behaviour therapy training. tDCS has evidence of effectiveness in treating symptoms of depression. This post marketing study evaluated the effect of Flow on depression, functioning, and health-related quality of life for primary care general practice patients with depression symptoms. Methods: Open-label patient cohort design with no control group. Thirty-one adult patients completed six weeks of Flow treatment. Average age 45.6 years (SD = 13.72) range from 20-75 years; 24 (77.4%) females and six males (23.6%). Pre- and post-intervention assessment with participant self-report measures: Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS), and European Quality of Life Five Dimension (EQ-5D-5L). Results: PHQ-9 reliable improvement and remission rates were 58.1% and 32.3%. There was a significant improvement in PHQ-9 and WSAS with large effect sizes. EQ-5D-5L results showed significant improvements in three dimensions and the health index score with medium effect sizes. Conclusion: Flow tDCS can be delivered through a primary healthcare general practice service and patients use it as prescribed and complete treatment course. tDCS has evidence as an effective depression treatment, the widespread availability of tDCS in primary care general practice should be considered.
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Clinical inertia: failure to intensify the therapy when needed in the management of Type 2 diabetes, retrospective analysis of Wandsworth (general practice) data (1998–2007)To describe the clinical inertia among primary care health professionals in the management of Type 2 diabetes retrospectively, and to identify the time lag in the intensification of pharmacotherapy to achieve the recommended HbA1c levels.
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A randomised controlled trial investigating the clinical and cost-effectiveness of Alpha-Stim AID cranial electrotherapy stimulation (CES) in patients seeking treatment for moderate severity depression in primary care (Alpha-Stim-D Trial)Major depression is the second leading cause of years lost to disability worldwide and is a leading contributor to suicide. However, first-line antidepressants are only fully effective for 33%, and only 40% of those offered psychological treatment attend for two sessions or more. Views gained from patients and primary care professionals are that greater treatment uptake might be achieved if people with depression could be offered alternative and more accessible treatment options. Although there is evidence that the Alpha-Stim Anxiety Insomnia and Depression (AID) device is safe and effective for anxiety and depression symptoms in people with anxiety disorders, there is much less evidence of efficacy in major depression without anxiety. This study investigates the effectiveness of the Alpha-Stim AID device, a cranial electrotherapy stimulation (CES) treatment that people can safely use independently at home. The device provides CES which has been shown to increase alpha oscillatory brain activity, associated with relaxation. The aim of this study is to investigate the clinical and cost-effectiveness of Alpha-Stim AID in treatment-seeking patients (aged 16 years upwards) with moderate to moderately severe depressive symptoms in primary care. The study is a multi-centre parallel-group, double-blind, non-commercial, randomised controlled superiority trial. The primary objective of the study is to examine the clinical efficacy of active daily use of 8 weeks of Alpha-Stim AID versus sham Alpha-Stim AID on depression symptoms at 16 weeks (8 weeks after the end of treatment) in people with moderate severity depression. The primary outcome is the 17-item Hamilton Depression Rating Scale at 16 weeks. All trial and treatment procedures are carried out remotely using videoconferencing, telephone and postal delivery considering the COVID-19 pandemic restrictions. This study is investigating whether participants using the Alpha-Stim AID device display a reduction in depressive symptoms that can be maintained over 8 weeks post-treatment. The findings will help to determine whether Alpha-Stim AID should be recommended, including being made available in the NHS for patients with depressive symptoms.
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Evaluating the clinical effectiveness of the NHS Health Check programme: a prospective analysis in the Genetics and Vascular Health Check (GENVASC) studyThe aim of the study was to assess the clinical effectiveness of the national cardiovascular disease (CVD) prevention programme — National Health Service Health Check (NHSHC) in reduction of CVD risk. Prospective cohort study. 147 primary care practices in Leicestershire and Northamptonshire in England, UK. The primary outcomes were NHSHC attributed detection of CVD risk factors, prescription of medications, changes in values of individual risk factors and frequency of follow-up. At recruitment, 18% of participants had high CVD risk (10%–20% 10-year risk) and 4% very high CVD risk (>20% 10-year risk). New diagnoses or hypertension (HTN) was made in 2.3% participants, hypercholesterolaemia in 0.25% and diabetes mellitus in 0.9%. New prescription of stains and antihypertensive medications was observed in 5.4% and 5.4% of participants, respectively. Total cholesterol was decreased on average by 0.38 mmol/L (95% CI −0.34 to −0.41) and 1.71 mmol/L (−1.48 to −1.94) in patients with initial cholesterol >5 mmol/L and >7.5 mmol/L, respectively. Systolic blood pressure was decreased on average by 2.9 mm Hg (−2.3 to −3.7), 15.7 mm Hg (−14.1 to −17.5) and 33.4 mm Hg (−29.4 to −37.7), in patients with grade 1, 2 and 3 HTN, respectively. About one out of three patients with increased CVD risk had no record of follow-up or treatment. Majority of patients identified with increased CVD risk through the NHSHC were followed up and received effective clinical interventions. However, one-third of high CVD risk patients had no follow-up and therefore did not receive any treatment. Our study highlights areas of focus which could improve the effectiveness of the programme.
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Cross sectional study to explore a causative link between COVID-19 infection and a subsequent prediabetes diagnosisEvidence suggests that SARS‐CoV-2 binds to the ACE2 receptors on pancreatic islets and can impair their insulin tolerance, potentially causing an acute diabetic presentation. However, there has perhaps been less exploration into whether infection with SARS-COV-2 can increase the prevalence of prediabetes as well as diabetes. Compared with type 2 diabetes, prediabetes is highly common, the prevalence is rapidly increasing, and most people are unaware of their high-risk status. Prediabetes is a long-lasting state with impaired glucose tolerance preceding type 2 DM. Concerning the pathophysiology of prediabetes and alterations in the immune system of the affected individuals a similar outcome of COVID-19 in prediabetes would be plausible. To identify whether an infection with COVID19 can be directly linked to the development of prediabetes. The prediabetes register in UK primary care setting was searched to identify relevant cohorts diagnosed before and after 31/01/2020. Data searches were carried out on the pre-diabetes register with positive PCR for ‘SARS-CoV-2’. The event dates of the positive PCR and prediabetes diagnosis were compared. If a positive PCR was recorded prior to a prediabetes diagnosis, the number of days between these events was calculated. 148 out of 254 people on the prediabetes register, were diagnosed on 31/01/20. 23 of these patients had a positive PCR test, 7 had positive PCR prior to their diagnosis. 106 patients were diagnosed before 31/01/20, 13 of these had had a positive PCR test. The rate of diagnosis post-positive PCR was significantly lower than the rate expected. However, our analysis did show that the prevalence of prediabetes during the pandemic was significantly higher than the pre-pandemic rate. The prevalence of prediabetes during the pandemic was significantly higher. However, this does not appear to be directly a result of COVID19 infection. Instead, it could be due to the changes in lifestyle during the lockdowns increasing the risk factors associated with developing prediabetes.
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Cross sectional study to look at the factors leading to therapeutic inertia in UK primary setting in the management of T2DMTo study factors associated with therapeutic inertia in the management of T2DM in UK primary setting and to develop a predictor model to estimate the probability of therapeutic inertia based on patient factors, clinical characteristics, and level of care provided.
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Therapeutic inertia amongst general practitioners with interest in diabetesAs the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.
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Assessment of response rates and yields for Two opportunistic Tools for Early detection of Non-diabetic hyperglycaemia and Diabetes (ATTEND). A randomised controlled trial and cost-effectiveness analysisTo assess the opportunistic use in primary care of a computer risk score versus a self-assessment risk score for undiagnosed type 2 diabetes. We conducted a randomised controlled trial in 11 primary care practices in the UK. 577 patients aged 40–75 years with no current diagnosis of type 2 diabetes were recruited to a computer based risk score (Leicester Practice Computer Risk Score (LPCRS)) or a patient self-assessment score (Leicester Self-Assessment Score (LSAS)). The rate of self-referral blood tests was significantly higher for the LPCRS compared to the LSAS, 118.98 (95% CI: 102.85, 137.64) per 1000 high-risk patient years of follow-up compared to 92.14 (95% CI: 78.25, 108.49), p = 0.022. Combined rate of diagnosis of type 2 diabetes and those at risk of developing the disease (i.e. impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)) was similar between the two arms, 15.12 (95% CI: 9.11, 25.08) per 1000 high-risk patient years for LPCRS compared to 14.72 (95% CI: 9.59, 22.57) for the LSAS, p = 0.699. For the base case scenario the cost per new case of type 2 diabetes diagnosed was lower for the LPCRS compared to the LSAS, £168 (95% Credible Interval (CrI): 76, 364), and £352 (95% CrI: 109, 1148), respectively. Compared to a self-assessment risk score, a computer based risk score resulted in greater attendance to an initial blood test and is potentially more cost-effective.
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A cross-sectional observational study of pneumococcal carriage in children, their parents, and older adults following the introduction of the 7-valent pneumococcal conjugate vaccineUsing nasopharyngeal carriage as a marker of vaccine impact, pneumococcal colonization and its relation to invasive disease were examined in children, their parents, and older adults in the United Kingdom following introduction of 7-valent pneumococcal conjugate vaccine (PCV7) and prior to 13-valent pneumococcal conjugate vaccine (PCV13). A cross-sectional observational study was conducted, collecting nasopharyngeal swabs from children aged 25 to 55 months who had previously received 3 doses of PCV7, their parents, and adults aged ≥65 years. Pneumococcal serotyping was conducted according to World Health Organization guidelines with nontypeable isolates further analyzed by molecular serotyping. A national invasive disease surveillance program was conducted throughout the corresponding period. Pneumococcus was isolated from 47% of children, 9% of parents, and 2.2% of older adults. For these groups, the percentage of serotypes covered by PCV7 were 1.5%, 0.0%, and 15.4%, with a further 20.1%, 44.4%, and 7.7% coverage added by those in PCV13. In each group, the percentage of disease due to serotypes covered by PCV7 were 1.0%, 7.4% and 5.1% with a further 65.3%, 42.1%, and 61.4% attributed to those in PCV13. The prevalence of carriage is the highest in children, with direct vaccine impact exemplified by low carriage and disease prevalence of PCV7 serotypes in vaccinated children, whereas the indirect effects of herd protection are implied by similar observations in unvaccinated parents and older adults.
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Clinical inertia in management of T2DMDiabetes is highly prevalent and serious chronic debilitating disease and reported to be the fourth main cause of death in Europe. Despite extensive evidence of benefits of tight glycemic control, large proportions of people with diabetes do not achieve target glycemic control. One major reason for this is clinical inertia which is “recognising the problem but failure to act” by health care professionals in primary care. The key issues in the management of people with T2DM include early detection of problems, realistic goal setting, improved patient adherence, better knowledge and understanding of pharmacotherapeutic treatment options and prompt intervention. Health care professionals must need to overcome clinical inertia and need to intensify therapy in an appropriate and timely manner.
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Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative studyFailure to intensify treatment in patients with Type 2 diabetes with suboptimal blood glucose control has been termed clinical inertia and has been shown to contribute to poorer patient outcomes. We aimed to identify and explore perceptions about clinical inertia from the perspective of primary healthcare providers. A qualitative study was conducted in Leicestershire and Northamptonshire, UK. Purposive sampling was based on healthcare providers working in primary care settings with 'higher' and 'lower' target achievement based on routine data. Twenty semi-structured interviews were conducted, face-to-face or by telephone. Thematic analysis was informed by the constant comparative approach. An important broad theme that emerged during the analysis was related to attribution and explanation of responsibility for clinical inertia. This included general willingness to accept a degree of responsibility for clinical inertia. In some cases, however, participants had inaccurate perceptions about levels of target achievement in their primary care centres, as indicated by routine data. Participants sought to lessen their own sense of accountability by highlighting patient-level barriers such as comorbidities and human fallibility, and also system-level barriers, particularly time constraints. Perceptions about ways of addressing the problem of clinical inertia were not seen as straightforward, further emphasizing a complex and cumulative pattern of barriers. In order to understand and address the problem of clinical inertia, provider, patient- and system-level barriers should be considered together rather than as separate issues. Acknowledgement of responsibility should be regarded positively as a motivator for change.
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Cross sectional Study to assess the quality of services provided to CKD patients in a UK Primary Care SettingTo find out whether patients have been monitored properly as recommended in the NICE guidelines and eventually to suggest practical implementations to improve monitoring of patients with CKD.