Horse sense: Recognizing a rare diagnosis in primary care

As the population ages and new therapies become available, general practitioners will have a significant role in the early detection, diagnosis, and management of dementia. However, both in Australia and globally dementia remains under-recognised and under-diagnosed in primary care. The aim of this study is to develop a complex intervention, informed by behaviour change theory, to improve rates of dementia diagnoses in Australian primary care. Co-design participants included GPs, general practice nurses, practice managers and reception staff. A program logic model was used to describe the essential activities and mechanisms of the intervention. Six behaviour changes: education, training, enablement, modelling, persuasion, and environmental restructuring—were identified to address the identified barriers to dementia diagnosis in primary care. The intervention is comprised of seven activities – peer-led online dementia education and training, geriatrician ‘drop-in’ online support sessions, quality improvement in dementia care sessions, stand-alone videos, auditing and benchmarking, a dementia risk alert tool and a set of dementia diagnosis and management decision-making resources. Using behaviour change theory can assist in the development of complex interventions aimed at changing clinical practice and may assist in their evaluation.

TeleDerm is a web-based service designed to provide general practitioners (GPs) with rapid assessment of dermatoscopic images of pigmented lesions and moles. During a 12-month period, GPs at the Hastings and Rother primary care trust referred a total of 660 lesion images from patients exhibiting less typical symptoms of cancer, who would otherwise have been routinely referred to hospital. The images were assessed by remote expert dermatologists. Of that total, 493 images (75%) were reported as displaying no suspect dermatoscopic structures, resulting in the GP discharging the patient. In addition, seven lesions (1%) were reported as displaying suspect dermatoscopic structures, resulting in the GP urgently referring the patient to hospital with a subsequent histological confirmation of melanoma. The overall costs per patient were reduced by 50%. In an independent survey, all 11 patients rated their experience as good to excellent. The results show that tele-dermatoscopy can provide GPs with an expert second opinion to increase the quality of diagnosis in primary care, reduce the costs of dermatology provision and provide a highly rated patient experience.

The aim of this analysis was to determine changes in patterns of depression screening and diagnosis over three years in primary and specialty mental health care in a large health maintenance organization (HMO) as part of a project to develop quality measures for adolescent depression treatment. Two series of aggregate data (2010-2012) were gathered from the electronic health records of the HMO for 44,342 unique adolescents (ages 12 to 21) who had visits in primary and mental health care. Chi square tests assessed the significance of changes in frequency and departmental location of Patient Health Questionnaire-9 (PHQ-9) administration, incidence of depression symptoms, and depression diagnoses. There was a significant increase in PHQ-9 use, predominantly in primary care, consistent with internally generated organizational recommendations to increase screening with the PHQ-9. The increase in PHQ-9 use led to an increase in depression diagnoses in primary care and a shift in the location of some diagnoses from specialty mental health care to primary care. The increase in PHQ-9 use was also linked to a decrease in the proportion of positive PHQ-9 results that led to formal depression diagnoses. The rate of depression screening in primary care increased over the study period. This increase corresponded to an increase in the number of depression diagnoses made in primary care and a shift in the location in which depression diagnoses were made, from the mental health department to primary care. The frequency of positive PHQ-9 administrations not associated with depression diagnoses also increased.

This article, one of 12 in a series on most commonly billed diagnoses in primary care, provides a comprehensive overview of the pathophysiologic processes related to urinary tract infections (UTIs). The clinical manifestations, diagnostic tests, treatments, and billing codes associated with UTIs will be described.

BackgroundIt can be impossible to assign a definitive diagnosis for symptoms reported or observed by primary health care patients. In these situations, symptomatic diagnoses are often used.AimThe aim of the present study was to examine the proportion of symptomatic diagnoses among primary health care patients. We also explored which symptomatic diagnoses were most frequently recorded, as well as their distribution by age and sex.Design & settingThis is a register-based study carried out in the public primary health care service of the city of Vantaa, Finland.MethodDiagnoses were entered according to the 10th revision of the International Classification of Diseases (ICD-10). The data consisted of every diagnosis entered into the electronic health record between 1 January 2016 and 31 December 2018. Both absolute numbers and relative proportions of various symptomatic diagnosis recordings (chapter ‘R’) were reported.ResultsOf all the recorded diagnoses (n = 503 001), the proportion of R-diagnoses was 13.5% (n = 67 905). Diagnoses of symptoms and signs involving the digestive system and abdomen (R10–19) (3.7% of all; n = 18 550), the circulatory and respiratory systems (R00–09) (3.5%; n = 17 426), general symptoms and signs (R50–69) (3.0%; n = 15 165), and the skin and subcutaneous tissue (R20–23) (2.0%; n = 9812) were most prevalent. Age was also a major factor determining how symptomatic diagnoses were distributed between men and women. Overall, symptomatic diagnoses were more common among women than men (14.1% and 12.4%, respectively). The major categories of symptoms and signs involving the digestive system and abdomen, the skin and the subcutaneous tissue, and general symptoms and signs, were more predominant among women, while symptoms and signs involving the circulatory and respiratory systems were more common among men.ConclusionA symptomatic diagnosis code was recorded in about one eighth of GP appointments, although there were significant sex differences in the prevalence within and between diagnosis groups.

Family practitioners and other staff working in primary care require comprehensive and accurate data on patients at the point-of-care if they are to provide high quality health services to their patients. Electronic patient records are an effective method of achieving this objective, by dispensing with the need to use difficult to access, and often illegible, paper-based records. Hence, the implementation of electronic patient records in primary care is a key objective of many health care systems, including both the USA and UK. This reflects a growing recognition of the potential benefits of electronic records on the safety, quality and efficiency of healthcare. Electronic patient records underpin many information technology initiatives in primary care, such as screening for identifying patients at high risk of cardiovascular disease, call–recall systems for asthma and other long-term disease management programmes, computerized decision support systems for prescribing, electronic ordering of tests and electronic referral systems to secondary care. These are all, however, dependant on comprehensive and accurate coded data. There are known to be large variations in the accuracy and completeness of the clinical information stored in electronic patient records. In a systematic review, Thiru et al. identified 52 studies that examined data quality in electronic primary care records. Quality of data was measured in different ways, most commonly by comparisons of rates derived from the electronic records with an external standard. Prescriptions had the highest rate of recording, probably because prescribing is a core function of many electronic patient record systems. The recording of diseases (i.e. diagnoses) varied, with completeness generally highest for diseases with clear diagnostic criteria. Lifestyle and socio-economic data had lower rates of recording than prescription or diagnostic data. In another systematic review, Jordan et al. identified 24 studies that examined morbidity coding in primary care. Recording of consultations was generally high (typically greater than 90%), but assigning a morbidity code during each consultation was more variable (66–99% complete). Coronary heart disease was the most commonly assessed disease register in previous studies and completeness of recording was generally moderate (typically around 70%). Positive predictive value of coronary heart disease registers was generally high (typically around 83–100%). Other diseases that were examined (such as asthma and epilepsy) showed similar patterns of completeness of recording and positive predictive value of recorded diagnoses, but rates were generally lower than for coronary heart disease. Two recent papers in Family Practice also look at the issues of recording and coding of data in primary care. Pascoe et al. identified major omissions in the cancer diagnoses held by five general practices in Leeds, UK. The recording of diagnoses in primary care was less complete and, when a diagnosis of cancer was recorded, it was generally less detailed than in the data held by the Regional Cancer Registry. Soler et al. describe the progress of the International Classification of Primary Care (ICPC) in the 21 years since its introduction. The classification, now endorsed by the World Health Organization, has been translated into 22 languages. The wide use of the ICPC facilitates international comparisons of clinical practice and coding in primary care. For the time being, however, the use of Read codes as the UK’s standard classification system in primary care makes comparisons with countries using ICPC difficult. One important conclusion of previous studies on the use of electronic patient records in primary care is that the completeness and accuracy of data entry relies mainly on the enthusiasm of family practitioners. There are currently no agreed reference standards for reporting data quality in primary care and this limits measurement of data quality in electronic patient records. Clinicians do understand the potential benefits from the use of electronic patient records in their practices, but also cite major barriers to their implementation. These include the capital cost of investment in information technology (this may be less of an issue in the UK where the capital costs are largely met by the NHS) and the workload implications. A second key area is the lack of standards that permit effective, accurate

Background:People diagnosed with cancer following emergency presentation have poorer short-term survival. To what extent this signifies a missed opportunity for earlier diagnosis in primary care remains unclear as little detailed data exist on the patient/general practitioner interaction beforehand.Methods:Analysis of primary care and regional data for 1802 cancer patients from Northeast Scotland. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) for patient and GP practice predictors of emergency presentation. Qualitative context coding of primary care interaction before emergency presentation.Results:Emergency presentations equalled 20% (n=365). Twenty-eight per cent had no relevant prior GP contact. Of those with prior GP contact 30% were admitted while waiting to be seen in secondary care, and 19% were missed opportunities for earlier diagnosis. Associated predictors: no prior GP contact (OR=3.89; CI 95% 2.14–7.09); having lung (OR=23.24; 95% CI 7.92–68.21), colorectal (OR=18.49; CI 95% 6.60–51.82) and upper GI cancer (OR=18.97; CI 95% 6.08–59.23); ethnicity (OR=2.78; CI 95% 1.27–6.06).Conclusions:Our novel approach has revealed that emergency cancer presentation is more complex than previously thought. Patient delay, prolonged referral pathways and missed opportunities by GPs all contribute, but emergency presentation can also represent effective care. Resources should be used proportionately to raise public and GP awareness and improve post-referral pathways.

Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis. To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds. Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed. In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8). At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

Primary Care Takes Course on Cultural Issues in Depression

Background Cancer is a growing public health burden and a leading cause of death and disability globally. An estimated 30-50% of cancer deaths are preventable through the modification of behavioral and metabolic risk factors. Primary care offers an essential platform for population-level cancer prevention and early detection, especially by leveraging existing screening and chronic disease monitoring infrastructure. This study, conducted in a single primary care clinic in Poland, evaluates metabolic markers routinely collected in this setting to assess their potential role in identifying cancer risk. Methods We conducted a cross-sectional study analyzing 347 adult patients diagnosed with cancer (ICD-10 codes: C00-C14, C15-C26, C30-C39, C43-C44, C50, C51-C58, C60-C63, C64-C68, C69-C72, C73-C75, C76-C80, C81-C96, D00-D48) between 2017 and 2022 in a single primary care clinic in Poland. Fasting glucose, total cholesterol, triglycerides, and body mass index (BMI) were selected because they are routinely measured in primary care settings and frequently associated with metabolic risk and cancer development. These parameters were analyzed in relation to cancer type using descriptive statistics, chi-square tests, and Kruskal-Wallis non-parametric analyses. Results Elevated fasting glucose (≥100 mg/dL) was significantly associated with cancer type (p = 0.0238). This abnormality was observed in 83.6% (N = 290) of all patients. Although BMI, cholesterol, and triglyceride levels were not significantly associated with cancer type, metabolic abnormalities were highly prevalent in the entire sample. A total of 89.1% (N = 309) of patients were overweight or obese, and nearly one-third (N = 110) presented with all four metabolic abnormalities concurrently. Only 2.3% (N = 8) of the patients had none of the measured metabolic risk factors. The vast majority, 97.7% (N = 339), had at least one metabolic abnormality. Given the high prevalence of metabolic disturbances, the possibility of selection bias should be considered, as individuals visiting primary care may be more likely to have pre-existing chronic conditions or risk factors under surveillance. Conclusions Routine, low-cost metabolic tests performed in primary care may offer useful insights into cancer risk patterns and could inform opportunistic risk stratification efforts. However, given the cross-sectional design of this study, the findings do not support causal inference. Integrating routinely collected metabolic data into public health frameworks may enhance early detection strategies and support timely diagnostic referrals. These results highlight the potential for scalable, population-based interventions within primary care to contribute to reducing the cancer burden, morbidity, and disability-adjusted life years.

Depression in adolescence: Screening and diagnosis in primary care in an integrated healthcare system.

IntroductionSpirometric testing in primary care is promoted by the QoF for GPs. The validity of such tests is questionable, due to numerous factors, including poor technique, machine maintenance and interpretive...

Objective To describe the contribution of primary care to the diagnosis and management of sexually transmitted infections in the United Kingdom, 1990-2000, in the context of increasing incidence of infections...

Deep vein thrombosis (DVT), a formation of blood clots within deep veins, mostly of the proximal lower limb, has an annual incidence of 1-2 per 1000. Patients who are affected by multiple chronic health conditions and who experience limited mobility are at high risk of developing DVT. Traditional DVT diagnosis involves probabilistic assessment in primary care, followed by specialised ultrasound scans (USS), mainly conducted in hospitals. The emergence of point-of-care ultrasound (POCUS), coupled with artificial intelligence (AI) applications, has the potential to expand primary care diagnostic capabilities. To assess the accuracy and acceptability of AI-guided POCUS for DVT diagnosis when performed by non-specialists in primary care. Diagnostic cross-sectional study coupled with a qualitative evaluation conducted at primary care DVT clinics. First, a diagnostic test accuracy (DTA) study will investigate the accuracy of AI-guided POCUS in 500 individuals with suspected DVT, performed by healthcare assistants (HCAs). The reference standard is the standard of care of USS conducted by sonographers. Second, after receiving both scans, participants will be invited to complete a patient satisfaction survey (PSS). Finally, semi-structured interviews with 20 participants and four HCAs, and three sonographers will explore the acceptability of AI-guided POCUS DVT diagnosis. This study will rigorously evaluate the accuracy and acceptability of AI-guided POCUS DVT diagnosis conducted by non-specialists in primary care.

SAT0354 Validity of Gout Diagnosis in Swedish Primary and Secondary Care