BackgroundJoint pain, specifically chronic knee pain (CKP), is a frequent cause of chronic pain and limitation of function and mobility among older adults. Multiple evidence-based guidelines recommend exercise as a first-line treatment for all patients with CKP or knee osteoarthritis (KOA), yet healthcare practitioners' attitudes and beliefs may limit their implementation. This systematic review aims to identify the attitudes, beliefs and behaviours of General Practitioners (GPs) regarding the use of exercise for CKP/KOA.MethodsWe searched four electronic databases between inception and January 2008, using subject headings to identify studies examining the attitudes, beliefs or behaviours of GPs regarding the use of exercise for the treatment of CKP/KOA in adults aged over 45 years in primary care. Studies referring to patellofemoral pain syndrome or CKP secondary to other causes or that occurring in a prosthetic joint were excluded. Once inclusion and exclusion criteria were applied, study data were extracted and summarised. Study quality was independently reviewed using two assessment tools.ResultsFrom 2135 potentially relevant articles, 20 were suitable for inclusion. A variety of study methodologies and approaches to measuring attitudes beliefs and behaviours were used among the studies. Quality assessment revealed good reporting of study objective, type, outcome factors and, generally, the sampling frame. However, criticisms included use of small sample sizes, low response rates and under-reporting of non-responder factors. Although 99% of GPs agreed that exercise should be used for CKP/KOA and reported ever providing advice or referring to a physiotherapist, up to 29% believed that rest was the optimum management approach. The frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89%; physiotherapy referral 44%-77%) than reviews of actual practice (exercise advice 5%-52%; physiotherapy referral 13-63%). Advice to exercise and exercise prescription were not clearly differentiated.ConclusionsAttitudes and beliefs of GPs towards exercise for CKP/KOA vary widely and exercise appears to be underused in the management of CKP/KOA. Limitations of the evidence base include the paucity of studies directly examining attitudes of GPs, poor methodological quality, limited generalisability of results and ambiguity concerning GPs' expected roles. Further investigation is required of the roles of GPs in using exercise as first-line management of CKP/KOA.

BackgroundGout is estimated to affect 1.4% of adults in the UK. Appropriate and timely management is essential to reduce the risk of further flares, complications, and to reduce cardiovascular disease risk. The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) have published guidance regarding the management of gout, thereby providing standards against which performance can be measured. This audit was designed to assess the extent to which patients diagnosed with gout in one primary care medical practice in North Staffordshire, UK, are managed in accordance with current best practice guidelines, and to identify strategies for improvement where appropriate.MethodsAudit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. An electronic search of the practice records was performed to identify adults with a diagnosis of gout. Medical record review with a descriptive analysis was undertaken to assess the extent to which medical management adhered to the predefined standards.ResultsOf the total ≥18 year-old practice population (n = 8686), 305 (3%) patient records included a diagnosis of gout. Of these, 74% (n = 226) had an electronic record of serum uric acid (SUA), and 11% (n = 34) and 53% (n = 162) a measure of estimated glomerular filtration rate (eGFR) ever and serum glucose since diagnosis respectively. 34% (n = 105) of patients had ever taken urate-lowering therapy with 25% (n = 77) currently prescribed this at the time of data extraction. Dose adjustment and monitoring of treatment according to SUA was found to be inadequate. Provision of lifestyle advice and consideration of comorbidities was also lacking.ConclusionsThe primary care management of gout in this practice was not concordant with national and international guidance, a finding consistent with previous studies. This demonstrates that the provision of guidelines alone is not sufficient to improve the quality of gout management and we identify possible strategies to increase guideline adherence.

BackgroundPeople are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked ‘what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?’MethodsThis realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.ResultsThe final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.ConclusionsThis study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.Trial registrationPROSPERO International prospective register of systematic reviews CRD42013003862Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0234-9) contains supplementary material, which is available to authorized users.

BackgroundExercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. A theoretical analysis framework, developed from sociocognitive theories, was used to underpin investigation of the key influences associated with GPs’ use of exercise for patients with CKP, to inform future interventions to optimise GPs’ use of exercise.MethodsA cross-sectional postal questionnaire survey investigated UK GPs’ reported use of exercise based on a patient case vignette. Factors influencing GPs’ exercise use (behaviour) were examined using attitude statements, free-text questions and multiple response option questions related to factors within the analysis framework. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes/beliefs and behaviour.ResultsFrom a total sample of 5000 GPs, 835 (17%) returned a questionnaire. Most respondents (n = 729, 87%) reported that they would use exercise. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that GPs should prescribe all patients local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and GP-related beliefs about capabilities (prior experience of insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed that they experienced time limitations were more likely to suggest general (2.17 (1.04,4.55)), or demonstrate local (2.16 (1.06,4.42)), exercises.ConclusionGPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP, particularly beliefs about role, responsibilities and skills in initiating exercise, and about the efficacy of exercise. Although the low response risks response bias, these results can inform future interventions to optimise GPs’ behaviour. The role of GP uncertainty and influences on clinical decision-making need further exploration, thus an amended analysis framework is suggested, which should be tested in future research.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0570-4) contains supplementary material, which is available to authorized users.

ObjectiveTo determine the patient experience of using a simple telehealth strategy to manage hypertension in adults.DesignAs part of a pragmatic service evaluation, the acceptability of, satisfaction with and ease of use of a simple telehealth strategy was determined via text, cross-sectional questionnaire survey administered by telephone, case studies, discussion groups and informal feedback from practices. This simple telehealth approach required patients to take home blood pressure (BP) readings and text them to a secure server (‘Florence’) for immediate automatic analysis and individual healthcare professional review.Participants124 intervention patients who used the Florence system.Setting10 volunteer general practitioner's (GP) practices in Stoke on Trent, UK, with poor health and high levels of material deprivation took part.ResultsPatient satisfaction was high. In particular, patients found the system easy to use, were very satisfied about the feedback from their GP regarding their BP readings, found the advice sent via Florence useful and preferred to send BP readings using Florence rather than having to go to the practice monthly to get BP checked. Overall satisfaction with the system was 4.81/5.00 at week 13 of the programme. Other advantages of being enrolled with Florence were improved education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur at a time that suited the patient rather than their practice.ConclusionsThis simple telehealth strategy for managing hypertension in the community was met with high levels of patient satisfaction and feelings of control and support. This management approach should thus be considered for widespread implementation for clinical management of hypertension and other long-term conditions involving monitoring of patients’ bodily measurements and symptoms as a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.

BackgroundGeneral Practitioners (GPs) respond poorly to postal surveys. Consequently there is potential for reduced data quality and bias in the findings. In general population surveys, response to postal questionnaires may be improved by reducing their length and offering incentives. The aim of this study was to investigate whether questionnaire length and/or the offer of an incentive improves the response of GPs to a postal questionnaire survey.MethodsA postal questionnaire survey was sent to 800 UK GPs randomly selected from Binley’s database; a database containing contact details of professionals working in UK general practices. The random sample of GPs was assigned to one of four groups of 200, each receiving a different questionnaire, either a standard (eight sides of A4) or an abbreviated (four sides of A4) questionnaire, with or without the offer of an incentive (a prize draw entry for a £100 voucher) for completion. The effects of questionnaire length and offer of incentive on response were calculated.ResultsOf 800 mailed questionnaires, 19 GPs did not meet inclusion criteria and 172 (adjusted response 22.0%) completed questionnaires were received. Among the four groups, response ranged from 20.1% (standard questionnaire with no incentive and abbreviated questionnaire with incentive) through 21.8% (standard questionnaire with incentive), to 26.0% (abbreviated questionnaire with no incentive). There were no significant differences in response between the four groups (p = 0.447), between the groups receiving the standard versus the abbreviated questionnaire (% difference -2.1% (95% confidence interval (CI) -7.9, 3.7)) or the groups offered an incentive versus no incentive (% difference -2.1% (95% CI -7.9, 3.7).ConclusionsStrategies known to improve response to postal questionnaire surveys in the general population do not significantly improve the response to postal questionnaire surveys among GPs. Further refinements to these strategies, or more novel strategies, aimed at increasing response specifically among GPs need to be identified in order to maximise data quality and generalisability of research results.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2288-15-3) contains supplementary material, which is available to authorized users.

Background: Idiopathic Pulmonary Fibrosis (IPF) is a debilitating disease characterized by exaggerated extracellular matrix deposition and aggressive lung structural remodeling. Disease pathogenesis is driven by fibroblastic foci formation, consequent on growth factor overexpression and myofibroblast proliferation. We have previously shown that both CTGF overexpression and myofibroblast formation in IPF cell lines are dependent on RhoA signaling. As RhoA-mediated regulation is also involved in cell cycle progression, we hypothesise that this pathway is key to lung fibroblast turnover through modulation of cyclin D1 kinetic expression.

ObjectivesMultimorbidity is an increasing challenge. Better understanding of lived experiences of patients, GPs and trainees, may advance patient care and medical education. This interpretative metasynthesis sought to i) understand lived experiences of patients, GPs and trainees regarding multimorbidity, ii) identify how similarities and differences in experiences should shape future solutions. MethodsEmpirical studies containing qualitative data and pertaining to lived experiences from our recent realist synthesis (PROSPERO 2013:CRD42013003862) were included. Following quality assessment, data were extracted from key studies to build an integrated analytic framework.Data from remaining studies were utilised to expand and refine the framework through thematic analysis of concepts within and between perspectives. Results21 papers were included in the meta-synthesis. Analysis of 70 concepts produced five themes: 1) goals of care and decision-making, 2) complexity, 3) meeting expectations, 4) logistics and 5) interpersonal dynamics. The complexities of multimorbidity lead to shared feelings of vulnerability, uncertainty and enforced compromises. Barriers to optimal care/education included system constraints, inadequate continuity and role uncertainty. DiscussionThere was little evidence of shared discussion of these challenges. Addressing these issues and more explicit exploration of the experiences of each group during interactions may improve delivery and satisfaction in care and education.