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Providing safety netting advice for lung cancer symptoms in primary care: patients preferred active advice
Lung cancer (LC) symptoms are often initially non-specific and have poor discriminatory value. The initial consultation for these symptoms may be to reassure patients but it is important to use safety netting strategies to ensure reconsultation in event that symptoms fail to resolve. However, the quality of safety netting has not been researched so far. A qualitative interview study by Black et al (BMC 2022;23:179) involved interview of 20 patients who recently saw their GP with respiratory symptoms which could potentially be presenting features of LC (eg, cough, fatigue, chest pain and weight loss) These patients were all above the age of 40 and had no previous diagnosis of cancer. Three GPs were also recruited for interviews. Some of the participants of the study were recruited pre-COVID-19 pandemic (face-to-face) consultations; the rest had telephone consultations. Some of the interviews were paired with both patient and general practitioner(GP) from the same consultation allowing for analysis of differences in approach and opinion on the consultation advice. There were clear themes demonstrating that patients preferred active safety netting, for example, booked in for reconsultation, specific time frame for symptoms to improve rather than advice to reconsult if not resolved. The study identified a mismatch between patient and GP perception of the diagnostic approach, which appear amplified in telephone consultations. Patients often did not understand the diagnostic approach taken, for example, feeling advanced imaging was required and not appreciating the blood tests and CXR were being used to exclude cancer. Patients also wanted to be involved in the diagnostic strategy and reasoning; most patients would have preferred being talked through what their doctor was trying to rule out and sequence of events going forward. Of note patients given passive safety-netting advice indicated they were less likely to reconsult and felt dismissed. Safety-netting should be active, face to face and detailed providing the patient with a clear plan they understand on the need to reconsult if the initial symptoms persist. Inadequate safety-netting may do harm and could delay diagnosis. Education is needed for doctors consulting patients with potential cancer symptoms to ensure that diagnoses are not delayed.
Antibiotic treatment for acute exacerbations of COPD: addition of antibiotics to steroids reduces treatment failure
Acute exacerbations of COPD (AECOPD) is common in primary care with bacterial cause the most common. There is ongoing variation in practice regarding antibiotic prescription due to concerns of efficacy and potential resistance. A retrospective cohort study by Wang et al (Respiration 2022;101:553) looked at the short-term and long-term effects of antibiotic prescribing on treatment failure (repeat steroid prescription within 30 days) and re-exacerbations (prescription of steroids and or antibiotics between 30 days and 1 year). An established research database was used to identify patients with COPD (defined by coding) having a prescription of steroids for an AECOPD in primary care between 2007 and 2017. Of the identified 1105 patients, 518 were prescribed antibiotics with steroids (exposed) and 587 had steroids alone (reference). Treatment failure was lower in the exposed group (adjusted OR, aOR 0.63, 95% CI 0.40 to 1.05). When examining the impact of specific antibiotics doxycycline, macrolides and co-amoxiclav all reduced treatment failure whereas amoxicillin did not (aOR 1.14, 95% CI 0.87 to 1.49). This study confirms the beneficial short-term effects of antibiotics in the management of community AECOPD.
Impact of COVID-19 pandemic on asthma exacerbations across the UK: down and staying low
Asthma exacerbations are most commonly managed in a GP setting (88% in primary care vs 12% in secondary care). In a retrospective study using a national primary care database, Shah et al (Lancet Regional Health – Eur 2022;19:100428) examined the impact of the COVID-19 pandemic on asthma exacerbation frequency. The study identified 100 362 patients with asthma exacerbations between 2016 and 2021 and looked at exacerbation rates in quarter-year intervals, reported as rate per 100 person-years. Results showed a substantial and sustained reduction (up to 63%) in asthma exacerbations in the 2020–2021 (23.0–44.8, excluding Q1 which was prior to lockdown) period compared with 2016–2019 (48.7 –88.9). Exacerbation rates during 2016–2019 showed clear seasonal variation which was lost in the post-2020 period. The reduction was consistent across regions of the UK and across age and sex groups. The study was not designed to identify the causes of this reduction but the fact that it was sustained throughout periods when lockdown restrictions eased counters hypotheses of reduced circulating respiratory viruses, improved air pollution and changes in healthcare access there were in place for only limited periods during the follow-up. Further work to understand the driver of the reduction is needed.
Interventions to recognise, refer and diagnose patients with LC symptoms: better referrals but no change in long-term outcomes
LC is common but may be diagnosed late due to non-specific presenting symptoms. Interventions to improve detection rate and outcomes of LC vary in nature and outcome measured limiting interpretation for clinicians. Saab et al (Nature Prim Care Respir Med 2022;32:42) completed a systematic review of seven studies investigating strategies that help primary healthcare professionals (HCPs) recognise and refer suspected LC patients quickly. The review found that an LC strategist programme (community/GP targeted LC awareness campaign) versus routine referral; reduced diagnostic interval process, (time from suspicious lesion on imaging to diagnosis) from 28 to 3 days (p<0.001). Attendance at continuing medical educational (CME) meetings led to an increase in CXR ordering (19%–27%) by HCP in primary care. CME and easy access to direct low-dose CT scans led to significantly better selection of patients for scans with a positive predictor rate of 13.3% (95% CI 8.7% to 19.1%) in HCP participating in specific CME compared with 6.1% (95% CI 3% to 11%) in those who did not participate. This review highlighted the importance of HCP education on both symptoms and specific pathways involved in LC diagnosis to improve speed and accuracy of referrals. However, the review could not identify improvements in LC staging at diagnosis or longer-term mortality improvement that is the ultimate goal of the interventions.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.