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11.00am, 3 December

Facilitator: Oliver van Hecke

Elizabeth Morris

The optimal dietary composition for people with type 2 diabetes (T2D) remains uncertain. However there is considerable patient and practitioner interest in the use of real-food, low-carbohydrate diets; these are a safe and effective option for weight loss, and may bring additional benefits for people with T2D. Proponents of low-carbohydrate diets commonly cite reduced hunger and sustained satiety compared to other low-calorie diets designed for weight loss, which could influence their longer-term sustainability. A variety of gut hormones released from the gastrointestinal tract have well established roles in appetite control, and their secretion is known to change with energy restriction; however the effect of manipulations of diet composition on these hormones in the context of weight loss is not well understood. To address this evidence gap, this study aims compare the effect of a hypoenergetic, low-carbohydrate weight loss diet with an isoenergetic low-fat diet, on appetite and glycaemia in people with T2D. Volunteers will consume either a low-carbohydrate or low-fat weight loss diet for 4 weeks, which are matched for energy content and predicted weight loss, but will differ primarily in the proportion of energy gained from fat or carbohydrate. By studying their appetite scores, gut hormones and blood glucose in response to a fixed breakfast, and energy intake at a meal where they are encouraged to eat until they feel full, at baseline and after a period of weight loss, we will be able to understand how the dietary composition of weight loss diets may influence appetite and glycaemic control.

Keywords: Polypharmacy, very old

Michael Harrison

Background: In western countries, there is a trend towards increasing amounts of undergraduate medical education being delivered in General Practice (GP). Newcastle University recently increased the amount of teaching delivered in GP in year 3 as part of wider curricular reform. Feedback has suggested dissatisfaction amongst some GP clinical teachers since the changes were introduced. Medical schools commonly encounter difficulties with recruitment and retainment of GP clinical teachers. Therefore, maintaining teaching engagement and commitment amongst GP clinical teachers is vital.

Aim: To explore how the introduction of a new year 3 curriculum affects future commitment to teach in year 3 GP clinical teachers

Methodology: This study applied the realist philosophy of science using realist inquiry. An initial theory speculating how the changes may affect future teaching commitment was developed. Data collection and analysis then aimed to refine the initial theory to generate a final theory (Programme Theory). This involved semi-structured telephone interviews of 10 GP teachers, with use of coding and analytical techniques consistent with realist principles.

Results and conclusions: The results suggest that certain aspects of the new curriculum result in reduced future teaching commitment e.g. prescriptive lesson plans, whereas others result in increased commitment e.g. opportunities to facilitate patient contact. Several mechanisms are identified, e.g. alterations to autonomy and sense of responsibility. Different GP teachers are affected in different ways, influenced by practice and individual contexts. The results may allow medical schools to develop a better understanding how GP teacher retention may be facilitated during GP teaching expansion.

Keywords: GP clinical teachers, teacher engagement, primary care undergraduate teaching

Lydia Holt

I research how communication patterns between patients and primary care clincians, including GPs, nurses, pharmacists and paramedics, influence consultation outcomes such as prescribing.

Keywords: qualitative, primary care, healthcare interactions

Helen Twohig (Wellcome Trust)

The problem: Polymyalgia rheumatica (PMR) causes pain, stiffness and disability in older adults. It can be challenging to diagnose and manage and patients report feeling that their condition is poorly understood by healthcare professionals. Measuring the impact of PMR from the patient’s perspective is important, yet there are no validated outcome measures to support patient and clinician decision-making.

The approach: We developed a patient-reported outcome measure (PROM) to assess PMR-related quality-of-life. Development involved qualitative interviews, iterative item development and application of classical and modern measurement theory methods. The construct validity, test-retest reliability and responsiveness of the resultant Polymyalgia Rheumatica-Impact Scale (PMR-IS) are currently being evaluated.

The learning: The qualitative study highlighted the mismatch between ‘textbook’ PMR and experiences of participants. The difficult balance between side effects of medication versus symptom control was apparent and many described mood disturbance, fear and a sense of vulnerability. A long-list of items for the PROM was developed from this data. Field-testing involving 250 participants, allowed item reduction and formation of dimension structure. The PMR-IS has four domains – symptoms, function, psychological impact and steroid side effects. The evaluation study recruited 200 people from primary and secondary care. Participants completed the PMR-IS, the modified Health Assessment Questionnaire (mHAQ) and the Short Form-36 (SF-36) at baseline and then the PMR-IS, the mHAQ and a series of anchor questions 2-6 weeks later. Data analysis is underway.

Why it matters: A PROM to measure PMR-related quality of life will enable the assessment of what truly matters to people with PMR to be incorporated into research into the condition and ultimately improve person-centred care for PMR.

Keywords: Polymyalgia rheumatica, patient reported outcome measures

Ananya Namdeo

The Evidence for Primary Care- Which Mixed Method Research Synthesis Methodologies are Best Suited for use in Primary Care?

GP’s routinely rely on evidence sources such as guidelines and systematic reviews to inform their decision-making and guide the treatment plans of patients in order to provide timely, evidence based care. In some clinical areas however, guidelines from influential sources such as NICE may unavailable or insufficient, leaving clinicians to decide the relevance and quality of many different competing types of evidence that may be available to them. This is especially true of mixed method reviews which have only recently become popularised.

Currently there are a number of methods to underpin mixed methods reviews, with some uncertainty as to which are most appropriate or robust. Guidelines and systematic reviews often utilise a range of methods although some may be constrained by stringent frameworks dictated by their respective commissioning bodies. In order to fill this knowledge gap, a series of reviews will be undertaken. The first explores how, and under which circumstances, mixed method synthesis methodologies are used in and identified set of General Practice systematic reviews. Further to this we will explore the reasons why certain methods are favoured over others and what difference this may make to the outcome of the synthesis.

Based on this work, areas of improvement in the use of mixed method synthesis methodologies will explored and used to identify an optimal synthesis method that will be specific and tailored for use in primary care, enabling clinicians to make fully informed decisions even in areas of complexity.