BJGP Interviews

What do patients really want? Rethinking general practice access

Today, we’re speaking to Professor Helen Atherton. Helen is Professor of Primary Care Research based at the University of Southampton.Title of paper: What do patients want from access to UK general practice?Available at: https://doi.org/10.3399/BJGP.2024.0582Widely accepted as perpetuated by the media is that patients are unhappy with access to general practice and desire faster access to a general practitioner. This review sought to summarise the research evidence about reported patient wants from access to general practice. Patients wanted to easily make an appointment in a timely fashion, to have a positive relationship with the practice, to see a specific clinician and choose consultation modality according to individual circumstance. Communication and being kept informed about access throughout the process of making and having an appointment, was something patients wanted, and this could be addressed by general practice.Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.480 - 00:01:00.150Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today.In today's episode, we're speaking to Professor Helen Atherton.Helen is professor of Primary Care Research based at the University of Southampton, and we've only just speaking to her recently on this podcast about the increasing digitalization of general practice. This time we're speaking to her about her recent paper here in the BJDP titled what Do Patients Want from Access to UK General Practice?So, hi, Helen.It's really nice to speak again about this area of research and I guess I just wanted to start by saying that access is such a loaded word and really, when it comes to general practice, it's part of a fairly negative media campaign against general practice. But it seems that this negative narrative just keeps getting pushed, despite lots of attempts to fix it.So I just wonder if you could reflect on that.Speaker B00:01:00.470 - 00:01:51.950Yeah, absolutely. So that the negative media coverage was one of the reasons that I wanted to do this review.So this review was a bit of a labour of love because I had a feeling from the work that I was doing on digital access and other research that actually the reality was probably quite different, what we were seeing in the headlines and having looked into it, although there's lots of research out there on patient experience and satisfaction, we have a national survey that looks at that. There wasn't anything about what patients actually want. And so that kind of.I thought, actually, wouldn't it be really interesting to find out from the evidence what they actually want and see if it does fit with the narrative we see in the papers and on social media. So, yes. So completely agree. And that was kind of where the idea came from, really.Speaker A00:01:52.420 - 00:02:08.180Yeah.And I just want to unpick what you really mean by access in this paper, because I think for some people it means, you know, just getting an appointment to see their GP within a day, but it can mean lots of different things to other people. So what did you conceptualize that as?Speaker B00:02:08.740 - 00:02:49.840Well, it was difficult.And you're right, there are lots of different definitions of access, and particularly in the research context, for us, we were interested in access to an appointment, so we were very focused on the processes that patient would go through in order to get the appointment, go to the appointment.And we did go back and forth several times with this review because it was so difficult to define and there will be other researchers who use different definition, but because we were so interested in a lot of the kind of media narrative. It just felt like the best fit to look at access to an appointment with a gp.Speaker A00:02:50.000 - 00:03:04.540So this paper was a systematic review and you looked at papers which explored different aspects of access. And I guess the big question here is, what did patients want in terms of access?I wonder if you could just give sort of a headline summary and then we can talk a bit more in depth about it.Speaker B00:03:04.780 - 00:03:56.070Sure. So what was interesting is I don't think their wants were particularly surprising or out of line with what general practice wants to deliver.That's the first thing to say. And it was things like wanting to choose a clinician that they've seen before, if they.If they've seen a clinician before, wanting to have choice around the skill mix. So which healthcare professional. They saw the consultation modality wanting to have a good relationship with the practice.They wanted ease of booking and relatively speedy access. But not. There wasn't any evidence that people all wanted to be seen on the same day, which is maybe how the media narrative goes.And there were also some things around wanting it to be easy to get to and having a nice waiting room. So really quite simple things as well.Speaker A00:03:56.230 - 00:04:19.350I think choice is a really interesting area to explore.So some people might not feel they have the right access if they get booked in, like you say with the gp, they don't know, or if they get booked in to see someone working in another clinical role in the practice.But I wonder what you thought about the implications, given the increasing lack of continuity of care and this widening multidisciplinary team in practice.Speaker B00:04:19.870 - 00:05:16.510Yeah. So it didn't escape our notice that a lot of what we were seeing was probably at odds with current policy around general practice.The fact that patients fully understand that continuity of care is important at times, and there's lots of evidence that that is the case. And general practice, as a rule, tends to encourage that, I would say. And then also with the skill mix at odds with the idea that you.You can kind of sub in other healthcare professionals as a way to tackle lack of capacity. Whereas I think patients are smarter than that and realise that sometimes it's appropriate, but other times it's not. Yeah.And then also with the digital as well.So, again, people wanting the choice, understanding that sometimes it's better to do things that way or more convenient, but not wanting to be forced down that route, which is kind of the way that we're going, really, in terms of policy for digital access.Speaker A00:05:16.990 - 00:05:24.830And. Yeah, talk us through that.What people thought about access in terms of the kind of consultation they got like a telephone or a face to face appointment.Speaker B00:05:24.830 - 00:06:12.650Yeah. So patients were happy to have those types of consultation.So when it came to use of remote consultations, patients were happy to do that where it met a need. So if they didn't want to come to the practice, they weren't able to.Perhaps if they had a sensory disability, lots of reasons why they wanted to do it, but wanting to have the choice about how that happened, which was interesting. So people would say they didn't want to have to travel to the practice because it wasn't convenient.This could be around work or childcare, or it might be that they had mobility issues, but there was generally a reason why they didn't want to be in the proximity of the general practice. And that's when remote consultations were what patients wanted.Speaker A00:06:13.450 - 00:06:35.840Yeah, fair enough.So it seems a lot of the time people just want a choice and I think it's interesting, particularly given the increase in a triage first approach in many practices.But there was something you mentioned in the article that I thought was quite interesting, which was about co production with patients to solve access problems. Just tell us what you think this should look like.Speaker B00:06:36.160 - 00:08:01.890So as well as doing this review, I'm involved in other research around access to general practice. And a big thing that we see happening is almost like a. Not a lack of communication, but a miscommunication between patients and practices.You know, not intentional, nobody's trying to confuse the other, but patients perhaps not really understanding the access systems in place, not understanding what is available to them. If they don't have a choice, why they don't have a choice.And so I think there's a lot of room for more kind of working together in terms of what that looks like. I think we have to be brave and ask patients what they want.This is a systematic review, so it looks at existing evidence and most of those studies were not focused on looking at just what patients wanted, they were looking at other things as well. I think if we were to ask them what they wanted, we might get a bit more insight into how things can be tweaked or changed.I think the problem is probably that that's quite a scary thing to say, what do you want? Because what if patients say a load of things that, you know, can't happen?But I think this review does quite a good job of showing that actually what patients want is quite simple and straightforward and those conversations together would perhaps generate some realistic solutions. Better communication outwards to patients in a way that they understand.Speaker A00:08:02.610 - 00:08:24.430That's really Interesting that you mentioned this mismatch because sometimes when I speak to patients, they say something to me like, oh, it's impossible to get through, impossible to get an appointment. And I'm looking on our appointment screens and seeing lots of empty slots in this week and next week. And I think our practice is doing really well.But obviously there's a mismatch in how we're perceiving access, I suppose.Speaker B00:08:24.750 - 00:08:36.830Yeah, that's.I think that's right and I think that's something that's been shown in research that I've been involved in, but also others working in academic primary care and it's how we tackle that mismatch, I think that is really important.Speaker A00:08:38.209 - 00:08:44.209Yeah. So you touched on your other research around access. What are the other things that you're looking at in terms of access to primary care?Speaker B00:08:44.529 - 00:10:16.670So I have co led a study with Professor Catherine Pope at the University of Oxford, where we looked at long term sustainability of access approaches in general practice and that study finished quite recently.So we're trying to disseminate some of those findings as well and seeing very similar results around this mismatch between the patient view and the practice view. But also other interesting observations like the changes to the role of the receptionist.So increasingly colleagues in academic primary care have been writing about this, but it's definitely the case that the introduction of digital services and triage and it's really the triage type approaches, has really changed the role of the receptionist.But there's not necessarily been any space or time for general practice to reflect on that, to understand whether that role needs to be developed or even professionalised. And it's perhaps something that we, you know, could consider looking at in more depth.Other things arising have been around the sheer amount of work that general practice is doing to manage access.So making tweaks and changes all the time to how access systems operate, which is almost a form of invisible work really, because it's not accounted for, but it's happening all the time. And I think probably really important to acknowledge if we're thinking about how we set up long term sustainable approaches to access.Speaker A00:10:17.230 - 00:10:27.770And if you could step into a practice where people felt dissatisfied with their access, what would you tell the practice team in terms how they could improve things or manage things better?Speaker B00:10:28.010 - 00:12:00.890Well, I think I'd probably start by assuring them that it wasn't a criticism of necessarily of how they were doing things, because that is absolutely not the case and that is certainly not what our research demonstrates.I would say that it's probably really important to open that dialogue and find out some more about what the specific issues are that patients are facing and perhaps have a look at where the kind of pinch points are in terms of patient dissatisfaction. The other thing is it's very difficult.I think when you're managing a huge amount of demand and having to kind of manage their capacity, it can be quite easy.And again, this is something that we saw, we've seen in some of the research I've done in general practices, to really focus on this kind of amorphous demand and not necessarily remember to think that for a patient, their individual encounter is what matters to them. There's probably some work to be done.I'm not quite sure what it would look like around examining what a patient journey looks like in that particular practice. So what happens to patients who call the practice and where do they end up? It's difficult.I don't know that I do have answers, but I think it's really great that we can shed some light on exactly what is happening and perhaps also shed some light on the fact that some of the policies that are meant to be helping probably are not helping when it comes to how patients experience and perceive general practice.Speaker A00:12:01.930 - 00:12:23.280Yeah. I don't know if you want to touch on that a bit more, because it does seem like the policy focus has been on faster access.But some of the results from this work, and I think your previous work as well, suggests that actually quick access isn't necessarily the main goal for some patients when they want access to their general practice.Speaker B00:12:23.750 - 00:13:04.290Yeah, absolutely. And it's much, much more complex than that. And you're absolutely right.We've seen an announcement in the last few weeks about the expansion of the NHS app and how patients will be able to do more on the app. But that completely ignores the fact that lots of people don't use the app. Even when they do use can be quite sporadic.It doesn't always match up with the systems that are in place in general practice for people to access care. So it doesn't always link up very well with messaging. There's an awful lot of work to be done.But if you read the headlines, it would appear that this is going to save time and improve patient experience as well.Speaker A00:13:04.690 - 00:13:19.170Yeah, it's going to be interesting to see what comes out of the upcoming long term plan, especially since the expansion of digital services and the NHS app seems to be such a critical part of that sort of three pronged approach to saving the nhs. Really.Speaker B00:13:19.490 - 00:13:53.710Yeah. And there's also a wider question, I think around what we want general practice to look like.So it seems that patients are saying they want it to keep looking like it's always looked, and be somewhere that they can see a clinician that they may know already in somewhere that is close to home and that they have a good relationship with, which is kind of at odds with some of the policies which, as you say, are pushing for fast access and high volumes of access, perhaps in a short space of time.Speaker A00:13:53.950 - 00:14:10.010So what would you say that this paper really brings to the table in terms of those negative media, media portrayals that we started this conversation about? Do you think it sort of reinforces them or does it suggest that actually those portrayals aren't completely capturing the patient experience?Speaker B00:14:10.410 - 00:14:58.710Yeah, I would say that they're not completely capturing the patient experience. And I think hopefully this review shows that what patients want isn't a million miles away from what general practice wants.And that yes, there are always going to be some things that are a compromise, but it's, it's not necessarily a deal breaker for patients because there are so many factors that are important to them. But I also hope that it shows that this is an area that we should be focusing more on.So it would be really great, for example, if the general practice patient survey, as well as asking people about their experience, perhaps ask people about what they wanted.I don't know how easy that would be to do, but it could be really useful in actually getting the perspective of the people who are using general practice on what they would like to see.Speaker A00:14:58.950 - 00:15:12.470Yeah, really fascinating work, Helen. And I know that you're doing a lot of work in this area, so, yeah, really look forward to seeing your other outputs in this area.But it's been great to have a chat about this paper. So I just wanted to say thanks again for joining me.Speaker B00:15:12.710 - 00:15:15.830Thanks for having me, and thank you.Speaker A00:15:15.830 - 00:15:50.880All very much for your time here and for listening to this BJGP podcast.Helen's research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com and just to say, this is the end of this season of the BJGP podcast and we're going to take a bit of an extended summer break. We'll be back on the 9th of September with a new season of podcasts talking about recent research and clinical practice articles in the the BJGP.So look forward to then. But until then, thanks again. And bye.

ADHD medication – practical tips for GPs on how to recognise common side effects and what to do

Today, we’re speaking to Dr Sara Noden, a GP with an extended role in ADHD, and Dr Nishi Yarger, Consultant Psychiatrist in adult ADHD services.Title of paper: A guide for primary care clinicians managing ADHD medication side effectsAvailable at: https://doi.org/10.3399/bjgp25X742653TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.320 - 00:00:55.720Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors at the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.Sara Noden, a GP with an extended role in ADHD, and Dr. Nishi Yarger, consultant psychiatrist in Adult ADHD Services.We're talking about the recent Clinical Practice article here in the BJGP titled A Guide for Primary Care Clinicians Managing ADHD Medication Side Effects. So, thanks. It's great to meet you both Sara and Nishi.This is a really topical area to highlight in the journal, and not least because it seems that every week there seems to be a new article in the media about the increasing diagnosis of adhd. So it's a really topical area to look at, but I guess, Sar, I just really wanted to start with what prompted you to write this article and why now?Speaker B00:00:56.620 - 00:01:39.320Yeah, so I think coming from a GP perspective, before I specialized in adhd, I think these medications did create a bit of anxiety, especially as they're controlled drugs, their stimulants, their specialist medications, and there was a lot that I didn't know about them as I since developed a special interest and it sort of demystified some of these medications. And I just.I think we wanted to pass on to primary care clinicians some of that knowledge that we've learned, some really basic things that they can look out for that may or may not be related to medications and some common things that they can advise and to know when to escalate secondary care and how to manage these patients, essentially.Speaker A00:01:39.560 - 00:01:54.040Yeah. And Saura, I wonder if you could just tell us a bit more about your role as a GP with an extended role in adhd.So you must be very much in demand at the moment, but talk us through what led you to sort of take that role and what your typical week is like.Speaker B00:01:54.320 - 00:02:58.810Yeah, So I think my interest in ADHD stemmed during my training years and I currently am working as a salary GP, but also working at CNWL under Dr. Jaga. I'm doing diagnosis and medication titrations. And I think my interest stemmed because of how prevalent ADHD is becoming.I was seeing such an increase in patients presenting to gp, suspecting they have ADHD and requesting referral, and reading about this treatment and what we can offer, I was really taken aback by not only how ADHD can impact a patient in terms of their symptoms and concentration of focus, but also the lifelong issues that can arise sometimes with adhd, like all the Research showing that it increases rates of depression, underachievement at school, even early death and accidental injuries. So I feel it's a really important, important condition for us to be able to pick up, to be able to refer promptly and start treatment.And that's where the interest started.Speaker A00:02:59.050 - 00:03:14.570And, Nishi, from your perspective, what's it like having a GP working with your team?And from a secondary care perspective, I wonder if you could just tell us a bit more about your impression on how secondary care and general practice communicate around ADHD and people living with it.Speaker C00:03:14.650 - 00:04:27.649It's been great having Sara in the team for many reasons. So I guess primarily we're very aware that we need to work more closely with primary care.There's so much back and forth with emails and us trying to be helpful to primary care primary care, having concerns and needing our input, that the idea of actually training primary care keeps coming up for us as a service, like, how much can we involve them, how much can we train them? It's such a huge area of work. We know more and more patients are coming forward and we know very much that it can't just stay a specialist service.So as a service, we're very keen to have involvement from primary care. So we have Sara and we also have a GP trainee, which is great from more selfish point of view.It's been great to have a GP in the team because ADHD patients often have a lot of medical comorbidity and it's been great for us to be able to discuss that with a GP instead of needing to contact a cardiologist or go to another specialist. We know that probably this is, you know, within the remit of a gp, so it works well both ways.Speaker A00:04:27.969 - 00:05:05.980Great.And I think, as you mentioned, you know, I don't think any specialty or general practice practitioner would feel that less collaboration is a good thing. So I think the more the better. And I guess I'd recommend people listening to go and read the full article here and take a close look at it.But I wanted to specifically focus on Table 1, which lists some common ADHD medication and then some key practical advice around prescribing it.But I wonder if you could just summarize some of the common areas we should be considering in general practice amongst patients who are being prescribed ADHD medication. What are your top tips?Speaker B00:05:06.300 - 00:06:14.360I think some of the most common symptoms and side effects that we see with patients taking medications are things like appetite suppression and weight loss.And there are some basic advice that can be offered to a patient who might be Experiencing these, such as having a big breakfast, taking the medication with or just before. Sorry, just after food. And if this is still a persistent issue, then we would encourage the GP to refer back to secondary care.Another common issue is sleep disturbance. And again, some advice the GP can give can be taking medication. Medication at different times of the day, such as taking it earlier.Often a lot of these things would have been worked out with the specialist when they're being titrated, and often by the time the patient gets to the gp, these symptoms would be stabilised and the patient would be stable.However, things can change and I think what the GP needs to look out for is any new symptoms or any new side effects that weren't present before and be able to identify what's normal, what's acceptable, what would be sufficient for simple advice and what needs to be flagged back up to the psychiatrist.Speaker A00:06:14.840 - 00:06:26.840And I guess that touches on the next thing, which is shared care agreements in ADHD prescribing. And I guess, where do you think the GP role lies here in terms of monitoring and assessing side effects of treatment for adhd?Speaker B00:06:27.880 - 00:07:16.120I think it's a really complex question, actually, and quite controversial because the NICE guidelines do say that the annual review should be done by someone with expertise in adhd, but often we know that that can fall on the gp.And I know there are lots of discussions in various areas across the country of how to best manage this and create a more uniform shared care agreement, which is really clear on who's doing the reviews.And I think essentially, if the GP is feeling confident and competent to do the reviews and they have a good pathway back to secondary care and a good support system to raise any red flags to, then that could be something that gps might be comfortable and can consider. But there are funding implications for that and I think that it's probably a wider issue that needs to be addressed. Absolutely.Speaker A00:07:16.280 - 00:07:18.520Nishi, do you have any thoughts about that at all?Speaker C00:07:18.680 - 00:09:38.930It's a very hot topic, really, because of the number of patients that are being diagnosed and that are taking treatment. For any service to manage annual reviews for thousands of people is not feasible.So I think, and I agree with Sara, that you know, where there is a level of confidence, and I think our hope with this article was to give gps confidence and to enable them to almost realize that they probably are able to do this. They. They manage such severe illness, they manage all kinds of medications, they. They do have the knowledge.So I guess we wanted to share that it's not that specialist an area for most patients can be managed. But we do appreciate that there are the more complex patients, there are the ones that do need to be seen in secondary care.And we would just really like a much smoother collaborative working where it's easy for the GP to ask and it's easy for us to see the person that would be the ideal.With shared care, the GP always knows I have someone I can speak to, I can send a quick email, I can get a response without the really hard kind of boundary of you have to do this and you have to do that.And I think within shared care, the fact that the GP is prescribing every month, there is a level of, you know, that's a huge responsibility to actually, you know, prescribe something and to know what you're prescribing and what the problems may be.And I guess there'll be situations where a patient might have been seen by someone in the GP practice saying, you know, I'm worried, I'm losing weight, and then the next prescription is due and the GP prescribes, but just knowing that, ah, that came up. Let me just think about that. Is that a problem here? And be able to respond confidently Or I need to speak to someone, I need to ask a question.So I think shared care is a big. Is kind of a big topic. But as Sara and I have discussed, GPs are, you know, are really top of their game and we think it is.I feel very much that the shared knowledge and the reassurance and the being this kind of incredibly supportive backup service would really help if we could. If we could achieve that.Speaker A00:09:39.970 - 00:09:53.070And the kind of systems that you're putting in place, having GPs with extended roles and trainees in your service, I think will only help upskill people going forward. So that might be a nice template for other, other areas to take on as well.Speaker C00:09:53.310 - 00:09:55.710Let's hope. Yeah.Speaker A00:09:55.790 - 00:10:32.730Yeah, brilliant. And it's really useful in the article as well.You have a list of typical medications and their typical and common side effects and some key practical advice around it. So I think that's really helpful for people to go back and take a look at as well.So for anyone listening, again, if you've got people on these medications and you're wondering about what the common side effects are and practical advice, I think that's a really helpful place to look for that. And I guess really my next question is about.Sorry, you touched on this and do you have any advice on when people should be referred back to secondary care for review? What are your thoughts on this?Speaker B00:10:33.050 - 00:11:23.100Yeah, it's A good question.So I think from the GP perspective, things to look out for, the red flags that would definitely prompt you to want secondary care input would be any patient presenting with manic or psychotic symptoms would absolutely need immediate psychiatry input and advice relating to their medication. And secondly, any time you're suspecting misuse or diversion that would prompt a secondary care referral.Any patient who's got new cardiac symptoms or high blood pressure and you need advice regarding the medication, whether stop or start, that would be a good time to get secondary care input.Any patient who's had weight loss, especially more than 5% weight loss, and you've excluded any of the physical health conditions you'd normally exclude with weight loss. These are the ones that come to mind. Nishi, do you have any other.Speaker C00:11:24.300 - 00:12:08.910I guess the only other ones are, and we do get this quite often is the patients that don't sleep, but partly, maybe linked to their medication, but often part of their ADHD or neurodiversity that often comes back to us as something to think about. And when the medications don't seem to work anymore, I guess that's the only other time.And again, there's a, often there's a very simple reason for it and hopefully gps can think about that. But it happens, you know, not, not often, but it does happen.Someone's life situation changes and actually their ADHD is more of a problem, the demands on them are greater and the medication doesn't seem as effective and that would be a very reasonable time to send someone back.Speaker A00:12:09.150 - 00:12:30.040And Sara, I know that you've really upskilled in this area and have got a lot of specialist knowledge about ADHD medication and management, but do you have any tips or advice just for regular jobbing GPs who might not have that expertise? Do you have anything that you want to tell them about, sort of maybe to boost their confidence or any tips that you want to sort of pass on to them?Speaker B00:12:30.120 - 00:13:18.790I think I've learned that it's not as complicated as it looks on the outside. I think, like I said at the beginning, a lot of gps feel a lot of anxiety about ADHD medications and I don't think they need to.There's not many ADHD medications and they all have very similar side effect profiles and things to look out for. So it's not like, like antipsychotics where there's lots of different things to think about for every individual medication.I think if I could give a take home message for gps, it's really to know what is normal with these medications and what needs escalating. And there are a lot of side effects that are normal and not to worry about immediately with these medications.So I'm hoping that in the Table 1, GPS can refer to that and feel more comfortable knowing, okay, this is something that we can expect and know when to escalate.Speaker A00:13:19.030 - 00:13:33.110And I guess from a general practice perspective, knowing our patients quite well over a long period of time helps us to sort of work out what's new or what's different and what may be down to the ADHD and what we need to be concerned about, really.Speaker B00:13:33.350 - 00:13:57.530Yeah, absolutely. I think in gp, we're in a unique position where we really know our patients. And like Nishi said, life circumstances do change.And although patients tend to be discharged when they're stabilized, anything in a patient's life can cause their medication to not work quite the same or a new side effect. And as gps, we're in a really good position to know what's normal for our patients and what's beyond our remit.Speaker A00:13:58.090 - 00:14:00.570Great. Anything that either of you want to add?Speaker C00:14:01.690 - 00:16:17.600I wanted to add something in terms of kind of simple things to reassure gps. I think the risk of misuse and diversion is a real fear for gps, understandably.But I think it would be good for them to know that the only medication out of the ones that we prescribe that really can be misused is dexamphetamine, and we don't prescribe it very much. So the other medications have been formulated such that they can't really be misused, they don't give that hit.And the rush that, you know, amphetamines would. Would give for people that do misuse them. So, you know, we tend to avoid prescribing dexamphetamine.We would only prescribe as someone who is a very low risk of misuse, you know, who does not have a history or very low risk. And the one that we prescribe more is lisdexamphetamine. So the kind of modified release formulation which can't be misused. So, you know, it's.It's formulated in that way. So I think this. This fear of diversion is. Is not as great as it needs to be.It did become a little bit of an issue when we had supply problems with lisdexamphetamine.We were needing to prescribe more dexamphetamine, but we were very aware that we don't want loads of dexamphetamine out there in the community, and it was only really prescribed when it should be, when it needed to be. So I think this idea of Lots of people misusing their medication isn't quite the case.And we know that people with ADHD are at greater risk of developing a substance misuse problem. We know that if their ADHD is treated, that risk is hugely reduced. They're a lot less likely to misuse drugs if they have ADHD treatment.They don't have the desire or the need to do that. So. And that often becomes a problem. Like someone say, oh, this person has misused in the past, they've had substance use problems in the past.We shouldn't be prescribing this. These medications for them. It's quite the opposite. Prescribe these medications for them and help them not fall back into that problem.So I think that should be. I hope it's reassuring.Speaker A00:16:18.240 - 00:16:21.040Thank you. Anything that you want to add, Sara?Speaker B00:16:21.760 - 00:16:48.500No, just for really gps to be aware of ADHD and feel a bit more comfortable with adhd, both in terms of picking up patients who are undiagnosed historically under diagnosed cohorts like women who have more internalized symptoms and to be comfortable referring and to be more comfortable in the shared care agreements and familiar with these medications that I think will be more commonly prescribed in the future.Speaker A00:16:49.110 - 00:17:12.470Thank you. Yeah. And as you point out, yes.As these medications and the prevalence of people taking them or increasing, it is an important area that we need to consider in general practice, especially as we take on prescribing.So thanks very much and I think that's been a really interesting chat around this area and a very topical and very practical article that you've both written. So thanks very much for your time. Thank you.Speaker C00:17:12.470 - 00:17:13.030Thank you.Speaker A00:17:14.400 -...

Risk of postural hypotension associated with antidepressants in older adults – what to think about when prescribing

Today, we’re speaking to Dr Cini Bhanu, GP and Academic Clinical Lecturer in the Primary Care and Population Health Department at University College London. Title of paper: Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary careAvailable at: https://doi.org/10.3399/BJGP.2024.0429Antidepressants are associated with postural hypotension (PH). This is not widely recognised in general practice, where antihypertensives are considered the worst culprits. The present study examined >21 000 older adults and found a striking increased risk of PH with use of all antidepressants (over a four- fold risk with SSRIs) in the first 28 days of initiation. TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.480 - 00:00:56.990Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today.In today's episode, we're speaking to Dr. Cini Banu, who is a GP in an academic clinical lecturer based in the Department of Primary Care and Population Health at University College London.We're here to talk about her recent paper in the BJGP titled Antidepressants and Risk of Postural Hypertension, A Self Controlled Case Series Study in UK Primary Care. So, hi Cinny, it's really nice to meet you today.I guess this is an interesting area to cover, especially as the prescribing rates for some antidepressant medications are increasing.But I don't know what your feeling is, but I'm not sure if many GPs would actually know that antidepressants are associated with poison postural hypertension. So, yeah, talk us through that.Speaker B00:00:57.310 - 00:01:18.350Yeah, so I think that's one of the reasons this study is so important.So definitely from conversations that I've had with gps that I work with and it's not commonly recognized that postural hypotension is associated with antidepressants, though it is by geriatricians, for example, where it's very.Speaker A00:01:18.350 - 00:01:41.850Well recognized and in this study used a big database to look at the risk of new postural hypertension associated with the use of antidepressants in people aged over 60.I guess there's quite a lot of in depth stuff in the methods, but I guess just for a summary for people who are interested in what you did, do you mind just sort of going over it at sort of like a high level?Speaker B00:01:41.850 - 00:02:54.200Yeah, yeah. So we looked at a big database, what we call a routine primary care database called imrd.And essentially this captures data from software that gps use like EMIS and Vision System and captures a whole load of information like problems, symptoms and prescriptions. So we went into this database and identified everyone over the age of 60 that might be eligible during our study period.And for this we looked at people that were contributing at least one full year of data between 2010 and 2018. And then within that we identified people with a first diagnosis of postural hypotension.And then again we made subgroups according to people who had this diagnosis but also had a first prescription of a new antidepressant during that time.And what we were interested in, and the methodology is called a self controlled case series, we weren't interested in who got postural Hypotension, because everyone was a case, but rather when that diagnosis happened in relation to antidepressant exposure.Speaker A00:02:55.230 - 00:03:07.310And we'll talk about those different time points in a bit, but I wonder if you could just talk us through why that focus on people aged over 60 and why this is so important, especially in that age group.Speaker B00:03:07.710 - 00:04:22.710Yes, so two big reasons.So, postural hypotension is very, very common in people aged over 60 and we know that it affects around a third of people living out in the community. It's largely under recognized and under detected by gps and in prim care.And postural hypotension in older adults has significant risk of adverse complications and long term effects, including risk of being admitted to hospital, falls, fractures, but also later down the line it increases your risk of stroke and cognitive decline. So it's a really important common diagnosis. We're probably not managing as well as we can in primary care.Second is that antidepressants are actually used quite commonly in this group of patients.So we know that for people with late life depression, they're more likely to be given an antidepressant treatment for their depression rather than another therapy. So over 80% of people with depression in this age group are given an anti, are prescribed an antidepressant.So there's very high risk with both the exposure and the outcome.Speaker A00:04:23.510 - 00:04:50.610And I guess this comes back to the fact that, yes, a lot of GPs might not know about this as a risk. So it's really important that you've done this research.And so you looked at these different time points of people after starting their antidepressants and risk of postural hypertension. But talk us through what you found here.So in people who were taking one of the most commonly prescribed antidepressant classes, SSRIs, what did you find here about the risks?Speaker B00:04:50.770 - 00:06:05.480Yeah, so we actually found some really interesting time variable trends with the risk of postural hypotension associated with ssri. So we looked at two specific time periods.And that was initiating the drug, which was between a short period, days 1 to 28, and then days 29 to 56, which we treated as initiation, and then a continuation period, day 57 onwards.And what we've seen in SSRIs, but also all of the antidepressant drugs, is this peak in your risk of developing a new diagnosis of postural hypotension within that acute day 1 to 28 period.And so that was mimicked across SSRIs, tricyclic antidepressants and the other antidepressant group for SSRIs in particular, we noticed a fourfold increase in that day 1 to 28 peak that gradually declined as time went on.And tricyclic antidepressants and other antidepressants had a similarly increased peak, not to the same extent, but about twofold that declined with time.Speaker A00:06:05.960 - 00:06:17.240And we know that tricyclic drugs are often prescribed for other things as well, like pain. So do we need to be careful when prescribing it at lower doses for things like neuropathic pain?Speaker B00:06:17.240 - 00:06:51.460We didn't look into dosing, but it's certainly likely that the majority of these prescriptions were prescribed in low doses for other indications, like neuropathic pain, as you. You've said, and insomnia. And we've already seen a twofold increased risk in that acute initiation period, likely for low doses.So there is certainly a risk to be aware of in older patients that we're prescribing tricyclic antidepressants to. And it's likely that as the dose increases, that this risk increases.Speaker A00:06:51.620 - 00:07:04.400And I think one thing that's really important here is that the effect sizes are actually pretty significant. So this could represent a fairly significant risk for patients, especially in that initial peak time that you mentioned.Speaker B00:07:04.960 - 00:07:38.380Absolutely, yes.And I think there's certainly a striking risk associated with SSRIs in this group, and a lot of it depends on the context of the person you're prescribing this medication to.So whilst we know there's a fourfold increased risk in this study, you may be more cautious with someone who is at greater risk of postural hypotension at their baseline anyway, either related to advancing age or other chronic conditions like diabetes or Parkinson's, for example.Speaker A00:07:38.700 - 00:07:53.740And I think what's really interesting is you point out in the paper that actually postural hypertension isn't highlighted as a common side effect in the BNF for these drugs. So it seems with such a significant effect that probably that's something that should be highlighted.Speaker B00:07:54.300 - 00:08:19.640Yes, that's something I think is really, really important.So you'll often see hypotension cited as a side, but they are quite different and the assessment is different and how you might manage it would be different too. So I think it's definitely really important that that increased risk of postural changes in blood pressure is documented for these medications.Speaker A00:08:20.760 - 00:08:46.019I think it's interesting because often when people start these medications, they might have an early review with a GP about how they're getting on with it. And often that that initial review really focuses on mood and how they're coping and may touch on side effects.But I'm not sure that at the moment that sort of initial review would include a check for postural hypertension, for instance.Speaker B00:08:46.179 - 00:09:28.160I think it's unlikely.And whilst many of us may be very good at asking about side effects more broadly, I think one of the barriers here is that a lot of patients may not recognize the symptoms of postural hypotension, or if they experience dizziness on standing and it's transient, they may not think it's important to report to their gp. And that's something that we've gauged from our PPI group that are involved in this study.So really, it does need for a clinician to ask directly about postural symptoms and maybe even check their lying and standing blood pressure.Speaker A00:09:28.320 - 00:09:39.500I guess that overlaps with what I was going to ask next, really, which was really, what should we be telling people starting these medications? And is there anything that GP should be doing differently in practice as a result?Speaker B00:09:40.060 - 00:10:32.290Yeah.So I think some really simple things about just warning patients that they might experience these side effects and symptoms to report, like dizziness on standing or other symptoms like blurred vision or feeling light headed on standing upright, are important to make note of and to report to report back in itself will make a huge difference. But just also some general advice around reducing falls risk during this period.Once you've initiated an antidepressant, which will look different from person to person, things like keeping well hydrated and reducing alcohol intake are all conservative measures that can reduce your risk of postural hypotension and its adverse outcomes.Speaker A00:10:32.530 - 00:11:03.330And we know that for some medications, side effect profiles might only last in that first initial period.So often for SSRIs, for instance, I might mention to a patient, you may experience some gastrointestinal type symptoms for the first couple of weeks, but they may ease. So do you think your findings would support that of maybe being a bit more cautious in that first month?But then how would you recommend we monitor that? Or do you think it's really that initial peak that people need to be looking out for?Speaker B00:11:03.650 - 00:12:06.680Yeah, it's an interesting question.And certainly the results in this study where we looked at the three antidepressants, that's what the consistent trends seem to show, that it's the early acute period that's of greatest risk and your risk subsides over time.And it probably does align in the way that different adverse effects like you've mentioned GI adverse effects and the pharmacodynamics and pharmacokinetics of a drug lead to this initial period being the highest risk.So what I would say is I think that period is definitely a key time where it seems that giving this type of preventative advice and potentially even monitoring people who are at high risk is of greatest importance. But whether or not they're completely risk free later down the line, I think that's a difficult question to answer.And again, it will be different based on who you have in front of you and what their underlying risk of developing postural hypotension is at baseline.Speaker A00:12:07.320 - 00:12:30.480Yeah.And I think this study is really important in highlighting that risk because I think there are some drug classes where you may be, as you say, quite cautious about prescribing because of a risk of postural hypertension. So you may be very cautious with the beta blocker in an elderly patient.But it's important, I think, to highlight these other drug classes as potential culprits because we. You don't want people falling over and.Speaker B00:12:30.800 - 00:13:00.760Absolutely, absolutely. Yeah. And I think traditionally we associate these antihypertensive and cardiovascular drugs as the ones to have the greatest effects.But a lot of studies show that this group of drugs, but also antidepressants and alpha blockers used for urinary symptoms all have very, very high risk of drug induced postural hypotension. So yeah, hopefully it highlights that range of risk.Speaker A00:13:01.720 - 00:13:32.300Yeah.And as you've mentioned, with some of these other drugs, for instance alpha blockers or antihypertensives, often they will be co prescribed, especially in a more elderly population. So it's really great to highlight the risk of additional drug classes as well.But yeah, I think that's been a really interesting discussion with a lot of really key take home messages for practitioners to take back to their work and to their patients. So yeah, I just wanted to say thanks very much for joining me to talk about this.Speaker B00:13:32.540 - 00:13:36.860Great. Thank you so much. Thanks for having me and thank you.Speaker A00:13:36.860 - 00:14:00.550All very much for your time and for listening to this BJGP podcast.Cini's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com and Cindy has told me that she will be presenting this work at the Society for Academic Primary Care Conference which is happening in Cardiff this year. Thanks again for listening and bye.

The ‘new kid on the block’ – same day versus routine care appointment systems in general practice

Today, we’re speaking to Dr Jamie Scuffell, GP and NIHR In Practice Fellow at King’s College London.Title of paper: Patterns in GP Appointment Systems: a cluster analysis of 3480 English practicesAvailable at: https://doi.org/10.3399/BJGP.2024.0556GP practices in the UK are using a wide range of different appointment systems to meet patient demand and improve access. This cluster analysis of NHS appointment data from 56 million appointments and 3480 English practices demonstrates two predominant models of primary care delivery. ‘Same day’ practices tend to fulfil appointments on the same day using GP telephone consultations. ‘Routine care’ practices tend to employ non-GP staff members offering face-to-face appointments and longer appointment wait times. ‘Same day’ care practices had younger and more urban populations. Episode transcriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.640 - 00:00:54.360Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.Jamie Scuffle, who is a GP in South London and an NIHR In Practice Fellow at King's College London. We're here to talk about a really topical issue in his new paper here in the bjgp.The paper is called Paper Patterns in GP Appointment A cluster analysis of 3,480 English practices.So, hi, Jamie, it's really great to meet you and talk about this work, I guess, really just to start, as you point out in this paper, each practice has their own systems and strategies to manage appointment booking. But how do you think that this impacts on access and patient appointment booking in each practice?Speaker B00:00:55.000 - 00:02:17.300Yeah, it's interesting because I think, as you say, appointment systems have developed even further, really, since COVID and we've ended up with this a quite interesting diverse range of implementing appointments across the country, across England at least.And I suppose the things that have changed are, you know, if you phone up a practice now, actually, you might not even phone them up, you might submit an online consult, you might be triaged, you might see not a gp, but a range of other professionals as well. And also it might not be done face to face, it might be done by telephone or online.In fact, there's a new appointment system range of things that have happened across England, and actually there's some evidence that that might relate to access in some ways. So we know lots of people who don't speak English struggle to navigate that system of getting an appointment, for example.And we also know from the qualitative evidence that there's some digital exclusion as well with appointments. So, yeah, so I think there's lots of issues with access and how that relates to appointment systems.And so far what we've done is looked at components of the appointment system and how that then affects access. But what we haven't really done much of is looking at the appointment system as a whole and how that might affect access.Speaker A00:02:18.180 - 00:02:33.200Yeah.So in this study, you wanted to look at patterns of primary care delivery in English GP practices, and you used this Appointments in General Practice data set. Can you tell us just briefly what's available in this data and what you were looking at here?Speaker B00:02:33.360 - 00:03:20.700It's a tremendous data set and I think could be very useful. So every English GP practice for every day of the week publishes up to NHS England.The appointments that have Happened for the day across lots of different categories, actually, so across whether they've been attended or not, or not attended, whether they're face to face or telephone or home visits or online also if they're GP or non GP appointments. And the sort of. The real clincher that is brand new is looking at appointment lead times as well.Whether these appointments were booked same day or whether they were booked more in advance when the data is good enough, which is an. If it's a very, very useful data set.Speaker A00:03:20.780 - 00:03:43.720Yeah, so you looked at data from about three and a half thousand practices this year. So as you mentioned, you weren't able to look at all practices due to quality issues.But just talk us through what you were looking at here and I guess, yeah, just start us off with telling us what you found and perhaps we'll get into how you group the practices as well into clusters. But yeah, tell us a bit more about what you found here.Speaker B00:03:43.720 - 00:05:23.440What we wanted to do was take a set of measures, I suppose, of an appointment book.So for every practice we said, well, actually we might define their appointment book by the proportion of people who see a GP or the proportion of people who have a telephone consult, or the proportion of people who are booked same day and seen same day. And we kind of came up with actually about 12, in the end, 12 measures of an appointment book.What we then wanted to do was kind of group together practices with similar characteristics and we picked two different types. I suppose these were the two poles at either end of the spectrum.And the two poles are that there's a more traditional, what we've called a routine care group of practices, and this is about two thirds of the English practices that we included.And the appointment characteristics they had were they are more likely to book in advance appointments rather than booked on the same day, more likely to be face to face appointments, interestingly, more likely to use not just GPs but also non GP appointments for delivering care. So they're the big categorization of the routine ones.So longer wait times, more likely to use non gps and more likely to have face to face appointments.And then I suppose there's the sort of the more the newer style of appointment system, which we've called the same day appointment system, and that's more likely to be led by GP telephone consults that happen and are booked on the same day. And in this case, same day appointment availability is quite substantially higher than the routine care practices.Speaker A00:05:23.600 - 00:05:34.560And you found that actually there was quite a lot of difference within the practice population and where the practice was based on these two sort of clusters. So the routine and the same day practices as well.Speaker B00:05:34.960 - 00:06:59.980Yeah.It's absolutely fascinating that it's not just differences in the appointment systems, but actually there are underlying differences, not just in the practice populations, but also in the workforce associated with each of those practices. So the practices that were same day, much more likely to be in urban serving urban populations rather than rural populations.Also, this might just be an account of. Because they're more likely to serve urban populations, they also serve more ethnically diverse populations.Interestingly, no big differences between deprivation. And then also the same day practices have a very slightly younger population overall than the routine care practices.List size is also slightly bigger with those same day practices compared to those that have a more routine approach. Also, differences in workforce.The number of direct patient care staff, full time equivalents per 10,000 people on the practice books is a bit higher in the routine care cluster than the ones who are delivering same day care.And the differences are that actually GP levels are pretty much the same, but the routine care cluster employs more nurses and more nurse practitioners and also employs slightly more administrative staff.Speaker A00:07:00.540 - 00:07:19.490Yeah.So you work as a GP and I just wonder from your own experiences whether what you found in this data reflects what you know or understand sort of on the ground and whether you had any insights from your own work, which might sort of explain why there are these differences, or if you had any thoughts about that.Speaker B00:07:19.650 - 00:08:44.140I did a whole load of locoming when I finished training, actually. It was fascinating to go to a dozen practices over a period of time and look at how the appointment system was set up.And I think when you're an individual GP behind a door, seeing patients, it's sometimes quite hard to anchor yourself in the wider picture of what's happening at other practices, even the one just down the road.So I think it's quite interesting to think about how especially the slightly more bigger practices where I work in South London do tend to have had a more of a same day approach to delivering appointments and have also been a little bit more telephone, triage, telephone first in their approach for a longer period of time.So I think the, I mean, one of the challenges of when you cluster these data is you can cluster into lots and lots of different clusters, but what you're trying to do is make it meaningful to and interpretable to people and practitioners. And I think those two very much.I can, I can picture practices that operate in those two different ways, even though they actually have quite close in geography together. Quite close in geography.And I suppose then it's interesting to think about not just how the appointment system is set up, but then kind of patient outcomes as well that might be associated with those two approaches.Speaker A00:08:44.620 - 00:09:13.990One sort of interesting area that some papers have looked at is this sort of balance between quicker access and other outcomes. So, yeah, as you point out, same day access might allow quicker access, but might tend to be on the phone.And whether that has impacts on other things in the practice, such as continuity of care. And what are your thoughts on that? And the balance shown in this data between sort of maybe quick access versus more routine type care.Speaker B00:09:14.310 - 00:10:12.150I think it's so interesting with the potential opportunities to increase continuity of care are actually potentially higher with more of a same day approach, or at least a same day triaged approach.I think depending on who you talk to, some people might say, well, actually if you are triaging patients, you could very well increase continuity of care.But I think our general feeling is that we know same day appointment availability isn't necessarily associated with increased patient satisfaction in the GP patient surveys. And then we also know that patient satisfaction is in some way associated for some people with continuity of care.So I think there's an argument for saying it could go either way with the same day approach either encouraging or discouraging continuity of care, depending on the context, which I have to say is difficult to get at with these data.Speaker A00:10:12.790 - 00:10:32.940But yeah, another area I was interested in in your data was that the same day access was associated with more urban practices and also a younger population. And I suppose it's just sort of thinking about the patterns of why this might be occurring.And do you think it's sort of patient driven or do you think it's practice driven?Speaker B00:10:33.500 - 00:12:18.490That's really interesting. I mean, we know. I think it's probably a bit of both. Let's start with practice driven.So we know that some of the ethnographic work demonstrates that practices organize appointment systems not just around clinical need, but also around demand. And they might not be the same.And also there are other components, as we've said, you know, there are workforce differences between these two practices as well, which may have come about as a result of the differences in appointment systems, or it may just be necessity that there's lower employment of GPs in these more routine traditional type approaches and therefore there's employment differences there. So the appointment system may have come about as a result of those practice factors.I think patient level factors are really interesting and I think that's where the work should go next. Although we know that the same day care type Practices do have a slightly younger population.What we don't know from these data is who is consulting more, who is consulting less.It might be that actually these same day practices do just as good a job or even better job at responding to clinical need once we take into account the consultation rates between two groups.So I think it'll be really interesting to try and look at these patient level data and look at the experience of a single patient with a particular characteristic who's, who's subject to different types of appointment systems and then see if that does really affect outcomes. I think that's, that would be a really interesting thing to do next.Speaker A00:12:18.970 - 00:12:47.610Yeah, so I guess that's sort of thinking about the impact of these different practice systems because we know that practices may decide to adjust their systems based, as you said, on their staffing or their patient population. But I guess as you mentioned, we don't really know what the impact is on for patient satisfaction.Or do you think there's some way you could match this to the GP patient survey or the GPPS survey to sort of look at satisfaction as well?Speaker B00:12:48.250 - 00:14:04.400Absolutely. Next step, I think is to try and do that. Yes. And if anyone's interested in any of this, I'm always really happy to speak to people, to collaborate.We've had some, few really good papers recently looking at the association between appointment data and patient experience from single components. So looking at same day appointments particularly and demonstrating that increasing.This is Patrick Birch, I think, and teams work in Manchester looking at the fact that if people have increased same day appointments that there might be a reduction in patient satisfaction and also scores of access and continuity in the patient survey.What would be really interesting is to try and look at this a little bit more causally, I think, and ideally identify where practices have changed deployment system and then look at corresponding changes in satisfaction.So I think one of the challenges is this is all ecological data and it's easy to draw strong conclusions from those data without really understanding the underlying mechanisms of what's happening. And as we've spoken about, there are lots of things going on in here.Speaker A00:14:04.400 - 00:14:07.800Any other key findings you want to highlight from this, this paper?Speaker B00:14:08.120 - 00:14:47.090Well, I suppose only just briefly to talk about the administrative differences between the two groups.I think it's really interesting that even though there might be a whole mechanical change in the same day approach practices and you know, it demonstrates that these practices are, they've got a bigger list size but they've also got potentially some administrative economies of scale as well in managing, in managing the appointment load that's coming through.There's a bit more work to understand what really is happening with the mechanics of these practices compared to the ones that have a more traditional approach.Speaker A00:14:47.650 - 00:15:07.460So it sounds like, yeah, there's a lot of more that we could do in the future in terms of research to understand what's going on. But from this paper, do you think that there's any nuggets that practices on the ground could pull from this research?And I think you've mentioned some of it just about sort of understanding their own appointment book and things. But do you have any thoughts about how this paper and the results could be used?Speaker B00:15:07.940 - 00:16:25.240I think it's really interesting to see the diversity and the grounding of your practice versus other people's other practices. And so I think that's one piece is just really understanding where you sit compared to others.I mean, the other real thing that would be great to understand a bit more is we spoke about the appointments in general practice data quality, and the data quality is limited really by the fact that when we look at our appointment books in gp, they're multicolored and all of the colours correspond to a particular category and those categories aren't well matched up to NHS England categories.And although we did do some work to show that the practices we did include and didn't include looked much the same in terms of demographic characteristics and practice characteristics, it would be nice to be able to do a full census of appointment systems and if there is a spare five minutes for any practice manager listening, to be able to just categorize those few appointment types will just mean that we can then, you know, help feedback some of these data that are going up to NHS England back down to gps and help to understand a little bit more about, you know, what's happening on the ground and be able to understand these effects a bit more, I think.Speaker A00:16:25.320 - 00:16:50.240And as you mentioned, I think you're absolutely right that at a national level and in terms of guiding policy, decision making and what the best sort of systems are, it's important to have a big picture look at the data. So I think that's really fascinating work, work that you've done here.But yeah, I think that's been a really interesting conversation around this area and good luck with your future work, but it's been great to chat to you about it.Speaker B00:16:50.640 - 00:16:52.040Thank you. It's been great to chat to you.Speaker A00:16:52.040 - 00:17:17.799Too, and thank you all very much for your time here and thanks for listening to this BJGP podcast. Jamie's original research article can be found on bjgp.org and the show notes and podcast audio can be found at bjgplife. Com.It's been great to talk again about some of the balancing between access, continuity and patient satisfaction, so do go back and take a read of Jamie's paper. Thanks again for listening and bye.

More chest x-rays lead to earlier lung cancer diagnoses and better cancer survival – what we can be doing differently in practice

Today, we’re speaking to Dr Steve Bradley, GP and Senior Clinical Lecturer based within the School of Medicine and Population Health at the University of Sheffield.Title of paper: General practice chest X-ray rate is associated with earlier lung cancer diagnosis and reduced all-cause mortality: a retrospective observational studyAvailable at: https://doi.org/10.3399/BJGP.2024.0466It is known that there is wide variation in the use of chest X-ray (CXR) by general practices, but previous studies have provided conflicting evidence as to whether greater utilisation of them leads to lung cancer being diagnosed at an earlier stage and improves survival. This observational study analysed data from the English national cancer registry on CXR rates for individual general practices, along with stage and survival outcomes; it found earlier stage at diagnosis and improved survival for patients diagnosed with cancer at practices that used the test more frequently. Increasing use of CXR by GPs for symptomatic patients, particularly by focusing on practices that use the test infrequently, could improve lung cancer outcomes.TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.640 - 00:01:06.820Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors at the Journal. Thanks for taking the time today to listen to this podcast.In today's episode, we're talking to Dr. Steve Bradley. Steve is a GP and senior clinical Lecturer based within the School of Medicine and Population Health at the University of Sheffield.Early diagnosis of cancer has been an area of research that is Steve's real strength. And we're here to discuss his recent paper here in the BJJP titled General Practice.Chest X Ray Rate is Associated with Earlier Lung Cancer Diagnosis and Reduced All Cause Mortality A Retrospective Observational Study. Hi, Steve, Great to speak again and to talk through this paper.I suppose I want to start by saying that, yes, we know that earlier diagnosis of cancer is a good thing because it can lead to earlier stages of diagnosis and treatment. And you start the paper with a short discussion about screening for lung cancer.But talk us through why this, this alone won't solve delays in lung cancer diagnosis and what else we need to be doing.Speaker B00:01:07.540 - 00:02:14.620So, yeah, this context is really important because screening is a hugely important development and the UK has led in many ways on lung cancer screening using low dose ct. And this, we hope is going to be very, very beneficial for patients.But it would be a mistake to think that this is going to solve the problem of lung cancer. And there's a few reasons for that.One is that only about half of people who get lung cancer would have been eligible for screening because screening concentrates on the highest risk population. And also we know that only about half of people who are invited for screening actually choose to participate in screening.So the upshot for general practice really is that most patients are still going to be coming through by symptoms and in the same way.So screening is good news in terms of lung cancer detection, but we still need to do as well as we can in terms of picking these patients up through symptomatic pathways. And actually, this is something we touched on in an editorial for BJGP about a year or 18 months ago, I think.Speaker A00:02:15.020 - 00:02:20.300Yeah. So talk us through that. What was that editorial focusing on? Just for people who may not have had a chance to read it.Speaker B00:02:20.620 - 00:03:10.660So it really was really discussing the situation where we are now in terms of awaiting for a national screening program for lung cancer screening and also considering the role of general practice.So we set out that, just as I've said, that the role of gps is still going to be very important for lung cancer detection, but also that there are certain considerations that are important for GPs in terms of understanding what the program is, because a lot of patients might come to us to talk about lung cancer screening.So it's good for us to have a basic understanding of what's involved and also some issues around the data that lung cancer screening uses, particularly smoking status.So it becomes particularly important for our smoking records to be as accurate as possible because a lot of decisions around eligibility for lung cancer screening may. May hinge on that.Speaker A00:03:10.740 - 00:03:20.340And just talk us through. So what were you trying to do in this paper?So in this paper you were looking at people sent for chest X rays in different practices, but talk us through why you wanted to look at this.Speaker B00:03:20.980 - 00:04:06.250Yeah, so this, this study was really inspired by earlier work which looked at rates of endoscopy requested from general practices and how that might affect outcomes for upper gastrointestinal cancers in terms of. Of when they are detected, what stage they are detected at.So One of my PhD supervisors, Matt Callister, had had this idea for this project, I think, going back around 15 years or longer, as to whether we could look at practices in terms of how much they use chest X ray, and then look at what happens to patients who are diagnosed with lung cancer, in terms of what stage of lung cancer they are diagnosed with, when they are diagnosed, and also with their survival as well. So that's really what we aim to do in this paper.Speaker A00:04:06.490 - 00:04:17.050Talk us through just briefly what you did and just. Yeah, it was quite a big study. But yeah, just briefly, how did you go about doing this?Because you looked at quite a lot of data, didn't you, to try to look at these different associations?Speaker B00:04:17.849 - 00:05:13.860So we took data on general practices from 2013 to 2017. So this is general practices in England. And we used the kinds of data that's available on general practice profiles.That website is also known as fingertips. And we got information on how often different general practices were requesting chest X ray in a year from the Diagnostic Imaging Data set.And then we also got data on lung cancer outcomes from the National Cancer Registry from the year after. So 2014 to 2018.So we put those together and we had Data on around 160,000 patients diagnosed with lung cancer in that period and information on general practices. Around 7,000 general practices.Speaker A00:05:14.500 - 00:05:23.780Let's go to what you found here. So what was that association between the rate of practice chest X rays and stage of cancer diagnosis? What did you find here?Speaker B00:05:24.520 - 00:07:23.330So what we did was we broke up practices in terms of how often they were requesting chest X rays, and we did that in two ways. One was in five groups into quintiles and that was adjusted based on factors like demography of the practice, smoking status, et cetera.And then we had another set of categories which was just based on what we call natural frequency. So just numbers that weren't into three categories that weren't adjusted.And the purpose for that was we wanted to be able to have a way that people in practices or who are working in the health system could just eyeball figures and get a sense of where practices were and how this might affect outcomes. So we had those different categories.And for the quintiles we found that practices in the top quintile of chest X ray requesting had both improved stage of diagnosis. So we find an odds ratio of 0.87 favoring early stage diagnosis. So that's stage one or two compared to late stage, stage three or four.So an odds ratio of 0.87. So that's, that's a really quite substantial improvement. And also improvements in survival.So hazards ratio of 0.92 favoring one year survival for that top quintile, 0.95 for five year survival as well. And that five year survival that's using only patients who survived to at least one year.So that's, that improvement isn't just a reflection of the improved one year survival. So we feel this is really quite important.The other categories with the three different groups that what we call the natural frequencies, we didn't see the quite the same scale effect in the top grip, the top third group, but that's, that's really probably a dilutional effect because they're broader categories. So the top group isn't showing us the same scale of effect.Speaker A00:07:23.650 - 00:07:39.410And you've sort of alluded to this, but you know, each practice will have its own specific population and demographics. Was there anything at a practice level that influenced the rate of chest X ray requests or stage of cancer diagnosis or survival?Speaker B00:07:40.740 - 00:08:39.100So in terms of how often practices request chest X rays. So we've looked at this previously in a paper published in bjgp.It was called something like association of chest X ray rate and general practices and populations. And what was surprising just was really how minimal the effect of any differences at all are and recorded characteristics between general practices.So I think in its entirety what we looked at, all of the factors, including differences in populations and practices, accounted for less than 20% of the variation. So most of the variation that's happening is not from things that we can record or understand.Probably most of this variation is to do with human beings and cultures and what we believe about chest X ray and how valuable we think the test is and adjust our habits and things like that. And that's important because those things can be changed and we can influence those things.Speaker A00:08:39.900 - 00:09:03.270Yeah. And I think that's sort of where I was going to go next, really. And I guess the question is why?So why would practice level, sort of rates of chest ray, chest X ray ordering impact on lung cancer diagnosis and survival? And I know that the data here might not have answered that question, but what are your best guesses about this?And you've alluded to this a bit in terms of human factors.Speaker B00:09:04.150 - 00:10:40.920Well, I mean, I think the mechanism this would be working is that if people are doing more, they're taking the opportunity to organize more chest X rays for these very common symptoms. And if you look at the NICE criteria, which they say we should consider an urgent chest X ray, they're really very broad, common symptoms.Things like cough, shortness of breath, weight loss, chest pain, also raised platelet count, tiredness.So really symptoms that people mention all the time, People might mention this as an aside, or they might mention it during a chronic disease review or something else.So there is probably flexibility in terms of what primary care teams do, in terms of what they do with those kinds of disclosures, whether they organize tests like chest X ray or not. So lung cancer is challenging because it usually presents with symptoms which are very common, very non specific.For example, a cough is the most common symptom, but cough is a very common symptom in general.So our thinking is really that if teams are more vigilant about how they investigate these common symptoms with chest X ray, they'll be picking up disease earlier.It's important to say there are limitations with chest X ray, but I think this evidence really gives us some grounds to say we should should use the test, even understanding that there are limitations in terms of accuracy. And although it isn't always successful in picking up lung cancer, it does do it a fair amount of the time and we can use it effectively.Speaker A00:10:41.560 - 00:11:07.350So we both used to work in Leeds where there used to be an open access chest X ray clinic or a self request chest X ray service. So this is where people aged 40 and over could, with symptoms potentially suggestive of lung cancer, could just walk in and request a chest X ray.Do you think that services like that should be made more widely available if more chest X rays potentially could lead to earlier diagnosis?Speaker B00:11:07.750 - 00:12:58.690Yeah. So this is a self request chest X ray service. So not to be confused with open access which tends to be used for the way that we request chest X rays.You know, you request, the GP requests it on the computer and then the patient turns up within two weeks, say, and they're able to just get it at their convenience. So, yes, self request services have been used in Leeds now for well over a decade and also are being used in Manchester and elsewhere.So, yes, I do think these could be used more widely and we know that they are successful in reaching the right patients, patients who have a history of smoking and patients from less affluent communities as well.And we know also that the proportion of these, these chest X rays that are leading to cancer diagnosis is around equivalent of what gps request as well. I think these services are a good thing, really, because there are patients who find it hard to access general practice to get appointments.There are patients who also don't want to talk about their symptoms and are worried that they're going to be given a lecture about smoking if they come with respiratory symptoms. And so it just suits some patients.I think in principle it's a sensible thing to do, but I think, particularly at the current time, where access to general practice is so difficult, or even where it isn't, even where it isn't that much of a problem, patients still have a perception that it is going to be very difficult to get a general practice appointment. So I do think it's a valuable thing to do. And we published a paper in BJGP at the start of this year.It was recommendations from the Roy Castle Lung Cancer Foundation Group on symptomatic diagnosis. And that was one of the points made in there about expanding these services.Speaker A00:12:59.090 - 00:13:19.030And you've mentioned about some of the limitations of chest X rays, and I know that you've done a lot of work around chest CT as well. And what do you think the role is of a chest ct? And do you think that patients with symptoms suggestive of lung cancer.Is there a balance between requesting a chest X ray or chest CT in general practice? What are your thoughts about that?Speaker B00:13:20.310 - 00:15:30.850It's difficult.The guidelines internationally almost all say that for most potential lung cancer symptoms, except for hemoptysis, coughing up blood, the chest X ray should be the first line test. But we know that there are problems in terms of accuracy.It's missing around about a fifth of cases of lung cancer, which is not something we should be complacent about because this is such a devastating disease and we need to pick it up as soon as possible.But there are really practical limitations around ct, and particularly in a country like the uk where we just have a lot less access to CT than other high income countries like Australia and the us. So I do think it's a balance actually.I think it would be a mistake to just give into a council of despair and that we think chest X rays rubbish and isn't worthwhile, particularly when it's going to be difficult for us to get CTs for our patients. But at the same time CT's kind of drawbacks as well, even if we did have perfect access in terms of over diagnosis as well.So in terms of what we should do practically, this is a kind of classic problem for gps, particularly in countries like the uk, where we have limited access to ct. And in theory all English gps now have access to urgent direct access ct.I think it's probably more complicated on the ground and I'm not sure if that theory has translated into practical reality for a lot of GPs working in England. So I think GPs really just need to use their intuition quite often. I said just use. It's actually a really difficult thing to do.But it depends, in short, it depends on how worried you are, you are about your patient and how concerned you are. And also it is the case that a lot of these symptoms overlap with other serious conditions, not just cancer.So even if you do get the perfect test that rules out lung cancer, the job isn't over there. You, you probably do need to think about other serious conditions as well.Speaker A00:15:31.650 - 00:15:48.630Fair enough.And yeah, we could sidestep into whole discussion here about so called gut feelings and when clinicians feel inclined to make certain decisions based on that intuition, that clinical intuition as you describe, which I think is a better way of conceptualizing gut feelings. Really.Speaker B00:15:48.870 - 00:16:14.720Yeah, I mean I think we could be, we could be frustrated by this and, and, and want clearer guidance and clearer evidence at the same time. This is really our job as clinicians and it's something we should take pride in and how we think through these problems.And this is why, this is why we're, we're here. So it is, it is one of the difficult aspects of the job, but it's also an aspect of the job we should take pride in as well, I think.Speaker A00:16:14.800 - 00:16:26.080And Steve, this is sort of, you know, your, really your area of focus and research and knowledge, but is there anything else you want to add here about chest X rays in general practice? Just before we wrap up?Speaker B00:16:26.240 - 00:17:23.730I think the take home here really is the chest X ray is a useful tool. The radiation dose is negligible. It's equivalent to a few days of natural exposure to radiation and the test is useful.So if the possibility of lung cancer is crossing your mind, I think a good first step is doing a chest X ray.And it's worthwhile knowing what just having the odd glance at what the NICE NG12 symptoms for possible lung cancer are because it's really surprising how broad these are. And a lot of our patients will come to us with these, with these symptoms.The other thing is that an increasing...