Creating and administering video vignettes for a study examining the communication of diagnostic uncertainty: methodological insights to improve accessibility for researchers and participants.

BACKGROUND: Studying clinician-patient communication can be challenging, particularly when research seeks to explore cause-and-effect relationships. Video vignettes - hypothetical yet realistic scenarios - offer advantages to traditional observational approaches by enabling standardisation and manipulation of a clinician-patient encounter for assessment by participants. While published guidelines outline stages to create valid video vignette studies, constructing high quality vignettes which are accessible to a wide range of participants and feasible to produce within time and budget restraints remains challenging. Here, we outline our methods in creating valid video vignettes to study the communication of diagnostic uncertainty. We aim to provide practically useful recommendations for future researchers, and to prompt further reflection on accessibility issues in video vignette methodology. METHODS: We produced four video vignettes for use in an online study examining the communication of diagnostic uncertainty. We followed established guidelines for vignette production, with specific consideration of how these might be applied pragmatically to save time and resources. Scripts were pilot-tested with 15 laypeople, and videos with 14 laypeople; pilot-testing involved both quantitative and qualitative analysis. RESULTS AND DISCUSSION: We demonstrate the usefulness of existing guidelines, while also determining that vignette production need not necessarily be expensive or time-consuming to be valid. Our vignettes were filmed using an iPhone camera, and featured a physician rather than a professional actor; nonetheless, pilot-testing found them to be internally and externally valid for experimental use. We thus propose that if care is taken in initial script development and if pragmatic choices are made regarding filming techniques and pilot-testing, researchers can produce valid vignettes within reasonable time and budget restraints. We also suggest that existing research fails to critically examine the potential benefits and harms of online video vignette methodology, and propose that further research should consider how it can be adapted to be inclusive of those from underserved backgrounds. CONCLUSIONS: Researchers creating video vignette studies can adapt the video vignette development process to suit time and budget constraints, and to make best use of available technology. Online methods may be harnessed to increase participant accessibility, but future research should explore more inclusive vignette design.

Operational failures in general practice: a consensus-building study on the priorities for improvement.

BACKGROUND: System problems, known as operational failures, can greatly affect the work of GPs, with negative consequences for patient and professional experience, efficiency, and effectiveness. Many operational failures are tractable to improvement, but which ones should be prioritised is less clear. AIM: To build consensus among GPs and patients on the operational failures that should be prioritised to improve NHS general practice. DESIGN AND SETTING: Two modified Delphi exercises were conducted online among NHS GPs and patients in several regions across England. METHOD: Between February and October 2021, two modified Delphi exercises were conducted online: one with NHS GPs, and a subsequent exercise with patients. Over two rounds, GPs rated the importance of a list of operational failures (n = 45) that had been compiled using existing evidence. The resulting shortlist was presented to patients for rating over two rounds. Data were analysed using median scores and interquartile ranges. Consensus was defined as 80% of responses falling within one value below and above the median. RESULTS: Sixty-two GPs responded to the first Delphi exercise, and 53.2% (n = 33) were retained through to round two. This exercise yielded consensus on 14 failures as a priority for improvement, which were presented to patients. Thirty-seven patients responded to the first patient Delphi exercise, and 89.2% (n = 33) were retained through to round two. Patients identified 13 failures as priorities. The highest scoring failures included inaccuracies in patients' medical notes, missing test results, and difficulties referring patients to other providers because of problems with referral forms. CONCLUSION: This study identified the highest-priority operational failures in general practice according to GPs and patients, and indicates where improvement efforts relating to operational failures in general practice should be focused.

Identifying how GPs spend their time and the obstacles they face: a mixed-methods study.

BACKGROUND: Although problems that impair task completion - known as operational failures - are an important focus of concern in primary care, they have remained little studied. AIM: To quantify the time GPs spend on different activities during clinical sessions; to identify the number of operational failures they encounter; and to characterise the nature of operational failures and their impact for GPs. DESIGN AND SETTING: Mixed-method triangulation study with 61 GPs in 28 NHS general practices in England from December 2018 to December 2019. METHOD: Time-motion methods, ethnographic observations, and interviews were used. RESULTS: Time-motion data on 7679 GP tasks during 238 hours of practice in 61 clinical sessions suggested that operational failures were responsible for around 5.0% (95% confidence interval [CI] = 4.5% to 5.4%) of all tasks undertaken by GPs and accounted for 3.9% (95% CI = 3.2% to 4.5%) of clinical time. However, qualitative data showed that time-motion methods, which depend on pre-programmed categories, substantially underestimated operational failures. Qualitative data also enabled further characterisation of operational failures, extending beyond those measured directly in the time-motion data (for example, interruptions, deficits in equipment/supplies, and technology) to include problems linked to GPs' coordination role and weaknesses in work systems and processes. The impacts of operational failures were highly consequential for GPs' experiences of work. CONCLUSION: GPs experience frequent operational failures, disrupting patient care, impairing experiences of work, and imposing burden in an already pressurised system. This better understanding of the nature and impact of operational failures allows for identification of targets for improvement and indicates the need for coordinated action to support GPs.

Improving access to appointments at Laurie Pike Health Centre.

BACKGROUND: Rising demand makes it increasingly difficult for patients to access appointments. Laurie Pike Health Centre (LPHC) operates a predominantly same-day booking policy in order to manage appointment requests from its 18 000 patients. We sought to quantify the number of requests, in order to estimate the unmet demand. AIM: 1) To estimate the met and unmet demand for same-day appointments; 2) To assess how capacity for same-day appointments compares to demand; 3) To analyse how well LPHC is utilising its available appointment slots. METHOD: We created a data collection tool to count the total number of patient requests by type. We grouped types into four categories: 1) medical appointment requests; 2) sick notes and results requests; 3) other appointment requests (such as healthcare assistant, nurse); and 4) admin/other. Category-specific percentages were applied to call log data to estimate the number of appointment requests per category. Capacity was measured by counting the total number of same-day GP/advanced nurse practitioner (ANP) appointment slots. Consultation records for GP/ANP appointments were analysed to assess the appropriateness of the booking. RESULTS: Estimated average demand for same-day GP/ANP appointments was 222 per day. Average same-day capacity was 112 slots. After introducing pharmacist and video consultations, average capacity increased to 194 slots per day, a shortfall of 28 appointments. Consultation records indicated that 41% of GP/ANP appointments could have been seen by other practitioners; for example, musculoskeletal practitioners (14%). CONCLUSION: GP/ANP appointments alone cannot meet patient demand but a diversified workforce might. Alongside this, efforts to improve care navigation may free up to 41% of GP/ANP appointment slots.

A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England.

OBJECTIVES: To explore how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England. We explored women's perceptions of deinfibulation, caesarean section and vaginal delivery; their experiences of care during pregnancy and labour; and factors that affect ability to access these services, in order to make recommendations about future practice. DESIGN: A descriptive, exploratory qualitative study using face-to-face semistructured interviews. Interviews were audio-recorded, transcribed and data were analysed using a thematic approach. An interpreter was used when required (n=3). SETTING: Participants recruited from 2 community centres in Birmingham, England. PARTICIPANTS: Convenience and snowball sample of 10 Somali women resident in Birmingham, who had accessed antenatal care services in England within the past 5 years. RESULTS: 3 core themes were interpreted: (1) Experiences of female genital mutilation during life, pregnancy and labour: Female genital mutilation had a significant physical and psychological impact, influencing decisions to undergo deinfibulation or caesarean section. Women delayed deinfibulation until labour to avoid undergoing multiple operations if an episiotomy was anticipated. (2) Experience of care from midwives: Awareness of female genital mutilation from midwives led to open communication and stronger relationships with women, resulting in more positive experiences. (3) Adaptation to English life: Good language skills and social support networks enabled women to access these services, while unfavourable social factors (eg, inability to drive) impeded. CONCLUSIONS: Female genital mutilation impacts Somali women's experiences of antenatal and intrapartum care. This study suggests that midwives should routinely ask Somali women about female genital mutilation to encourage open communication and facilitate more positive experiences. As antenatal deinfibulation is unpopular, we should consider developing strategies to promote deinfibulation to non-pregnant women, to align with current guidelines. Women with unfavourable social factors may require additional support to improve access to English antenatal care services.

Rare case of eosinophilic granulomatosis with polyangiitis in two patients with α-1-antitrypsin deficiency (PiSZ).

We present two cases of eosinophilic granulomatosis with polyangiitis occurring with α-1-antitrypsin deficiency, both PiSZ phenotype. The simultaneous occurrence of these two conditions has seldom been described in the literature, despite evidence of an association between α-1-antitrypsin deficiency and other forms of vasculitis. Both patients had pulmonary involvement and reported intermittent exacerbations of vasculitic symptoms. Both patients were managed on low-dose oral steroids and azathioprine remaining well with occasional exacerbations. It is important to consider whether there is an association between eosinophilic granulomatosis with polyangiitis and α-1-antitrypsin deficiency, as this may lead to more severe pulmonary symptoms during exacerbations. If a genetic association between the two conditions is found, clinicians should be aware of the possible need to screen for α-1-antitrypsin deficiency in appropriate patients.