Impact of Increased Patient-Clinician Virtual Visits During the COVID-19 Pandemic on Medical Student Enthusiasm for Future General Practice Careers.

BACKGROUND: The COVID-19 pandemic restricted the availability of face-to-face primary care visits. This rapidly increased the proportion of primary care patient-clinician visits conducted virtually and asynchronously (remote consultations via video, telephone, and web-based text/email), altering the educational environment for medical students. Our study explored the impact of the increased proportion of primary care visits conducted virtually and asynchronously, on medical students' self-reported interest in pursuing a career in general (family) practice. METHODS: We conducted a cross-sectional survey study of medical students at six universities within England and Wales to explore the impact of the increased proportion of primary care visits conducted virtually and asynchronously on medical students' interest in pursuing a career in general practice. RESULTS: One hundred fifty-four medical students were recruited between December 2020 and May 2021; 79 (51%) of the participants reported being less interested in pursuing a career in general practice as a result of the increased proportion of virtual and asynchronous primary care visits during the COVID-19 pandemic. This increased to 104 (68%) of the participants reporting being less interested should primary care visits continue to be delivered virtually or asynchronously by default. Analysis of open-ended survey questions identified a poorer educational experience, concerns regarding the impact on patient care, an isolated working environment and technological challenges as key negative themes. CONCLUSIONS: Sociable, supportive working and learning environments and offering equitable care are important motivators for the future workforce. There is a need to develop robust training and assessment in patient-clinician virtual visits and asynchronous communication and to integrate this into curricula.

Targeted encouragement of GP consultations for possible cancer symptoms: a randomised controlled trial.

BACKGROUND: For some common cancers, survival is lower in the UK than in comparable high-income countries. AIM: To assess the effectiveness of a targeted postal intervention (to promote awareness of cancer symptoms and earlier help seeking) on patient consultation rates. DESIGN AND SETTING: A two-arm randomised controlled trial was carried out on patients aged 50-84 years registered at 23 general practices in rural and urban areas of Greater London, Greater Manchester, and the North East of England. METHOD: Patients who had not had a consultation at their general practice in the previous 12 months and had at least two other risk factors for late presentation with cancer were randomised to intervention and control arms. The intervention consisted of a posted letter and leaflet. Primary outcome was the number of consultations at the practice with patients randomised to each arm in the 6 months subsequent to posting the intervention. All patients with outcome data were included in the intention-to-treat analyses. RESULTS: In total, 1513 patients were individually randomised to the intervention (n = 783) and control (n = 730) arms between Nov 2016 - May 2017; outcome data were available for 749 and 705 patients, respectively, with a statistically significantly higher rate of consultation in the intervention arm compared with the control arm: 436 versus 335 consultations (relative risk 1.40, 95% confidence interval = 1.11 to 1.77, P = 0.004). There was, however, no difference in the numbers of patients consulting. CONCLUSION: Targeted interventions of this nature can change behaviour; there is a need to develop interventions that can be more effective at engaging patients with primary care. This study demonstrates that targeted interventions promoting both awareness of possible cancer symptoms and earlier health seeking, can change behaviour. There is a need to develop and test interventions that can be more effective at engaging the most at-risk patients.

Improving Access to Psychological Therapies for older adults: auditing management of newly diagnosed mild and moderate depression in six general practices within the Birmingham and Solihull CCG.

BACKGROUND: The first-line treatments for mild-moderate and moderate-severe depression according to the National Institute for Health and Care Excellence clinical guidelines for the management of depression in adults are psychological therapies followed by or alongside pharmacological treatment. We conducted an audit of patient records (as recorded by general practitioners (GPs)) to compare practice to the guidelines. METHODS: Incident cases were retrospectively identified from electronic primary care records (SystmOne). From 40 320 registered patients, cases were identified based on previously coded new diagnoses of depression in the 2016-2017 and 2017-2018 Quality and Outcomes Framework (QOF) years. Patient notes were screened for exclusion criteria (mental health problems that would alter management pathway) and for records of management discussions (pharmacological or psychological therapies) at the diagnostic appointment. RESULTS: In 2016-2017 (n=315), psychological therapies for depression were discussed at 63.2% of diagnostic appointments, they were most discussed at appointments with those aged 18-29 years (70.8%), but this decreased with age to 56.3% of appointments with those aged ≥65 years. In 2017-2018 (n=244), psychological therapies were discussed at 70.9% of diagnostic appointments but were discussed at more appointments with those aged 18-29 years (81.6%) and at less appointments with those aged ≥65 years (39.4%). Discussion of pharmacological management was similar for all age groups in 2016-2017 (89.9%) and 2017-2018 (93.0%). IMPLICATIONS: For patients aged ≥65 years, psychological therapies are featuring less in management discussions with GPs or are not being recorded. Recommendations for change implemented at the practice included feedback of results and professional reminders throughout the 2019-2020 QOF year.

Effectiveness of physical activity promotion and exercise referral in primary care: protocol for a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Physical inactivity is the fourth leading risk factor for global mortality. Reducing sedentary behaviour and increasing physical activity are efficacious for improving many physical and mental health conditions including cardiovascular disease, type 2 diabetes and depression. Reducing sedentary behaviour and increasing physical activity can also be effective at reducing obesity; however, sedentary behaviour and reduced physical activity are also associated with mortality independently. Despite this, most adults in the UK do not currently meet the UK Chief Medical Officers' guidelines for weekly physical activity. As most adults visit their general practitioner at least once a year, the primary care consultation provides a unique opportunity to deliver exercise referral or physical activity promotion interventions. This is a protocol for a systematic review of randomised controlled trials for the effectiveness of physical activity promotion and referral in primary care. METHODS: A comprehensive literature search of Embase, MEDLINE (Ovid), Web of Science (Core Collection), Scopus, CINAHL, PsycINFO, and The Cochrane Library (CENTRAL) will be conducted for studies with a minimum follow-up of 12 months that report physical activity as an outcome measure (by either self-report or objective measures) including an intention to treat analysis. The authors will screen papers, first by title and abstract and then by full text, independently assess studies for inclusion, appraise risk of bias and extract data. The quality of the evidence will be assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluations) approach. The primary outcome will be participation in physical activity at 12 months. Pooled effects will be calculated using random effects models. Results will be submitted for publication in a peer-reviewed journal and for presentation at UK national primary care conferences. DISCUSSION: This systematic review and meta-analyses will summarise the evidence for the effectiveness of physical activity promotion and referral as interventions for improving physical activity, as well as whether studies using objective measures of physical activity have similar effects to those studies using self-report measures. This knowledge has importance for primary care clinicians, patients and, given the focus of the recent NHS long-term plan on preventive medicine, those making policy decisions. SYSTEMATIC REVIEW REGISTRATION: The protocol is registered with PROSPERO the international prospective register of systematic reviews, ID CRD42019130831.

Factors associated with cognitive impairment in patients with newly diagnosed type 2 diabetes: a cross-sectional study.

OBJECTIVES: Type 2 diabetes (T2DM) is strongly associated with cognitive impairment but the factors within T2DM that predispose to cognitive impairment are less well understood, while previous studies have investigated samples with T2DM of widely varying duration. We aimed to investigate the factors associated with cognitive impairment in patients with newly diagnosed T2DM. METHOD: In a multi-ethnic sample with T2DM diagnosed in the last 6 months, we assessed cognitive function using the 13-item modified telephone interview for cognitive status (TICS-M). Cognitive function was assessed both categorically (impairment defined as lowest 10% of scores with the remainder as controls) and as continuous TICS-M score. Its associations were tested in univariate and multivariate analyses with a range of biological, psychological and sociodemographic factors. RESULTS: Of 1790 participants, 1680 had a complete TICS-M assessment at baseline. After controlling for covariates, older age (p < 0.001) and lower verbal intelligence (p < 0.001) were associated with both cognitive impairment and lower TICS-M scores, while non-white ethnicity (p < 0.001), female gender (p = 0.02) and higher HbA1c (p = 0.002) were associated with lower TICS-M scores. Depression (defined as Patient Health Questionnaire-9 score ≥10), elevated inflammatory markers and body mass index were not associated with cognitive function after controlling for covariates. CONCLUSION: Age, verbal intelligence, female gender and HbA1c are associated with cognitive performance in T2DM soon after diagnosis. Previously reported associations with depression and inflammatory markers may occur later as causes or consequences of T2DM. Longitudinal analyses are needed to assess potentially modifiable factors predicting cognitive decline in early T2DM.

The association between depressive symptoms and systemic inflammation in people with type 2 diabetes: findings from the South London Diabetes Study.

OBJECTIVE: The prevalence of depression and depressive symptoms is increased twofold in people with type 2 diabetes compared with the general population and is associated with worse biomedical outcomes and increased mortality. Type 2 diabetes, cardiovascular disease, and depression in nondiabetes subjects are independently associated with raised concentrations of circulating inflammatory markers, but it is not known if a similar association is observed in type 2 diabetes. We tested the hypothesis that higher depressive symptom scores in newly diagnosed type 2 diabetes patients were associated with higher concentrations of inflammatory markers. RESEARCH DESIGN AND METHODS: Depressive symptoms in adults with newly diagnosed type 2 diabetes recruited from primary care were assessed using the Patient Health Questionnaire-9. Twelve markers of inflammation (C-reactive protein [hs-CRP], interleukin-4 [IL-4], IL-6, IL-10, vascular endothelial growth factor [VEGF], tumor necrosis factor-α [TNF-α], IL-1ß, IL-1 receptor antagonist [IL-1RA], monocyte chemotactic protein-1 [MCP-1], white blood cell count [WBC], adiponectin, and triglyceride [TG]) were measured. Covariates included sociodemographic factors, adiposity, macrovascular disease, HbA1c, and prescribed medication. The association between each inflammatory marker and depressive symptom score was estimated by multiple linear regression. RESULTS: The baseline cohort consisted of 1,790 participants. After adjusting for covariates, CRP (B = 0.13, P < 0.001), IL-1ß (B = 0.06, P = 0.047), IL-1RA (B = 0.13, P < 0.001), MCP-1 (B = 0.11, P = 0.001), WBC (B = 0.13, P < 0.001), and TG (B = 0.10, P < 0.001) were associated with depressive symptoms. CONCLUSIONS: Increased inflammation may be involved in the pathogenesis of depressive symptoms in type 2 diabetes and contribute to the increased risk of complications and mortality in this group.