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Use and impact of point-of-care ultrasonography in general practice: a prospective observational study.

ABSTRACT: OBJECTIVES:To describe how general practitioners (GPs) use point-of-care ultrasonography (POCUS) and how it influences the diagnostic process and treatment of patients. DESIGN:Prospective observational study using an online questionnaire before and after POCUS. SETTING:Office-based general practice. PARTICIPANTS:Twenty GPs consecutively recruited all patients examined with POCUS in 1 month. PRIMARY AND SECONDARY OUTCOME MEASURES:We estimated the use of POCUS through the indication for use, the frequency of use, the time consumption, the extent of modification of the examination and the findings.The influence on the diagnostic process was estimated through change in the tentative diagnoses, change in confidence, the ability to produce ultrasound images and the relationship between confidence and organs scanned or tentative diagnoses.The influence of POCUS on patient treatment was estimated through change in plan for the patient, change in patient's treatment and the relationship between such changes and certain findings. RESULTS:The GPs included 574 patients in the study. POCUS was used in patient consultations with a median frequency of 8.6% (IQR: 4.9-12.6). Many different organs were scanned covering more than 100 different tentative diagnoses. The median time taken to perform POCUS was 5 min (IQR: 3-8). Across applications and GPs, POCUS entailed a change in diagnoses in 49.4% of patients; increased confidence in a diagnosis in 89.2% of patients; a change in the management plan for 50.9% of patients including an absolute reduction in intended referrals to secondary care from 49.2% to 25.6%; and a change in treatment for 26.5% of patients. CONCLUSIONS:The clinical utilisation of POCUS was highly variable among the GPs included in this study in terms of the indication for performing POCUS, examined scanning modalities and frequency of use. Overall, using POCUS altered the GPs' diagnostic process and clinical decision-making in nearly three out of four consultations. TRIAL REGISTRATION NUMBER:NCT03375333.

SUBMITTER: Aakjær Andersen C

PROVIDER: S-EPMC7500300 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Use and impact of point-of-care ultrasonography in general practice: a prospective observational study.

Aakjær Andersen Camilla C Brodersen John J Davidsen Annette Sofie AS Graumann Ole O Jensen Martin Bach B MBB

BMJ open 20200917 9

<h4>Objectives</h4>To describe how general practitioners (GPs) use point-of-care ultrasonography (POCUS) and how it influences the diagnostic process and treatment of patients.<h4>Design</h4>Prospective observational study using an online questionnaire before and after POCUS.<h4>Setting</h4>Office-based general practice.<h4>Participants</h4>Twenty GPs consecutively recruited all patients examined with POCUS in 1 month.<h4>Primary and secondary outcome measures</h4>We estimated the use of POCUS t ...[more]

PMID: 32948563

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Project description:BackgroundThe use of point-of-care ultrasonography (POCUS) performed by general practitioners (GPs) in primary care settings is increasing. Previous studies have focused on GP-reported outcomes and little is known about patients' perspectives on the use of POCUS technology within the general practice consultation. The purpose of this study was to examine patients' experiences with POCUS in general practice within the areas where GPs have indicated that POCUS affected aspects of the consultation.MethodsA questionnaire was developed using a mixed methods sequential design. Analytical themes from interviews with GPs were converted into items in a questionnaire by the research team. The questionnaire was then further developed in several rounds of pilot tests involving both patients and GPs. The final questionnaire was used in a cohort study conducted in 18 Danish office-based general practice clinics from January 2018 to August 2018. All patients examined with POCUS were asked to complete the questionnaire on tablets immediately after their consultation.ResultsOut of 691 patients examined, 564 (81.6%) questionnaires were available for analysis. The patients reported that they were well informed about the purpose (98%) and the results (97%) of the POCUS examination; however, 29% reported that they were not informed about the difference between POCUS and an imaging-specialist's ultrasound examination. Almost all patients (99%) reported that POCUS was integrated naturally into the consultation, and 45% reported that POCUS improved the doctor-patient relationship. The majority of patients felt that they had been more thoroughly examined (92%) and taken more seriously (58%) when POCUS was part of the consultation. They felt POCUS gave them a better understanding of their health problem (82%), made them feel more secure (86%) and increased their trust in the physician's assessment (65%). Moreover, the patients reported that POCUS use improved the level of service (95%) they experienced and the quality of care (94%) in general practice.ConclusionWe found that an examination including POCUS in general practice was a positive experience overall for the majority of patients. Future research should further explore reasons for patient confidence in POCUS and whether or not the reassuring value of POCUS is valid.Trial registrationClinicalTrials.gov Identifier: NCT03416608.

Project description:BACKGROUND:PaTz (palliative care at home) is a method to improve palliative care in the primary care setting in the Netherlands. PaTz has three basic principles: (1) local GPs and DNs meet at least six times per year to identify and discuss their patients with a life-threatening illness; (2) these meetings are supervised by a specialist palliative care professional; (3) groups use a palliative care register on which all identified patients are listed. Since the start in 2010, the number of PaTz-groups in the Netherlands has been growing consistently. Although the theory of all PaTz-groups is the same, the practical functioning of PaTz-groups may vary substantially, which may complicate further implementation of PaTz as well as interpretation of effect studies. This study aims to describe the variation in practice of PaTz-groups in the Netherlands. METHOD:In this prospective observational study, ten PaTz-groups logged and described the activities in their meetings as well as the registered and discussed patients and topics of discussions in registration forms for a 1 year follow-up period. In addition, non-participatory observations were performed in all participating groups. Meeting and patient characteristics were analysed using descriptive statistics. Conventional content analysis was performed in the analysis of topic discussions. RESULTS:While the basic principles of PaTz are found in almost every PaTz-group, there is considerable variation in the practice and content of the meetings of different PaTz-groups. Most groups spend little time on other topics than their patients, although the number of patients discussed in a single meeting varies considerably, as well as the time spent on an individual patient. Most registered patients were diagnosed with cancer and patient discussions mainly concerned current affairs and rarely concerned future issues. CONCLUSION:The basic principles are the cornerstone of any PaTz-group. At the same time, the observed variation between PaTz-groups indicates that tailoring a PaTz-group to the needs of its participants is important and may enhance its sustainability. The flexibility of PaTz-groups may also provide opportunity to modify the content and tools used, and improve identification of palliative patients and advance care planning.

Project description:BACKGROUND:General practitioners increasingly use point-of-care ultrasonography despite a lack of evidence-based guidelines for their appropriate use in primary care. Little is known about the integration of ultrasonography in general practice consultations and the impact of its use on patient care. The purpose of this study was to explore general practitioners' experiences of using ultrasonography in the primary care setting. METHODS:Adopting an explorative phenomenological approach, we performed semi-structured interviews with general practitioners who used ultrasonography in their daily work. Thirteen general practitioners were recruited stepwise, aiming for maximum variation in background characteristics. Interviews were conducted at the general practitioner's own clinic. Transcription and systematic text condensation analysis began immediately after conducting each interview. RESULTS:The general practitioners described using ultrasonography for both selected focused examinations and for explorative examinations. The two types of examinations were described differently for each of the following emerging themes: motivation for using ultrasonography, ultrasonography as part of the consultation, selection of an ultrasound catalogue, and consequences of the general practitioner's ultrasound examination. The general practitioners had chosen and integrated their own individual ultrasound catalogue of focused examinations as a natural part of their consultations. The focused examinations were used to answer simple clinical questions and they had a significant impact on the patients' diagnoses, clinical pathways and treatments. The general practitioners considered their own catalogue of focused examinations as their comfort zone. However, they also performed explorative ultrasound examinations outside their catalogue. These scans were performed to train, gain or maintain ultrasound competences or as explorative examinations driven by curiosity. The explorative ultrasound examinations rarely had an impact on patient care. CONCLUSIONS:This study describes how general practitioners found their own way of using ultrasonography in general practice and selected a personal catalogue of ultrasound examinations that was applicable, relevant and meaningful for their daily clinical routines. This study may serve to inform implementation strategies in general practice by offering insights into central aspects that drive general practitioners' behaviours.

Project description:IntroductionGout is the most common inflammatory arthritis in the Dutch general practice population and is often managed with long-term uric acid lowering treatment. The clinical relevance of this treatment in preventing gout attacks is unclear.Primary research questionWhat is the frequency of self-reported gout attacks and what is the effect of allopurinol use in patients diagnosed with gout in general practice?Methods and analysisAdult patients with a diagnostic consultation code for gout in the year 2013, 2014 or 2015 will be invited to participate in this prospective observational cohort study. Patients with a limited life expectancy will be excluded. Baseline measurements will include blood pressure, body mass index and a blood sample (estimated glomerular filtration rate, serum uric acid, cholesterol (low-density lipoprotein (LDL) and high-density lipoprotein), glucose (fasting)). At the 2-year follow-up, patients will receive questionnaires every 3 months. The questionnaires at baseline, 12 months and 24 months assess the frequency of gout attacks, the presence of tophi, comorbidity, medication use, quality of life, diet and lifestyle. The questionnaires in between only assess the frequency of gout attacks and medication use for gout. Descriptive statistics will be used to calculate the mean frequency of self-reported gout attacks during the 2-year follow-up. The propensity score for each patient being offered allopurinol is estimated and used to match patients with and without allopurinol treatment. We will compare the frequency of gout attacks in these groups using multilevel Poisson regression analyses. With this type of analysis, we can calculate the corrected estimated effect of allopurinol on gout attack frequency.Ethics and disseminationThe research protocol was approved by the Medical Ethical Committee of the Erasmus Medical Centre in Rotterdam. The knowledge generated by this study will be transferred to the Dutch College of General Practitioners, conferences and to (inter)national peer-reviewed journals.Trial registration numberNTR6329; Pre-results.

Project description:BackgroundPulmonary aspiration of gastric contents is a serious perioperative complication. Patients with gastric cancer may experience delayed gastric emptying. However, the role of qualitative and quantitative gastric ultrasound assessments in this patient population before anesthesia induction has not yet been determined.MethodsAdult patients with gastrointestinal cancer were recruited and examined using gastric point-of-care ultrasound (POCUS) before anesthetic induction from March 2023 to August 2023 in a tertiary cancer center. Three hundred patients with gastric cancer were conducted with POCUS prior to induction, and three hundred patients with colorectal cancer were included as controls. The cross-sectional area (CSA) of the gastric antrum and gastric volumes (GV) were measured and calculated. We determined the nature of the gastric contents and classified the antrum using a 3-point grading system. A ratio of GV to body weight > 1.5mL/Kg was defined as a high risk of aspiration.ResultsIn patients with gastric cancer, 70 patients were classified as grade 2 (23%, including 6 patients with solid gastric contents) and 63 patients (21%) were identified as having a high risk of aspiration. Whereas in patients with colorectal cancer, only 11 patients were classified as grade 2 (3.7%), and 27 patients (9.7%) were identified as having a high risk of aspiration. A larger tumor size (OR:1.169, 95% CI 1.045-1.307, P = 0.006), tumor located in antrum (OR:2.304, 95% CI 1.169-4.539,P = 0.016), gastrointestinal obstruction (OR:21.633, 95% CI 4.199-111.443, P < 0.0001) and more lymph node metastasis (OR:2.261, 95% CI 1.062-4.812, P = 0.034) were found to be positively while tumor site at cardia (OR:0.096, 95% CI 0.019-0.464, P = 0.004) was negatively associated with high aspiration risk in patients with gastric cancer.ConclusionThe Gastric POCUS prior to induction provides an assessment of the status of gastric emptying and can identify the patients at high risk of aspiration, especially those with gastric cancer.Trial registrationChinese Clinical Trial Registry ( www.chictr.org.cn ) identifier: ChiCTR2300069242; registered 10 March 2023.

Project description:ObjectivesFirst, to examine general practitioner (GP) knowledge about the care (needs) of their patients; second, to examine the quality of GP follow-up care; third, to examine the transmission of patient care information from hospitals/emergency services (ES) to GPs.Setting105 general practices from the representative Belgian Network of Sentinel General Practices (SGP) in Flanders, the largest region of Belgium, during 2013-2016.Participants245 suicide attempts by regular patients.Outcomes measuresTen care-related measures, including three indicators of quality of follow-up care, were based on data reported by the SGP on structured forms at baseline and at two follow-up points in time.ResultsAs for GP knowledge, 10.5% of SGP failed to report whether suicidal risk was noticed in patients seen in the month preceding the attempt; 9.0% whether there were previous attempts; 22.5% whether the patient was receiving mental health treatment at follow-up and 22.0% whether suicidal behaviour was repeated at follow-up. Relatively more patients≥65 years had no suicide risk evaluation (OR 3.54; 95% CI 1.11 to 11.26). As for quality of follow-up care, there was a GP-patient contact following 90.5% of the attempts, follow-up appointments were planned following 43.4% of the attempts and there was a GP contact with patient proxies following 62.8% of the attempts. Patient age ≥65 years (OR 4.09; 95% CI 1.79 to 9.33), a recent GP-patient contact preceding the attempt (OR 1.97; 95% CI 1.13 to 3.43), depression of patient (OR 1.96; 95% CI 1.14 to 3.37) and a suburban SGP area (OR 2.34; 95% CI 1.13 to 4.82) were determinants of an increased quality of care sum. GPs received patient care information from a hospital (ES) for 67.8% of eligible attempts, with SGP practice location being a determinant.ConclusionsGPs are highly involved in the care of suicide attempters but there is room for improvement, also in informational continuity from hospital (ES) to GPs.

Project description:ObjectiveTo investigate the effect of opiate substitution treatment at the beginning and end of treatment and according to duration of treatment.DesignProspective cohort study. Setting UK General Practice Research Database.ParticipantsPrimary care patients with a diagnosis of substance misuse prescribed methadone or buprenorphine during 1990-2005. 5577 patients with 267?003 prescriptions for opiate substitution treatment followed-up (17?732 years) until one year after the expiry of their last prescription, the date of death before this time had elapsed, or the date of transfer away from the practice.Main outcome measuresMortality rates and rate ratios comparing periods in and out of treatment adjusted for sex, age, calendar year, and comorbidity; standardised mortality ratios comparing opiate users' mortality with general population mortality rates.ResultsCrude mortality rates were 0.7 per 100 person years on opiate substitution treatment and 1.3 per 100 person years off treatment; standardised mortality ratios were 5.3 (95% confidence interval 4.0 to 6.8) on treatment and 10.9 (9.0 to 13.1) off treatment. Men using opiates had approximately twice the risk of death of women (morality rate ratio 2.0, 1.4 to 2.9). In the first two weeks of opiate substitution treatment the crude mortality rate was 1.7 per 100 person years: 3.1 (1.5 to 6.6) times higher (after adjustment for sex, age group, calendar period, and comorbidity) than the rate during the rest of time on treatment. The crude mortality rate was 4.8 per 100 person years in weeks 1-2 after treatment stopped, 4.3 in weeks 3-4, and 0.95 during the rest of time off treatment: 9 (5.4 to 14.9), 8 (4.7 to 13.7), and 1.9 (1.3 to 2.8) times higher than the baseline risk of mortality during treatment. Opiate substitution treatment has a greater than 85% chance of reducing overall mortality among opiate users if the average duration approaches or exceeds 12 months.ConclusionsClinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment. Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality.

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Use and impact of point-of-care ultrasonography in general practice: a prospective observational study.

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Use and impact of point-of-care ultrasonography in general practice: a prospective observational study.

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