BJGP editor, Euan Lawson, discusses 10 interesting papers from the last year at the Royal Society of Medicine's general practice and primary care update.
No. 10. Heavy Menstrual Bleeding
Women's experiences of heavy menstrual bleeding and medical treatment: a qualitative study in primary care, Brittany Dutton and Joe Kai, British Journal of General Practice 2023; 73 (729): e294-e301. DOI: https://doi.org/10.3399/BJGP.2022.0460
Heavy menstrual bleeding (HMB) is known to significantly affect women's health and quality of life, with pressure to conceal symptoms. Recent evidence on women's experiences of HMB and its treatment after seeking primary care is lacking. This research shows the debilitating impact of HMB on women, and the challenges they can still face, including overcoming taboo and low general awareness that treatment can help. Women had widely differing experiences of current medical treatments for HMB in general practice and emphasised how they valued patient-centred communication in helping them.
No. 9. Hoarding disorder
Hoarding disorder: evidence and best practice in primary care, Sharon Morein-Zamir and Sanjiv Ahluwalia, British Journal of General Practice 2023; 73 (729): 182-183. DOI: https://doi.org/10.3399/bjgp23X732513
Hoarding is characterised by excessive clutter and difficulty discarding. While many people may report dissatisfaction and difficulties with such symptoms alongside excessive acquisition, only when these lead to clinically significant distress and/or impairment in social, occupational, or other important areas of functioning is the diagnosis of HD considered. Hoarding is associated with significant physical, psychological, and social morbidity leading to reduced quality of life. Even safety can be affected by possessions that congest and clutter active living areas and substantially compromise their intended use. Relationships within the household, with extended family and friends, and even with neighbours may come under strain. HD is found across the world, with a prevalence of approximately 2% and with similar rates for males and females. Despite the prevalence and considerable personal costs, recognising and providing appropriate care can prove challenging.
No. 8. Diagnosing Heart Failure
Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study, Clare J Taylor, José M Ordóñez-Mena, Sarah L Lay-Flurrie, Clare R Goyder, Kathryn S Taylor, Nicholas R Jones, Andrea K Roalfe and FD Richard Hobbs, British Journal of General Practice 2023; 73 (726): e1-e8. DOI: https://doi.org/10.3399/BJGP.2022.0278
International guidelines recommend natriuretic peptide (NP) testing in primary care to prioritise referral for heart failure (HF) diagnostic assessment. European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guidelines differ significantly in their recommended NP referral threshold. The current study found at the lower ESC threshold fewer HF diagnoses were missed but more referrals from primary care would be required. Healthcare systems need to balance the risk of a missed or delayed diagnosis for individual patients with capacity in diagnostic services. An NP level below both the ESC and NICE thresholds was reliable in ruling out HF. Conclusion: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.
No. 7. Suicide Prevention
Suicide prevention targeting middle-aged males: the role of primary care, Karen Wetherall and Rory O'Connor, British Journal of General Practice 2023; 73 (732): 292-294. DOI: https://doi.org/10.3399/bjgp23X733197
Evidence across a range of studies suggests that, on average, 80% of people who die by suicide have been in contact with primary care in the year before dying by suicide, and 44% in the preceding month. Although this represents a significant opportunity for preventative measures, the challenges of identifying who is at risk and how to optimally intervene remain stark. Of all suicide deaths registered in 2021 in England and Wales, three-quarters were by males. Moreover, middle-aged males are the highest risk group, as from 2010 onwards, the suicide rates for males aged 45–64 years are higher than every other age-specific group (20.1 deaths per 100 000 in 2021). Therefore, this group represents an important target for suicide prevention efforts, although age and gender alone are insufficient for suicide risk detection purposes. To address this challenge we need to better characterise risk in this group. The authors discuss elements of suicidal motivations (background factors and triggers), factors that form the intention and enaction of these. They list a set of factors that govern transition form ideation to behaviour including: access to means, planning, impulsivity, exposure to suicidality in others, high pain endurance, fearlessness about death, past suicidal behaviour and mental imagery around death.
No. 6. Withdrawing anti-depressants
Withdrawing from SSRI antidepressants: advice for primary care, Emilia G Palmer, Sangeetha Sornalingam, Lisa Page and Maxwell Cooper, British Journal of General Practice 2023; 73 (728): 138-140. DOI: https://doi.org/10.3399/bjgp23X732273
Some general take home points from the article:
No. 5. Postural Hypertension
Incidence of postural hypotension recorded in UK general practice: an electronic health records study, Cini Bhanu, Irene Petersen, Mine Orlu, Daniel Davis and Kate Walters. British Journal of General Practice 2022; DOI: https://doi.org/10.3399/BJGP.2022.0111
Standardised recording of postural BP may help increase identification and recording of postural hypotension in GP records. A postural BP drop detected within 60s of standing upright is adequate and more likely to be associated with adverse clinical outcomes. This is a pragmatic approach that could be incorporated into existing routine care for high-risk groups including older adults (such as the NHS 'Over 75 health check'), and can be carried out by auxiliary healthcare professionals or via ambulatory home BP monitoring, which is now more widely used
Early identification of postural hypotension (that is, before the onset of clinical sequelae such as falls and ischaemic events) may allow for a window of opportunity. This can be used to adjust high-risk drugs, optimise CVD status, and provide practical advice on hydration that may reduce subsequent adverse outcomes.
Finally, postural hypotension and its association with serious adverse outcomes in older people is gaining attention in research. It is recognised as an important marker of neurovascular dysfunction and a contributor to cognitive decline. Therefore, understanding current practice and approaches for improving postural hypotension detection is increasingly important.
Future research should consider age–sex interactions, with greater differences in rates of postural hypotension among males and females in older age groups (>70 years).
No. 4. Hypertension and reverse dipping
Diagnosing hypertension in primary care: a retrospective cohort study to investigate the importance of night-time blood pressure assessment, Laura C Armitage, Shaun Davidson, Adam Mahdi, Mirae Harford, Richard McManus, Andrew Farmer, Peter Watkinson and Lionel Tarassenko, British Journal of General Practice 2023; 73 (726): e16-e23. DOI: https://doi.org/10.3399/BJGP.2022.0160
ABPM has become less frequent in primary care since the COVID-19 pandemic, with HBPM often the preferred alternative; however, HBPM cannot measure night-time blood pressure, and patients whose night-time BP does not dip, or rises (reverse dipping), have poorer cardiovascular outcomes. Researchers used BP data collected for the two cohorts, three systolic BP phenotypes (dipper, non-dipper, and reverse dipper). Not measuring night-time BP puts all groups, other than dippers, at risk of failure to identify hypertension. As a result of this study, it is recommended that GPs should offer ABPM to all patients aged ≥60 years as a minimum when assessing for hypertension.
No. 3. Registering patients without documents
Reluctance of general practice staff to register patients without documentation: a qualitative study in North East London, Kitty Worthing, Pooja Seta, Isa Ouwehand, Anita Berlin and Megan Clinch, British Journal of General Practice 2023; 73 (729): e276-e283. DOI: https://doi.org/10.3399/BJGP.2022.0336
Previous research shows that people are often refused GP registration if they do not have access to documentation, highlighting a discrepancy between guidance and practice that has not been previously explored. Current third-sector initiatives to improve inclusive registration have largely focused on reiterating guidance and explaining to staff why people may not have access to documentation. This study found that reluctance to register this group was common, and reluctance was generally fuelled not by lack of knowledge of the guidance, but by workplace and resourcing pressures, and moral judgements concerning who should be entitled to NHS services based on immigration status. The perceived practical and financial burdens relate to overall increases in workload and the current funding model utilised in general practice. Initiatives to improve access must acknowledge such concerns, alongside addressing the wider malignant impact of the 'Hostile Environment' policies on individual staff decision making.
No. 2. Treatment burden and "missingness"
Treatment burden for people experiencing homelessness with a recent non-fatal overdose: a questionnaire study, Caitlin Jones, Frances S Mair, Andrea E Williamson, Andrew McPherson, David T Eton and Richard Lowrie, British Journal of General Practice 2023; 73 (735): e728-e734. DOI: https://doi.org/10.3399/BJGP.2022.0587
This study aimed to address the knowledge gap of treatment burden among people experiencing homelessness (PEH), who are known to experience high levels of multimorbidity. PEH reported high levels of treatment burden, especially in domains focusing on the impact of self-management on activities and wellbeing. This adds to barriers for PEH maintaining their health and participating effectively in their self-care. Understanding more about treatment burden in PEH can help inform future tailored healthcare interventions and enable evaluation of the impact of such interventions.
No. 1. Wax on, wax off
Ear wax management in primary care: what the busy GP needs to know, Kevin J Munro, Thomas C Giles, Christine Smith-Howell and Irwin Nazareth British Journal of General Practice 2023; 73 (727): 90-92. DOI: https://doi.org/10.3399/bjgp23X732009
Perhaps one of the key messages is that there is a lack of good evidence to guide care but from what can be gleaned here are some take home messages:
The full article can be viewed online:
https://bjgplife.com/the-editors-choice-ten-top-bjgp-articles-from-2022-23/
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