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12.30pm, 4 November

Facilitator: Nadeem Qureshi

Charles Hay

Axial spondyloarthritis (axSpA) is an inflammatory arthritis characterised by chronic back pain, fatigue, and inflammation of the sacroiliac joint and lumbar spine which can result in the formation of bony growths and fusion of sections of the spine. Prevalence of this lifelong condition is approximately one in 200. The delays experienced by patients in receiving their diagnosis of axSpA is currently the longest of any inflammatory arthritide, with estimates of patients experience several years of delay. This thesis aims to investigate the length of diagnostic delay in axSpA, its causes, and possibilities for its reduction. A sequential mixed-methods approach unifies the following studies. A systematic review was firstly undertaken to ascertain the length of diagnostic delay in axSpA. This study focused on population-based observational studies which reported a time-period of diagnostic delay and, where available, any factors associated with the extent of delay experienced. The review found that diagnostic delay ranges internationally from 2 to 8 median years, 5 years in the UK. Of 38 identified factors, 6 (male sex, radiographic disease, juvenile onset, enthesitis, a lack of inflammatory back pain and HLA-B27 negativity) are associated with increased delay by more than one study. A qualitative study is utilising semi-structured interviews of axSpA patients and healthcare professionals, to explore barriers and facilitators of axSpA diagnostic delay. These data will be thematically analysed. Following the qualitative study, a case-control study will be undertaken using primary care data to investigate reasons for presentation and diagnoses prior to patients’ diagnosis of axSpA.

Keywords: Axial spondyloarthrits, diagnostic delay, systematic review, qualitative study, case-control

Ian Bennet-Britton

Understanding the benefits and limitations of continuous, risk-based, consultation peer-review in out-of-hours general practice: An interview evaluation study

Background: Unwarranted variation in clinical practice is an area of increasing interest due to the costs and harms of too much or too little healthcare. Determining the extent to which the practice of individual clinicians is unwarranted requires detailed assessment of the clinician-patient interaction. Such assessment is limited in routine general practice with implications for the safety and efficiency of care. A potential mechanism to fulfill such a role is a risk-based, continuous, consultation peer-review system developed and used by an out-of-hours general practice provider in Bristol over the last 10 years. This interview evaluation study sought to understand the benefits and limitations of a such a system.

Methods: 20 semi-structured interviews with clinicians subject to the peer review system, peer review team and senior management team members. Inductive thematic analysis of transcripts with independent coding of a subset of transcripts to ensure consensus over coding and generation of themes.

Results: The intervention was felt to benefit clinician learning and practice, assurance and evidencing clinician competence and organisational quality and safety assurance. Factors that may limit the usefulness of the intervention included the quality and frequency of feedback, selection of cases for review, the extent of clinician experience and motivation, and level of organisational support. Conclusion: Continuous, risk-based, consultation peer-review is perceived a potentially useful methodology to identify and minimise unwarranted variation in clinician practice in out-of-hours primary care.

Keywords: Safety, quality, peer-review, workforce, variation

Samya Sarfaraz

Problem: India was named as the most dangerous country for women with regards to risk of harassment, and the dangers from tribal and cultural practices in 2018. There are various factors which may be enforcing traditional gender norms, in turn perpetuating violence. This study aims to understand how different forms of media are influencing society, especially adolescent populations, shaping their views of relationships and how this has an impact on the prevalence of domestic violence.

Approach: There are two key components if this project:

1. Secondary thematic analysis of a pilot study conducted in Lucknow, Uttar Pradesh in April 2019: 15 semi-structured interviews with teachers, NGO workers and paediatricians to understand why sex and relationship education (SRE) programs are not being implemented, especially as this a key intervention to reduce domestic violence by recommend by WHO.
2. Review current literature – online databases will be searched and relevant papers will be analysed using the Cochrane GRADE system to assess the quality of evidence.

Findings: The results of the pilot study, highlighted that “media”- in the form of films, books and social networking sites - plays a vital role in how intimate relationships are perceived, established and experienced by adolescents. Additionally cultural stigma around sex and rigid gender roles are preventing the implementation of education programs.

Consequences: The Lucknow Adolescent Health Group part of the Uttar Pradesh branch of the Indian Academy of Paediatrics has been involved with the pilot study and recommendations of this work will be shared with them.

Keywords: India, Domestic Violence, Adolescent Health, Media

Beth Bareham

Background: Risks of harm from drinking increase with age, as alcohol affects health conditions and medications that are common in later life. Different types of information and experiences affect older people’s perceptions of effects of alcohol on their bodies, which must be navigated when supporting healthier decisions for drinking.

Aim: To explore how older people understand effects of alcohol on their health; and how these perspectives are navigated in supportive discussions in primary care to promote healthier alcohol use.

Design and Setting: A qualitative study consisting of semi-structured interviews and focus groups with older (≥65 years) non-dependent drinkers and primary care practitioners in Northern England.

Method: Twenty-four older adults and 35 primary care practitioners participated in interviews and focus groups. Data were analysed thematically, applying principles of constant comparison.

Results: Older adults were motivated to make changes to their alcohol use when they experienced symptoms, and if they felt that limiting consumption would enable them to maintain their quality of life. The results of alcohol-related screening were useful to provide insights into the potential effects for individuals. Primary care practitioners motivated older people to make healthier decisions by highlighting individual risks of drinking, and potential gains of limiting intake.

Conclusion: Later life is a time when older people may be open to making changes to their alcohol use, particularly when suggested by practitioners. Older people can struggle to recognise potential risks, or perceive little gain in acting upon perceived risks. Such perceptions may be challenging to navigate in supportive discussions.

Keywords: Alcohol, older people, health promotion, primary care

Sophie Hollerbach

Patients’ experiences of primary care consultations during pandemics are not widely studied. However, it is critically important to hear about patients’ experiences of seeking help in a pandemic and understand their views in order to provide excellent care, increase patient satisfaction, and improve health outcomes.

The objective was to understand the views and experiences of patients with respiratory tract infections seeking help during the pandemic. Participants were recruited from GP surgeries and via social media. Semi-structured interviews were conducted with ten patients in the UK between 6th April and 8th June 2020 and analysed using inductive thematic analysis.

Some patients initially called helplines for advice but did not perceive them as helpful for a number of reasons, including time constraints and focus on a symptom checklist rather than the patients’ concerns. When patients consulted primary care, healthcare professionals took time to listen, provide advice and care, and therefore met the needs of the patients to a large extent. Previous relationships with the healthcare providers had a positive impact on the consultation. Patients were happy to consult by phone or video due to the decreased risk of infection. They were reassured and confident in following safety netting advice.

While there has been some concern about patient satisfaction with remote care during the pandemic, our study found that patients were pleased with the consultations in primary care which is important for GPs to know. Despite the uncertainty, GPs can provide good care by listening actively and providing advice that reassures patients.

Keywords: COVID-19, patient experience, telemedicine, pandemic, primary care