Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK.
The premier primary care research meeting in the United Kingdom and Ireland, the Society of Academic Primary Care (SAPC) meeting, was hosted by the Royal College of Surgeons in Ireland.
Margaret Cupples, a long time friend and colleague, gave the opening keynote address, guiding us through the evolving patterns of morbidity and mortality in cardiovascular disease, the changing impact of various risk factors, and reviewed some of her own work in secondary prevention. She added a contemporary flavour by illustrating the differential cardiovascular mortality and morbidity across the UK which shows a significantly greater problem in Scotland, Wales and Northern Ireland. While the overall picture has improved over time, risk factors such as diabetes, physical inactivity and obesity had worsened, contrasting with improvements in hypertension and smoking. There has been an exponential increase in the rates of PCI while rates of CABG have remained steady. Cardiovascular medication use has increased (sixfold), perhaps due to better or earlier diagnosis and increased availability of drugs. But, one of Margaret’s particular research interests is in physical activity and I enjoyed her review of the work of Jerry Morris, a pivotal researcher in the field who was still swimming and walking up until his death aged over 99 years. But, how does she see the most effective ways of encouraging behavioural change? Being active needs a social context, peer and employer support and, reflecting on the modest effect of medically focused lifestyle interventions, she gave us an example of a major community intervention. When asked by Simon Griffin if doctors should focus on treating the sick, rather than exercise interventions, Margaret agreed, saying that she doesn’t feel we should focus only on individualised advice and that it may be better look at community and broader population interventions.
Multimorbidity is a recurring theme and, among the short paper presentations, I was interested in Anders Prior’s presentation where he looked at the association between perceived stress, multimorbidity and increased risk of hospital admissions. He wondered if addressing mental health, while treating physical health, might reduce admissions. Susan Smith pointed out that most patients with multimorbidity have high levels of anxiety and that the relationship is very difficult to disentangle.
David Blane explored the literature on the role of primary care in managing obesity and, from his realist review of the gap between policy and practice, emphasised the difficulties in management. I especially liked his description of a realist review: It looks at what works, for whom, in what circumstances, how, and why. You start with a theory and review to refine the theory. Mystery solved.
Chris Burton’s “elevator pitch” based on a discrete choice analysis suggested that, while everyone says communication skills are important, patients with chronic illness would trade this for personalised information: Its the message, not the medium, that’s important.
Editors like article titles that are designed to be picked up in electronic searches but conference titles are created to attract an audience and allow more room for imagination. I liked Jessica Watson’s title and, indeed, her talk: “I’m fishing really – Inflammatory marker testing in primary care: a qualitative study.” And, similarly, Jennifer Liddle’s, “It’s just a great muddle when it comes to food – exploring patients decision making around diet and gout.”
The Helen Lester Lecture is one of the highlights of the SAPC Meeting and Chris Dowrick gave a beautifully crafted, reflective, and moving talk- an artistic and poetic journey through our understanding of suffering. He described our curious ambivalence and lack of acknowledgement of patients suffering. Compassionate and thoughtfully positive, he also recognised that it is exhausting and debilitating and cautioned us to protect ourselves from the raw reality of patient’s lives. But, we take short cuts: Making a diagnosis of depression gives us an easy out, which is perhaps why GPs over diagnose depression. Cross cultural communication difficulties can also create barriers where we may replace loss with illness and suffering with depression. Acknowledgement may be first step but the patient needs an opportunity to tell their story. Chris finished on a note of hope and optimism. Evidence based hopefulness. You can listen to this in his own words in the video where I caught up with him after his talk.
Jennifer Walker, who won the traveling award from Australia, described the work of her team in examining barriers to colo-rectal cancer screening in Australia and, in particular, use of their CRISP risk assessment tool. Screening is recommended for those aged over 50 years of age but only 36% participate. Looking at barriers to use of the CRISP model of risk assessment in general practice, they identified four categories: Coherence- did the clinical staff understand value of risk prediction tools; Cognitive participation –did the doctors engage, did they really buy into this. Collective action- what is the capacity to include it within existing systems and, Reflexive monitoring. You can see a webcast of her original talk in Australia here.
Kamal Mahtani, the Yvonne Carter award winner, explained the detail behind research into the direct oral anticoagulants (DOACs). While there is an overall trend of increased use in the UK, there is considerable variation in prescribing and use remains low compared to other countries. There is still clinical uncertainty and we need to develop tools to help explain their use to our patients. Most of the evidence (82%) for effectiveness comes from 4 mega trials and many of the audience would have been surprised that, for a published trial that may run to 13 pages, the technical details may contain 285 page. Access to this data is essential but it can take a long time to get the clinical data reports.
Matthias Egger, in his keynote address, looked at the deficiencies in our current models of research publication and dissemination and, in particular, the many opportunities for bias- too many to list individually- that can occur along the way from conception of a trial, to publication and citation. He gave an example by looking at the subsequent publication of posters and abstracts presented at a conference – how long it takes and the obvious distortion of evidence by those published or not. Creating the baseline at an earlier stage in research, where researchers seek ethics permission, we see that those studies with a positive results have a 2.6 times greater likelihood of publication. Authors were also criticised because they do not always report the primary outcome, misreport primary outcomes, and even create new primary outcomes that are not in the protocol. But, journal editors didn’t escape criticism either, admonished for not always adhering to the guidelines they promote.
Theo Verheij is one of the leading researchers in infectious disease management in family medicine. In his plenary lecture he looked at patient safety issues related to infectious disease. The best predictive models to accurately detect serious illness are limited and, even when sensitivity and specificity look good, the positive and negative predictive value are low, thus recent research has focused on augmenting prediction models by near patient testing to guide more appropriate treatment. It was also fascinating to hear that, even when antibiotics are prescribed, about one third of patients don’t actually take them. Theo’s overall message was that we can reduce prescribing without significantly missing cases. The subsequent discussion, with contributions from the world’s leading primary care infectious disease experts, agreed that we significantly over-prescribe to cover the very small risk of missing a patient with pneumonia. We cannot avoid the risks but we need to accept it and have more open discussion.
One of the more difficult problems to manage in family medicine is insomnia so I looked to Hazel Everitt’s talk for answers. Cognitive behaviour therapy is effective but of limited availability, the “Z” drugs are effective but habit forming, so doctors try other strategies including anti-histamines and antidepressants. But, for antidepressants, evidence does not support practice. I admired their remarkable commitment in translating so many trials from Chinese. She smiled as she concluded, that like many Cochrane reviews, her conclusion was that we need better quality evidence. Frank Moriarity discussed inappropriate prescribing, classifying these as acts of commission and of omission, and pointing out that prescribing problems don’t always mean too much medicine – that there can also be too little medicine.
Listening to so many enthusiastic and committed family medicine researchers, it is easy to forget that some patients slip through the cracks in our health care systems but a series of presentations reminded us of the forgotten in society. Patrick O’Donnell looked at strategies to improve primary health care in marginalised groups. The term “Hard to reach groups” hardly begins to describe his research population of traveling people, migrant groups, drug addicts and sex workers. Using participatory research to help understand their real world experiences its clear that, for many marginalised groups, health care is pushed far down their daily priorities. But, one patient’s words ring as a particular indictment : “The wealthy get more, get better time, from the doctors than people who haven’t got the money for it.”
Gerry Bury discussed the experience of family doctors dealing with opiate addiction and, as drug problems have become so widespread, he believes training in managing patients with opiate addiction should be a compulsory part of GP training. Stated explicitly, he says that current training no longer meets our responsibilities to the community nor the needs of our profession. This was endorsed by Austin O’Carroll, who has been providing health care to homeless people for many years.