Saturday, June 10, 2023

Incorporating POCUS into general practice got stalled – but now it’s back on the agenda

Ultrasonography has become better and more accessible for GPs over the last decade, but will it become mainstream in Irish general practice? asks Dr Brendan O’Shea

Some time ago, I was having a coffee with our IT Guy at the practice. He has been with us for over 20 years, we enjoy shooting the breeze, I understand what a great job he does, and he kindly forgives me my profound ignorance and disinterest regarding the nuts and bolts of computering, (not an actual word – Ed) as long as the infernal machines perform as expected.

I asked him, ‘If you were a character from the Bible, who would you be ?’ With a twinkle in his eye, he smartly replied ‘Well, it would have to be Pontius Pilate….’ I was somewhat taken aback. He explained, ‘Well, I tell them exactly what I think of it (ie the IT problem of the day), and then I wash my hands of it !’

Naturally, he asked me who would I pick, to which I answered ‘John the Baptist,’ whose business was trying to look around corners, peer into the future, and intimate that wonderful things were about to happen. Of course, it didn’t end well for John the Baptist. He may have had great theological insight, with a nose for the future, but his head ended up on a plate as a result of upsetting the powers that were.

Now, don’t spend too much time ruminating about who you would be as a character from the Bible…..(God, obviously – Ed) but we might spend a few moments reflecting on GP POCUS (GP Point of Care Ultrasound), and whether it might become a more important part of General Practice?

POCUS – Point of Care Ultrasound – what is it, and where did it come from?
During the last two decades, as ultrasonography (US) became better, and less expensive to perform, US spread beyond the confines of the radiology department, and the exclusive prerogative of radiologists and radiographers, and out onto wards, now outside of hospitals, and into the hands of physicians from many specialties, including general practice. GP POCUS is now formally taught to GP Trainees in many other health systems, including Spain and Germany for example.

It is unofficially taught to our own trainees in Ireland during their hospital posts, who have opportunity to acquire skills and experience, particularly when doing ED, Obstetric Posts, and some OPDs. When these numbers of Trainees progress to GP Training Posts in Training Practices, as matters stand in Ireland, these skills atrophy, as GP POCUS at present is still limited to a relatively very small number of trend-setting GPs, who have personally invested to establish GP POCUS as part of their practice.

GP POCUS – Is it any good?
During the last 20 years, there is an emerging body of evidence which supports the availability of GP POCUS, in a variety of contexts. A recent Danish study (Kiritharan et al. BMC Health Services Research (2022) 22:55) compares outcomes in bleeding in early pregnancy managed in GP with/without GP Pocus, examining clinical and cost outcomes, unequivocally supporting GP POCUS in terms of reduced hospital admissions.

The very extensive analysis includes a (2021) fee at the practice level for performing POCUS of €32 per examination. Further, it is estimated that practice management with GP POCUS was on average €110 less expensive than in practices without. The study does not reflect the recent inflation in most economies since 2021, and does not take into account either patient or physician satisfaction.

A slightly earlier paper from Norway (Scan J of Primary Health Care 2020, 38, No. 2, 219–225) reported on the volume of scanning carried out by Norwegian GPs from 2009-2016, which simply skyrocketted during the study period, with 30 per cent of Norwegian GPs submitting claims for GP POCUS by 2016. Sorensen and Hunskaar (Ultrasound J (2019) 11:31) carried out a systematic review including 19 papers on GP POCUS, and concluded favourably on its broader use.

Andersen et al. (BMC Family Practice (2019) 20:89) carried out an attractive qualitative study with a sample of 34 GPs on their experience of establishing GP POCUS, and overall reporting positively on this as a valuable development.

Clearly the Danes and Norwegians (neither usually known for their frivolous exuberance) may have gotten carried away by POCUS, but GP POCUS is well established as an increasingly routine part of Scandinavian General Practice, as well as in most other European Health Systems.

GP POCUS – what needs to be done?
In 2017, the ICGP established a Special Interest Group for GP POCUS. The group reviewed the evidence and reflected on the collective experience of its own members (most of whom were clearly among the early innovator demographic). Somewhat difficult discussions were had with Medical Indemnifiers, rather better ones within the relevant ICGP Committees (particularly Educational Governance), and in 2019, the GP POCUS Group, headed by Dr Tony O’Sullivan, successfully recruited for a foundation course in GP POCUS, as a collaboration with the University of Bournemouth, which has significant experience in training NHS GPs in POCUS. The course launched well, was fully subscribed, but then there was the matter of the lockdown, which stopped it dead in its tracks, as undertaking scanning for training purposes was inconsistent with public health advice and guidance.

As I write, the needs of the learners in this initial course are being considered, and thought is being given on how to complete their learning.

A second course is being launched in May 2023 (watch this space) as a collaboration with ProMed. Run over seven months, it will include two in-person training days, and a volume of asynchronous online activity where learners collect a portfolio of in-practice scans, and have these considered by two Colleagues, Dr Andy Walden and Dr Lorenzo Christoni, who have skills and extensive expertise in teaching GP POCUS in a variety of settings in the NHS. You might be interested!

In order to move GP POCUS beyond the early adapter demographic, there is a need to assist General Practices with an equipment grant, with a wider bandwith in training capacity and opportunity, and a reasonable schedule of payment for the performance of scans – by both the PCRS and the Health Insurers.

Training Practices (several hundred of them!) can doubtlessly avail of Trainees bringing their experience in from their hospital posts to kick start the process.

The ICGP has been singularly effective in attracting ever larger numbers of our younger colleagues onto the rapidly expanding National GP Training Scheme.

Ensuring that we are better at more rapidly introducing aspects of innovative practice into both training and practice is an important part of ensuring (as far as possible) that the discipline of general practice is seen as progressive and intrinsically attractive – where things are really happening.

GP POCUS is a part of innovative practice, likely to be particularly of interest to younger colleagues, and some of us hope that it can be properly reflected in the Great Review of General Practice, now about to commence, and in that complex process between the HSE, the IMO, the ICGP, and to a lesser extent, the Private Health Insurance Industry.

Historically, timely innovation in Irish general practice has been a very stop-start affair, and most usually undertaken only for the most pressing of problems, and for issues that relate to all of GPs, as opposed to what might be considered as (important) minority/niche interests. Surely it’s time for this to change?

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