Parkinson's disease: a scoping review of the quantitative and qualitative evidence of its diagnostic accuracy in primary care.

BACKGROUND: Parkinson's disease is a multisystem condition that usually presents as a movement disorder in clinical practice. There is no objective method for its diagnosis and therefore the current diagnostic process is based on characteristic clinical signs and symptoms. As the presenting symptoms can be vague and non-specific, there is often a delay in diagnosis leading to mismanagement and delayed treatment initiation. In the UK, GPs identify and initially assess individuals with Parkinson's disease and refer them to specialists for formal diagnosis and treatment initiation. AIM: To use a scoping review to examine the available evidence on the accuracy of Parkinson's disease diagnosis in primary care and to assess the potential for GPs to make a diagnosis and initiate treatment, and hence avoid harmful delays. DESIGN AND SETTING: The scoping methodology as proposed by Westphaln and colleagues that is a modified version of Arksey and O'Malley's original framework was followed. All findings were reported according to PRISMA guidelines for scoping reviews. METHOD: Four databases (EMBASE, PubMed Central, Cochrane, and CINAHL) and references lists of relevant published literature were systematically searched for all types of literature available in English on the accuracy of Parkinsonism or Parkinson's disease diagnosis in primary care. There were no search restrictions placed on countries, type of studies, or age. Two reviewers independently screened titles and abstracts followed by full-text screening. RESULTS: Out of 1844 studies identified, only six studies met the inclusion criteria. Five were from high-income and one from a middle-income nation. Of these, three studies identified significant knowledge gaps of GPs in diagnosing Parkinson's disease using a questionnaire-based assessment. Delay in appropriate referral because of delayed symptom identification was reported in one study. Only one study compared the accuracy of primary care Parkinson's disease diagnosis with that of specialists, and reported that, although specialists' diagnosis showed more sensitivity, GPs had higher specificity in diagnosing Parkinson's disease. However, this study was found to have methodological issues leading to bias in the findings. CONCLUSION: This scoping review shows that there are no well-conducted studies assessing the accuracy of Parkinson's disease diagnoses when made by GPs. This calls for more focused research in this area as diagnostic delays and errors may lead to potentially harmful but preventable delays in treatment initiation resulting in decreased quality of life for individuals with Parkinson's disease.

Gender inequalities across ethnicities in primary care cancer referrals: scoping review protocol.

BACKGROUND: Early cancer diagnosis is associated with improved mortality and morbidity; however, studies indicate that women and individuals from ethnic minorities experience longer times to diagnosis and worse prognosis compared to their counterparts for various cancers. In countries with a gatekeeper healthcare system, such as UK, most suspected cancer referrals are initiated in primary care. AIM: To understand the extent of evidence available on the relationship between primary care cancer referral pathways and cancer outcomes in relation to gender across different ethnic groups. This will identify research gaps and enable development of strategies to ease potential inequalities in cancer diagnosis. DESIGN & SETTING: A scoping review based on the Joanna Briggs Institute methodology. PRISMA-ScR will be used. METHOD: Electronic databases and private collections of the team members will be searched for studies. Two independent reviewers will carry out the study selection and data extraction. Based on participants, concept and context framework, this review will consider studies after year 2000 that explored the relationship between gender, across various ethnic groups, and cancer outcomes following primary care cancer referral in countries with gatekeeper healthcare systems (UK, New Zealand, Sweden, Australia, Canada, Denmark, Ireland and Norway). Results will be presented as a narrative analysis. CONCLUSION: The results are expected to provide an overview of the discrepancies in primary care cancer referrals based on gender across ethnic groups, which will be crucial to define an appropriate range of strategies to ease any inequalities in primary healthcare cancer diagnosis. OPEN SCIENCE FRAMEWORK PROTOCOL REGISTRATION: https://osf.io/jvtxb.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review.

BACKGROUND: Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow. METHODS: A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed. RESULTS: The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue". CONCLUSIONS: The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

Cardiovascular Risk Profiles amongst Women in a Multiethnic Population in Inner City Britain: A Potential Impact of Anaemia.

The risk of diabetes is markedly reduced in men with iron deficiency anaemia (IDA). The nature of this relationship in women is not clear, nor is there information about the influence of ethnicity, given the increased susceptibility of diabetes amongst South Asians and Afro-Caribbeans. We reviewed 3563 patients with a diagnosis of anaemia from 2000 to 2007. The age-adjusted prevalence of vitamin B12 deficiency and IDA was calculated, together with cardiovascular comorbidities amongst Caucasians, South Asians, and Afro-Caribbeans. The prevalence of vitamin B12 deficiency (women only) or IDA was markedly higher in South Asians compared to Caucasians and Afro-Caribbeans. Among women with IDA, diabetes was more prevalent among South Asians (45%, 95% CI 39.0-51.0) compared to Caucasians (3.0%, 2.1-4.0); P < 0.001. Among South Asian women with vitamin B12 deficiency, the prevalence of diabetes was reduced 8.5% (5.2-12.0). South Asian women with vitamin B12 deficiency had a higher prevalence of myocardial infarction (MI) and ischemic heart disease (IHD), but this relationship was reversed in IDA. IDA is associated with a greater prevalence of diabetes in South Asian women, but it is not coordinated by a greater risk of macrovascular complications. Given the cardiovascular impact of diabetes in South Asians, this association merits further study in relation to its pathophysiological implication.

Microvascular diabetic complications are more prevalent in India compared to Mauritius and the UK due to poorer diabetic control.

Type 2 diabetes mellitus (T2DM) is a growing worldwide problem with WHO estimates suggesting that 300 million people will be affected by 2025. T2DM could result in both microvascular and macrovascular complications but the presentation of these complications could vary globally and be influenced by diabetic control. We investigated the prevalence of these complications by surveying 787 patients of south-Asian origin in diabetic clinics in the UK (n=351), Mauritius (n=173) and India (n=263). We found the prevalence of microvascular complications such as retinopathy (India 16.3%; Mauritius 2.3%; UK 2.6%), nephropathy (India 20.5%; Mauritius 10.5%; UK 2.3%) and neuropathy (India 8.4%; Mauritius 1.2%; UK 5.1%) complications to be significantly higher in India compared to Mauritius and the UK (p<0.05). Interestingly, macrovascular complications such as cardiovascular disease were significantly more prevalent in Mauritius and the UK compared to India (p<0.05). The use of diabetic medication such as Metformin, Sulphonylureas and Insulin was significantly higher in the UK and Mauritius compared to India (p<0.05). The mean HbA1c was significantly higher in India compared to the UK (India 8.68%; UK 8.30%). Our results suggest that microvascular complications are higher in India due to poorer diabetic control. Our findings could be explained by late-onset presentation of diabetic patients in India due to the lack of primary care initiatives to screen and monitor treatment of T2DM. Furthermore, the poor diabetic control in India could reflect a dearth of clinical, evidence-based-knowledge regarding diabetic medication amongst Indian physicians. In view of the global increase in T2DM, this is a major concern for Indian healthcare.