Alex Burrell is a GP in Bristol.
Yonder is a diverse selection of primary care relevant research stories beyond the mainstream biomedical literature.
Prescribing and deprivation
The health gap between people in the most and least deprived areas continues to grow. This Welsh study aimed to explore this through the most common intervention made by healthcare professionals: prescribing. Using publicly available prescribing data, patterns were compared for selected groups of medications between GP practices with populations in the 20% most and least deprived areas of Wales from April 2018–March 2023.1 Medication groups were selected for inclusion as they were currently, or had previously been, national prescribing indicators. The results are unsurprising: hypnotics, anxiolytics, antidepressants, and statins were prescribed significantly more in the most deprived areas; hormone replacement therapy was prescribed significantly more in the least deprived areas. The drivers behind the differences and potential solutions are not explored, though I’m sure most readers could think of a few of each.
Delayed antibiotic prescriptions
Antimicrobial resistance is a global health concern and affects us all. One way to improve antimicrobial stewardship is delayed, or back-up, antimicrobial prescriptions (DP). This realist review aimed to understand how, when, why, and in what circumstances DP works.2 For those unfamiliar with realist methodology, the results are presented in a series of context-mechanism-outcome configurations: while this is perfect for understanding and explaining a complex intervention, it is quite difficult to summarise in a pithy paragraph so it’s well worth reading the article in full. The key concept is uncertainty in various forms, and how this may be mitigated, provoked, or exacerbated by DP. This leads to several useful recommendations, including reframing DP as an ‘active’ prescribing alternative to immediate antibiotics and emphasising clinical situations where immediate antibiotics offer little or no benefit.
Pre-hospital antibiotics in sepsis
Early recognition and treatment of sepsis is vital. In this Norwegian study, ambulance staff in a rural area with a long transport time to hospital were trained to recognise sepsis, administer antibiotics, and take blood cultures: the aim was to give patients with suspected sepsis infection site-specific intravenous antibiotic treatment within 1 hour of ambulance arrival.3 In Norway, all GPs work shifts in the municipal emergency out-of-hours service and are asked to attend the highest acuity cases alongside the ambulance.4 Of the 328 patients included, a GP was present at almost half. The presence of a GP significantly increased the likelihood of a correctly identified source of infection and corresponding treatment (86.1% versus 72.6%, P = 0.009). Median time to the start of antibiotic treatment was 44 minutes, 76 minutes before median arrival at hospital. As there was no comparator, we can’t tell whether this intervention directly affected patient outcomes, but for those with long journeys to hospital (+/– the wait in the ambulance outside accident and emergency), this could be of real benefit.
Differential attainment
Differential attainment (DA) refers to ‘the discrepancy in achievement between different groups of doctors.’ 5 This qualitative study aimed to explore the experiences of GP registrars who faced career progression barriers and DA: these were doctors who had been released from GP training programmes in the UK due to exam failure but could return to training through a targeted scheme. The three key themes through interviews with a small but diverse group of participants make for challenging reading: career uncertainty; psychological injury; and social injury. There are some hard-hitting quotes on the impact on these doctors’ lives, including the significant financial hit from having to resit exams multiple times. These impacts lasted, even when people had made it through training: ‘There are a lot of good GPs out there that are really, really scarred for life … you feel worthless. It makes you feel helpless. It devalues what you’ve worked so hard for and it takes away a lot of the pleasure of loving a career that you’ve worked so hard towards.’
References
1. Boldero R, Hinchliffe A, Griffiths S, et al. Prescribing by level of deprivation in Wales: an investigation of selected medicine groups. J Epidemiol Community Health 2024; 78(12): 785–792.
2. Mcleod M, Campbell A, Hayhoe B, et al. How, why and when are delayed (back-up) antibiotic prescriptions used in primary care? A realist review integrating concepts of uncertainty in healthcare. BMC Public Health 2024; 24(1): 2820.
3. Andersson L-J, Simonsen GS, Solligård E, Fredriksen K. Timely empirical antibiotic therapy against sepsis in a rural Norwegian ambulance service: a prospective cohort study. BMC Health Serv Res 2024; 24(1): 1320.
4. Burrell A, Booker M, Hjortdahl M. GPs in the ambulance service: comparisons across the North Sea. BJGP Life 2024; 18 Apr: https://bjgplife.com/gps-in-the-ambulance-service-comparisons-across-the-north-sea (accessed 20 Nov 2024).
5. Edirisooriya M, Shah R, Griffin A. Consequences of career progression barriers experienced by doctors in GP training: an interpretative phenomenological study. Educ Prim Care 2024; DOI: 10.1080/14739879.2024.2395401.
Featured photo by Mpho Mojapelo on Unsplash.
