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Qualitative study of practices and challenges when making a diagnosis of asthma in primary care.

ABSTRACT: Misdiagnosis (over-diagnosis and under-diagnosis) of asthma is common. Under-diagnosis can lead to avoidable morbidity and mortality, while over-diagnosis exposes patients to unnecessary side effects of treatment(s) and results in unnecessary healthcare expenditure. We explored diagnostic approaches and challenges faced by general practitioners (GPs) and practice nurses when making a diagnosis of asthma. Fifteen healthcare professionals (10 GPs and 5 nurses) of both sexes, different ages and varying years of experience who worked in NHS Lothian, Scotland were interviewed using in-depth, semi-structured qualitative interviews. Transcripts were analysed using a thematic approach. Clinical judgement of the probability of asthma was fundamental in the diagnostic process. Participants used heuristic approaches to assess the clinical probability of asthma and then decide what tests to do, selecting peak expiratory flow measurements, spirometry and/or a trial of treatment as appropriate for each patient. Challenges in the diagnostic process included time pressures, the variable nature of asthma, overlapping clinical features of asthma with other conditions such as respiratory viral illnesses in children and chronic obstructive pulmonary disease (COPD) in adults. To improve diagnostic decision-making, participants suggested regular educational opportunities and better diagnostic tools. In the future, standardising the clinical assessment made by healthcare practitioners should be supported by improved access to diagnostic services for additional investigation(s) and clarification of diagnostic uncertainty.

SUBMITTER: Akindele A

PROVIDER: S-EPMC6637121 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Qualitative study of practices and challenges when making a diagnosis of asthma in primary care.

Akindele Adeola A Daines Luke L Cavers Debbie D Pinnock Hilary H Sheikh Aziz A

NPJ primary care respiratory medicine 20190717 1

Misdiagnosis (over-diagnosis and under-diagnosis) of asthma is common. Under-diagnosis can lead to avoidable morbidity and mortality, while over-diagnosis exposes patients to unnecessary side effects of treatment(s) and results in unnecessary healthcare expenditure. We explored diagnostic approaches and challenges faced by general practitioners (GPs) and practice nurses when making a diagnosis of asthma. Fifteen healthcare professionals (10 GPs and 5 nurses) of both sexes, different ages and var ...[more]

PMID: 31316068

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Project description:ImportanceDespite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors.ObjectiveTo explain why primary care has not begun to integrate comprehensive cancer survivorship services.Design, setting, and participantsComparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes.Main outcomes and measuresDescription of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care.ResultsThe 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care.Conclusions and relevanceTo increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.

Project description:BackgroundIn recent years, healthcare has faced many different crises around the world such as HIV-, Ebola- or H1N1-outbrakes, opioid addiction, natural disasters and terrorism attacks). In particular, the current pandemic of Covid-19 has challenged the resilience of health systems. In many healthcare systems, primary care practices play a crucial role in the management of crises as they are often the first point of contact and main health care provider for patients. Therefore, this study explored which situations are perceived as crises by primary care practice teams and potential strategies for crisis management.MethodsA qualitative observational study was conducted. Data were collected in interviews and focus groups with experts from primary care practices and stakeholders focusing on primary care practices in Germany such as physicians, medical assistants, practice managers, quality managers, hygiene managers and institutions on health system level (politics, research and health insurance). All interviews and focus groups were audio-recorded and transcribed verbatim. A qualitative content analysis was performed using a rapid qualitative analysis approach first, followed by a thematic analysis.ResultsTwo focus groups and 26 interviews including 40 participating experts were conducted. Many different situations were perceived as crises, varying from issues in the practice organization to problems on health system level and international disasters. Distinct aspects associated with the perception of a crisis situation by interviewees were the presence of emotional reactions, a need for organizational changes and a lack of necessary resources. A broad spectrum of possible strategies was discussed that could help to cope with or even prevent the emergence of an actual crisis. In particular, strengthening communication within practice teams and resilience among employees was perceived to be fundamental for improving responses to crises or preventing them.ConclusionsThe study provides perspectives of primary health care workers on crises in health, that could inform health policy regarding prevention and management of future crises in primary care facilities.

Project description:BackgroundPeople with prediabetes are at high risk of developing type 2 diabetes and its complications, such as cardiovascular diseases and premature mortality. Primary prevention and health maintenance are therefore imperative. Evidence has shown that prediabetes can be prevented or delayed with behavioural change, mainly in eating habits and physical activity. Interventions that use a person-centered approach can lead to improvements in self-management, quality of life, and health outcomes. Nevertheless, there is a need for further research that engages healthcare professionals and people with prediabetes in constructing and implementing preventive programs. The purpose of this study is to explore and describe how healthcare professionals perceive prediabetes, the current challenges in its detection and treatment, and what is needed to improve quality of care.MethodsThis qualitative study was conducted in Region Stockholm. A total of 26 primary health care professionals participated in individual interviews: 15 diabetes nurses and/or district nurses, five general practitioners, five dietitians, and one physiotherapist. Interview transcripts were analyzed with qualitative content analysis.ResultsThe analysis revealed two main themes that emphasize the need to make prediabetes more visible in primary health care. Despite the healthcare professionals' engagement and their motivation to improve prediabetes care, ad hoc practices and the absence of clear screening guidelines and referral pathways made it harder to focus on primary prevention. Supporting professionals in implementing structured care for people with prediabetes might encourage more efficient interprofessional collaboration and contribute to better strategies for promoting behavioural change.ConclusionsEstablishing prediabetes care guidelines, supporting health care professionals´ knowledge and skills in prediabetes care, and implementing interprofessional referral pathways are some steps to enhance prediabetes detection and care precedence in primary health care. These steps could lead to more preventive care and ensure patient safety and health care equity.

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Project description:BACKGROUND:Despite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario. METHODS:Three types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n =?20) included in this study were nurse practitioners (n =?13) and family physicians (n =?7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach. RESULTS:Our analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian. CONCLUSIONS:PCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.

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Qualitative study of practices and challenges when making a diagnosis of asthma in primary care.

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Qualitative study of practices and challenges when making a diagnosis of asthma in primary care.

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