Showing papers in "British Journal of General Practice in 2007"

Prognostic factors for musculoskeletal pain in primary care: a systematic review.

Abstract: Background Estimating the future course of musculoskeletal pain is an important consideration in the primary care consultation for patients and healthcare professionals. Studies of prognostic indicators tend to have been viewed in relation to each site separately, however, an alternative view is that some prognostic indicators may be common across different sites of musculoskeletal pain. Aim To identify generic prognostic indicators for patients with musculoskeletal pain in primary care. Design of study Systematic review. Setting Observational cohort studies in primary care. Method MEDLINE, EMBASE, PsychINFO and CINAHL electronic databases were searched from inception to April 2006. Inclusion criteria were that the study was a primary care-based cohort, published in English and contained information on prognostic indicators for musculoskeletal conditions. Results Forty-five studies were included. Eleven factors, assessed at baseline, were found to be associated with poor outcome at follow up for at least two different regional pain complaints: higher pain severity at baseline, longer pain duration, multiple-site pain, previous pain episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction. Conclusion Despite substantial heterogeneity in the design and analysis of original studies, this review has identified potential generic prognostic indicators that may be useful when assessing any regional musculoskeletal pain complaint. However, Its unclear whether these indicators, used alone, or in combination, can correctly estimate the likely course of individual patients9 problems. Further research is needed, particularly in peripheral joint pain and using assessment methods feasible for routine practice.

Health risk appraisal in older people 1: are older people living alone an ‘at-risk’ group?

Abstract: Background In the UK, population screening for unmet need has failed to improve the health of older people. Attention is turning to interventions targeted at ‘at-risk’ groups. Living alone in later life is seen as a potential health risk, and older people living alone are thought to be an at-risk group worthy of further intervention. Aim To explore the clinical significance of living alone and the epidemiology of lone status as an at-risk category, by investigating associations between lone status and health behaviours, health status, and service use, in non-disabled older people. Design of study Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal in older people. Setting Four group practices in suburban London. Method Sixty per cent of 2641 community-dwelling non-disabled people aged 65 years and over registered at a practice agreed to participate in the study; 84% of these returned completed questionnaires. A third of this group, ( n = 860, 33.1%) lived alone and two-thirds ( n = 1741, 66.9%) lived with someone else. Results Those living alone were more likely to report fair or poor health, poor vision, difficulties in instrumental and basic activities of daily living, worse memory and mood, lower physical activity, poorer diet, worsening function, risk of social isolation, hazardous alcohol use, having no emergency carer, and multiple falls in the previous 12 months. After adjustment for age, sex, income, and educational attainment, living alone remained associated with multiple falls, functional impairment, poor diet, smoking status, risk of social isolation, and three self-reported chronic conditions: arthritis and/or rheumatism, glaucoma, and cataracts. Conclusion Clinicians working with independently-living older people living alone should anticipate higher levels of disease and disability in these patients, and higher health and social risks, much of which will be due to older age, lower educational status, and female sex. Living alone itself appears to be associated with higher risks of falling, and constellations of pathologies, including visual loss and joint disorders. Targeted population screening using lone status may be useful in identifying older individuals at high risk of falling.

Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies.

Abstract: Background Guidance from the National Institute for Health and Clinical Excellence recommends one or two questions as a possible screening method for depression. Ultra-short (one-, two-, three- or four-item) tests have appeal due to their simple administration but their accuracy has not been established. Aim To determine whether ultra-short screening instruments accurately detect depression in primary care. Design of study Pooled analysis and meta analysis. Method A literature search revealed 75 possible studies and from these, 22 STARD-compliant studies (Standards for Reporting of Diagnostic Accuracy) involving ultra-short tests were entered in the analysis. Results Meta-analysis revealed a performance accuracy better than chance ( P <0.001). More usefully for clinicians, pooled analysis of single-question tests revealed an overall sensitivity of 32.0% and specificity of 97.0% (positive predictive value [PPV] was 55.6% and negative predictive value [NPV] was 92.3%). For two- and three- item tests, overall sensitivity on pooled analysis was 73.7% and specificity was 74.7% with a PPV of only 38.3% but a pooled NPV of 93.0%. The Youden index for single-item and multiple item tests was 0.289 and 0.47 respectively, suggesting superiority of multiple item tests. Re-analysis examining only ‘either or’ strategies improved the ‘rule in’ ability of two- and three-question tests (sensitivity 79.4% and NPV 94.7%) but at the expense of being able to rule out a possible diagnosis if the result was negative. Conclusion A one-question test identifies only three out of every 10 patients with depression in primary care, thus unacceptable if relied on alone. Ultra-short two- or three-question tests perform better, identifying eight out of 10 cases. This is at the expense of a high false-positive rate (only four out of 10 cases with a positive score are actually depressed). Ultra-short tests appear to be, at best, a method for ruling out a diagnosis and should only be used when there are sufficient resources for second-stage assessment of those who screen positive.

Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines.

Abstract: Background GPs9 adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes. Aim To explore and synthesise qualitative research on GPs9 attitudes to and experiences with clinical practice guidelines. Design of study Systematic review and meta-synthesis of qualitative studies. Method PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis. Results Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs9 experience, preserving the doctor–patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs9 reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours. Conclusion Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.

Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review.

Abstract: Background Despite the health benefits of physical activity, most adults do not take the recommended amount of exercise. Aim To assess whether exercise-referral schemes are effective in improving exercise participation in sedentary adults. Design of study Systematic review. Method Studies were identified by searching MEDLINE, CINAHL, EMBASE, AMED, PsycINFO, SPORTDiscus, The Cochrane Library and SIGLE until March 2007. Randomised controlled trials (RCTs), observational studies, process evaluations and qualitative studies of exercise-referral schemes, defined as referral by a primary care clinician to a programme that encouraged physical activity or exercise were included. RCT results were combined in a meta-analysis where there was sufficient homogeneity. Results Eighteen studies were included in the review. These comprised six RCTs, one non-randomised controlled study, four observational studies, six process evaluations and one qualitative study. In addition, two of the RCTs and two of the process evaluations incorporated a qualitative component. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35). This means that 17 sedentary adults would need to be referred for one to become moderately active. This small effect may be at least partly due to poor rates of uptake and adherence to the exercise schemes. Conclusion Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies.

Measuring disease prevalence: a comparison of musculoskeletal disease using four general practice consultation databases.

Abstract: Background Primary care consultation data are an important source of information on morbidity prevalence. It is not known how reliable such figures are. Aim To compare annual consultation prevalence estimates for musculoskeletal conditions derived from four general practice consultation databases. Design of study Retrospective study of general practice consultation records. Setting Three national general practice consultation databases: i) Fourth Morbidity Statistics from General Practice (MSGP4, 1991/92), ii) Royal College of General Practitioners Weekly Returns Service (RCGP WRS, 2001), and iii) General Practice Research Database (GPRD, 1991 and 2001); and one regional database (Consultations in Primary Care Archive, 2001). Method Age-sex standardised persons consulting annual prevalence rates for musculoskeletal conditions overall, rheumatoid arthritis, osteoarthritis and arthralgia were derived for patients aged 15 years and over. Results GPRD prevalence of any musculoskeletal condition, rheumatoid arthritis and osteoarthritis was lower than that of the other databases. This is likely to be due to GPs not needing to record every consultation made for a chronic condition. MSGP4 gave the highest prevalence for osteoarthritis but low prevalence of arthralgia which reflects encouragement for GPs to use diagnostic rather than symptom codes. Conclusion Considerable variation exists in consultation prevalence estimates for musculoskeletal conditions. Researchers and health service planners should be aware that estimates of disease occurrence based on consultation will be influenced by choice of database. This is likely to be true for other chronic diseases and where alternative symptom labels exist for a disease. RCGP WRS may give the most reliable prevalence figures for musculoskeletal and other chronic diseases.

Cultural factors and patients' adherence to lifestyle measures.

Abstract: Background Non-adherence to preventive and therapeutic lifestyle recommendations among patients at high risk of cardiovascular disease is more prevalent and varied than previously thought. The problem needs to be addressed by those who are involved in the care of these patients. Aim To measure adherence and barriers of complying with lifestyle recommendations among patients with high cardiovascular risk factors. Design of study Prospective study. Setting Six family-practice health centres in Kuwait. Method Data are from 334 Kuwaiti adult males and females with hypertension, type 2 diabetes, or both, who completed a routine clinic visit in one of six family practice centres. Trained staff used a structured questionnaire to obtain a detailed medical history regarding exercise habits and barriers to compliance with diet and exercise programmes. Clinical criteria assessed were height, weight, and the control of blood pressure and blood sugar. Results From the study sample, 63.5% of patients reported that they were not adhering to any diet regimen, 64.4% were not participating in regular exercise, and 90.4% were overweight and obese. The main barriers to adherence to diet were unwillingness (48.6%), difficulty adhering to a diet different from that of the rest of the family (30.2%), and social gatherings (13.7%). The main barriers to adherence to exercise were lack of time (39.0%), coexisting diseases (35.6%), and adverse weather conditions (27.8%). Factors interfering with adherence lifestyle measures among the total sample were traditional Kuwaiti food, which is high in fat and calories (79.9%), stress (70.7%), a high consumption of fast food (54.5%), high frequency of social gatherings (59.6%), abundance of maids (54.1%), and excessive use of cars (83.8%). Conclusion The majority of individuals in the sample were overweight, did not engage in recommended levels of physical activity, and did not follow dietary recommendations. Additional cultural and demographic variables need to be considered to improve adherence to lifestyle measures.

Diagnosing depression in primary care using self-completed instruments: UK validation of PHQ-9 and CORE-OM.

Abstract: There is increased emphasis on routine assessment of depression in primary care. This report is the first UK validation of two self-completed measures: the Patient Health Questionnaire (PHQ–9) and the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE–OM). Optimum cut-off points were established against a diagnostic gold standard in 93 patients. PHQ–9 sensitivity = 91.7% (95% confidence interval [CI] = 77.5 to 98.3%) and specificity 78.3% (95% CI = 65.8 to 87.9%). CORE–OM sensitivity = 91.7% (95% CI = 77.5 to 98.2%) and specificity = 76.7% (95% CI = 64.0 to 86.6%). Brief self-rated questionnaires are as good as clinician-administered instruments in detecting depression in UK primary care.

Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: Retrospective cohort study

Abstract: Background Intensive glycaemic control can reduce the risk of microvascular complications in people with type 2 diabetes. Aim To examine the extent of monitoring and glycaemic control of patients with type 2 diabetes prescribed oral agents and/or insulin, and to investigate transition to insulin. Design of study Retrospective cohort study. Setting A total of 154 general practices in the UK contributing to the DIN-LINK database between 1995 and 2005. Method People with type 2 diabetes were identified using Read codes and prescribing data. Outcome measures were: glycaemic monitoring and control on multiple oral agents and/or insulin, and transition to insulin. Results A total of 14 824 people with type 2 diabetes were prescribed multiple oral agents concurrently, of whom 5064 (34.16%) had haemoglobin A 1c (HbA 1c ) assessments 6 months before and following initiation of their last oral therapy. Mean HbA 1c before therapy was 9.07%, which dropped to 8.16% following therapy (mean difference 0.91%, 95% confidence interval [CI] = 0.86 to 0.95, P 1c assessments, 3153 (62.26%) had evidence of poor glycaemic control following therapy. Median time to insulin for patients prescribed multiple oral agents was 7.7 years (95% CI = 7.4 to 8.5 years); 1513 people began insulin during the study and had HbA 1c assessments 6 months before and following insulin. Mean HbA 1c before insulin was 9.85% (standard deviation [SD] 1.96%) which decreased by 1.34%, (95% CI = 1.24% to 1.44%) following therapy, but 1110 people (73.36%) still had HbA 1c ≥7.5%. Conclusion Many people with type 2 diabetes received inadequate monitoring and had poor glycaemic control. Intensive management is required to reduce the risk of microvascular complications.

Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors.

Abstract: Background Most studies on the incidence of the carpal tunnel syndrome and the relation of this disorder with occupation are population-based. In this study we present data from general practice. Aim To compare incidence rates of carpal tunnel syndrome in 1987 with those in 2001, and to study the relationship between carpal tunnel syndrome and occupation. Design of study Analysis of the data of the first and second Dutch National Survey of General Practice, conducted in 1987 and 2001, respectively. Setting General practices in The Netherlands. Method One hundred and three general practices in 1987 with 355 201 listed patients, and 96 practices with 364 998 listed patients in 2001, registered all patients who presented with a new episode of carpal tunnel syndrome. Patient and GP populations were representative for The Netherlands. Results The crude incidence rate was 1.3 per 1000 (95% confidence interval [CI] = 1.0 to 1.5) in 1987, and 1.8 per 1000 (95% CI = 1.7 to 2.0) in 2001. In males it was 0.6 (95% CI = 0.5 to 0.7) and 0.9 (95% CI = 0.8 to 1.0) respectively; in females 1.9 (95% CI = 1.7 to 2.1) and 2.8 (95% CI = 2.6 to 3.1). At both study periods, peak incidence rate occurred in the 45–64-year age group: in 2001 this peak reached 4.8 per 1000 (95 CI = 4.1 to 5.4) for females and 1.6 (95 CI = 1.2 to 2.0) for males. Women who performed unskilled and semi-skilled work had 1.5 times greater risk of acquiring carpal tunnel syndrome than women with higher-skilled jobs (P Conclusion In 2001 the crude incidence rate of carpal tunnel syndrome was 1.5 times higher than in 1987, but the difference was not statistically significant after subdividing by age and sex. In both years the female:male ratio was 3:1. Incidence rates were related to the job level of women, but not of men.

Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people

Abstract: Background Social isolation is associated with poorer health, and is seen by the World Health Organisation (WHO) as one of the major issues facing the industrialised world. Aim To explore the significance of social isolation in the older population for GPs and for service commissioners. Design of study Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. Setting A total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London. Method Demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services. Results More than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health. Conclusion The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.

Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care.

Abstract: Background Serious infections in children (sepsis, meningitis, pneumonia, pyelonephritis, osteomyelitis, and cellulitis) are associated with considerable mortality and morbidity. In children with an acute illness, the primary care physician uses signs and symptoms to assess the probability of a serious infection and decide on further management. Aim To analyse the diagnostic accuracy of signs and symptoms, and to create a multivariable triage instrument. Design of study A prospective diagnostic accuracy study. Setting Primary care in Belgium. Method Children aged 0–16 years with an acute illness for a maximum of 5 days were included consecutively. Signs and symptoms were recorded and compared to the final outcome of these children (a serious infection for which hospitalisation was necessary). Accuracy was analysed bivariably. Multivariable triage instruments were constructed using classification and regression tree (CART) analysis. Results A total of 3981 children were included in the study, of which 31 were admitted to hospital with a serious infection (0.78%). Accuracy of signs and symptoms was fairly low. Classical textbook signs (meningeal irritation impaired peripheral circulation) had high specificity. The primary classification tree consisted of five knots and had sensitivity of 96.8% (95% confidence interval [CI] = 83.3 to 99.9), specificity 88.5% (95% CI = 87.5 to 89.5), positive predictive value 6.2% (95% CI = 4.2 to 8.7), and negative predictive value 100.0% (95% CI = 99.8 to 100.0), by which a serious infection can be excluded in children testing negative on the tree. The sign paramount in all trees was the physician9s statement ‘something is wrong’. Conclusion Some individual signs have high specificity. A serious infection can be excluded based on a limited number of signs and symptoms.

Health problems of people with intellectual disabilities: the impact for general practice.

Abstract: This study aimed to analyse the health problems and prescriptions of people with intellectual disabilities registered with GPs. Within the Second Dutch National Survey of General Practice evidence was gathered on the differences in health problems between people with intellectual disabilities and control persons (without intellectual disabilities). In a 1:5 matched sample, people with intellectual disabilities paid 1.7 times more visits to GPs. They presented a different morbidity pattern, and received four times as many repeat prescriptions. People with intellectual disabilities increase a GP's workload.

Quality of clinical primary care and targeted incentive payments: an observational study

Abstract: Background Payments for recorded evidence of quality of clinical care in UK general practices were introduced in 2004. Aim To examine the relationship between changes in recorded quality of care for four common chronic conditions from, 2003 to 2005, and the payment of incentives. Design of study Retrospective observational study comparing incentivised and non-incentivised indicators of quality of care. Setting Eighteen general practices in England. Method Medical records were examined for 1156 patients. The percentage of eligible quality indicators achieved for each patient was assessed in 2003 and 2005. Twenty-one quality indicators referred to asthma and hypertension: six subject to and 15 not subject to incentive payments. Another 15 indicators referred to depression and osteoarthritis which were not subject to incentive payments. Results A significant increase occurred for the six indicators linked to incentive payments: from 75% achieved in 2003 to 91% in 2005 (change = 16%, 95% confidence interval [CI] = 10 to 22%, P <0.01). A significant increase also occurred for 15 other indicators linked to ‘incentivised conditions’; 53 to 64% (change = 11%, 95% CI = 6 to 15%, P <0.01). The ‘non-incentivised conditions’ started at a lower achievement level, and did not increase significantly: 35 to 36% (change = 2%, 95% CI = −1 to 4%, P = 0.19). Conclusion The introduction of financial incentives was associated with substantial apparent quality improvement for incentivised conditions. For non-incentivised conditions, quality did not appear to improve. Patients with non-incentivised conditions may be at risk of poorer quality care.

Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections

Abstract: Background Adhesive capsulitis is a common, painful, and disabling condition that has been managed with corticosteroid injections for over 50 years There is debate over the use of single or multiple injections, but no systematic review has investigated the effects of administering multiple injections Aim To assess the efficacy of treating adhesive capsulitis of the shoulder with multiple corticosteroid injections Design of study Systematic review Method An English language search for randomised controlled trials was conducted from: MEDLINE®, EMBASE, CINAHL, PEDro, SIGLE, National Technical Information Service, British National Bibliography, Index of Scientific and Technical Proceedings® databases, and the Cochrane Library Randomised controlled trials were identified from reference lists of review and eligible articles The studies were assessed using a recognised rating system of methodological trial quality The conclusions and results of the identified studies, based on their main outcome measures, were then summarised Results Nine randomised controlled trials were identified and four studies were rated as high quality Three high quality studies showed a beneficial effect for the use of multiple corticosteroid injections with outcome measures of pain reduction, improved function, and increased range of shoulder movement Conclusion The evidence suggested that multiple injections were beneficial until 16 weeks from the date of the first injection Up to three injections were beneficial, with limited evidence that four to six injections were beneficial No evidence was found to support giving more than six injections

Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices

Abstract: Background GPs are urged to prescribe antibiotics less frequently, despite lack of evidence linking reduced antibiotic prescribing with reductions in resistance at a local level. Aim To investigate associations between changes in antibiotic dispensing and changes in antibiotic resistance at general-practice level. Design of study Seven-year study of dispensed antibiotics and antibiotic resistance in coliform isolates from urine samples routinely submitted from general practice. Setting General practices in Wales. Method Multilevel modelling of trends in resistance to ampicillin and trimethoprim, and changes in practice total antibiotic dispensing and amoxicillin and trimethoprim dispensing. Results The primary analysis included data on 164 225 coliform isolates from urine samples submitted from 240 general practices over the 7-year study period. These practices served a population of 1.7 million patients. The quartile of practices that had the greatest decrease in total antibiotic dispensing demonstrated a 5.2% reduction in ampicillin resistance over the 7-year period with changes of 0.4%, 2.4%, and −0.3% in the other three quartiles. There was a statistically significant overall decrease in ampicillin resistance of 1.03% (95% confidence interval [CI] = 0.37 to 1.67%) per decrease of 50 amoxicillin items dispensed per 1000 patients per annum. There were also significant reductions in trimethoprim resistance in the two quartiles of practices that reduced total antibiotic dispensing most compared with those that reduced it least, with an overall decrease in trimethoprim resistance of 1.08% (95% CI = 0.065 to 2.10%) per decrease of 20 trimethoprim items dispensed per 1000 patients per annum. Main findings were confirmed by secondary analyses of 256 370 isolates from 527 practices that contributed data at some point during the study period. Conclusion Reducing antibiotic dispensing at general-practice level is associated with reduced local antibiotic resistance. These findings should further encourage clinicians and patients to use antibiotics conservatively.

Hypertension guideline recommendations in general practice: Awareness, agreement, adoption, and adherence

Abstract: Background: GPs vary greatly in their clinical management of hypertension, for reasons that are poorly understood. Aim: To explore G Ps' awareness of current hypertension guidelines and their self-reported implementation of them in clinical practice. Design of study: Questionnaire survey via the internet. Setting: Primar y care. Method: Survey of GPs (n = 401), based on the ' awareness-to-adherence' model of behavioural change. Results: While awareness of recommendations was high, agreement and adoption were often less so. Almost all practitioners (99%) were aware of the guidance on statin therapy but fewer than half (43%; 95% confidence interval [CI] 38-48%) adhered to the recommendation in practice. Three-quarters (77%) were aware that blood pressure should initially be measured in both arms, but only 30% agreed with the recommendation (95% CI = 26 to 34%), And 13% (95% CI = 10 to 16%) adhered to it. Although the adoption of a recommendation was usually consequent on agreement with it, 19% of GPs (95% CI = 15 to 23%) reported adherence to financially-incentivised guidance on statin therapy without either being aware of it or in agreement with it. No significant association was found among age, sex, year of graduation, or post held and level of awareness, agreement, or adoption. Conclusion: The specific barrier and action needed to promote application of hypertension guidelines varies with each clinical action. Lack of awareness is seldom the problem. Most GPs are unlikely to implement elements of guidance they disagree with even if given financial incentives. High adherence requires a reflective workforce that can respond to the scientific evidence underpinning the guidance. © British Journal of General Practice 2007.

Chronic diseases: what happens when they come in multiples?

Abstract: Multimorbidity is the coexistence of two or more chronic diseases in an individual.1 Prevalence studies indicate that it is the normal state of affairs, especially in patients over the age of 65 years.1 A smaller sub-group of patients are more severely affected by multimorbidity as the combination and severity of their conditions results in significant loss of function, poor quality of life, and frequent hospital admissions. There is a need to examine the health care of patients with multimorbidity, as they often receive fragmented specialist care which does not meet their needs, or indeed support their professional carers, especially in primary care. Chronic disease care is now based on protocol driven management for a single disease across primary and secondary care.2 The commonly used term ‘comorbidity’ implies that there is an index disease to which coexistent diseases relate and may share an aetiology and perhaps a solution. In clinical practice individual patients often suffer from a collection of chronic illnesses which may or may not have a common aetiology, but which require greatly differing and often incompatible management. This is why we use the term multimorbidity here. Individuals with multimorbidity are more likely to die prematurely, be admitted to hospital, have longer hospital stays, poorer quality of life, and a loss of physical functioning.3,4 They are more likely to suffer from depression, to be receiving multiple medications, and to have consequent difficulties with adherence to treatment and polypharmacy.5,6 Qualitative research indicates that patients with multimorbidity identify loss of function and polypharmacy as key problem areas.7 There are multiple barriers to self-care including physical limitations and aggravation of one condition by treatment of another.8 Research also highlights difficulties accessing care8 and problems with healthcare providers, particularly specialists.7 Analysis …

Public beliefs on antibiotics and respiratory tract infections: an internet-based questionnaire study

Abstract: Background Patient expectations are among the strongest predictors of clinicians9 antibiotic prescribing decisions. Although public knowledge, beliefs, and experiences of antibiotics contribute to these expectations, little is known about these public views. Aim To gain insight into public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections. Design of study Cross-sectional, internet-based questionnaire study. Setting Members of the general public aged 16 years and over in the Netherlands. Methods Public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections, as well as predictors of accurate knowledge of antibiotic effectiveness, were measured using 20 questions with sub-items. The questionnaire was given to a Dutch community-based nationwide internet panel of 15 673 individuals. Of these, 1248 eligible responders were invited to participate; 935 responders (75%) completed the questionnaire. Results Of the participants, 44.6% accurately identified antibiotics as being effective against bacteria and not viruses. Acute bronchitis was considered to require treatment with antibiotics by nearly 60% of responders. The perceived need for antibiotics for respiratory tract infection-related symptoms ranged from 6.5% for cough with transparent phlegm, to 46.2% for a cough lasting for more than 2 weeks. Conclusion Public misconceptions on the effectiveness of, and indications for, antibiotics exist. Nearly half of all responders (47.8%) incorrectly identified antibiotics as being effective in treating viral infections. Doctors should be aware that unnecessary prescribing could facilitate misconceptions regarding antibiotics and respiratory tract infections. Expectations of receiving antibiotics were higher for the disease label ‘acute bronchitis’ than for any of the separate or combined symptoms prominently present in respiratory tract infection. Public beliefs and expectations should be taken into account when developing interventions targeting the public, patients, and physicians to reduce unnecessary prescribing of antibiotics for respiratory tract infections.

Procalcitonin versus C-reactive protein for predicting pneumonia in adults with lower respiratory tract infection in primary care.

Abstract: Background The role of procalcitonin in diagnosing bacterial infection has mainly been studied in patients with severe infections. There is no study on the value of procalcitonin measurements in adults with lower respiratory tract infection (LRTI) treated in primary care. Aim To evaluate the accuracy of plasma procalcitonin in predicting radiographic pneumonia, bacterial infection, and adverse outcome in a population of adults with LRTI treated in primary care. Design of study Prospective, observational study. Setting Forty-two general practices and an outpatient clinic at the Department of Infectious Diseases, Odense University Hospital, Denmark. Method A total of 364 patients with LRTI were prospectively enrolled from 42 general practices. Patients were examined with chest radiography, microbiological analyses, and measurements of C-reactive protein (CRP) and procalcitonin. The outcome measure was hospitalisation within 4 weeks of enrolment. Results Median procalcitonin was 0.05 ng/ml, which was below the functional sensitivity of the assay (0.06 ng/ml). In predicting radiographic pneumonia, bacterial infection, and hospitalisation, the sensitivities of procalcitonin >0.06 ng/ml were 0.70, 0.51, and 0.67, and of CRP ≥20 mg/l were 0.73, 0.56, and 0.74 respectively. Corresponding positive predictive values were between 0.09 and 0.28. Conclusion Both procalcitonin >0.06 ng/ml and CRP ≥20 mg/l were associated with radiographic pneumonia, bacterial infection, and subsequent hospitalisation, but positive predictive values were too low for any of the two inflammatory markers to be of use in clinical practice. To measure procalcitonin values accurately in the primary care setting, a more sensitive method is needed, but there was no indication that procalcitonin is superior to CRP in identifying patients with pneumonia, bacterial aetiology, or adverse outcome.

Adults with Down's syndrome: the prevalence of complications and health care in the community

Abstract: Background Individuals with Down9s syndrome are predisposed to a variety of medical conditions which can impose an additional, but preventable, burden of secondary disability. Although there are guidelines for health checks and medical management of children with Down9s syndrome, the needs of adults are relatively neglected. Aim To determine the prevalence of common medical problems in adults with Down9s syndrome, and to assess current practice regarding medical surveillance of these patients. Design of study Detailed notes analysis. Setting Data were obtained from the primary care records of adults with Down9s syndrome living in the Newcastle upon Tyne and Gateshead areas. Method Case notes were reviewed to obtain details regarding complications and to determine the frequency of medical surveillance of individuals with Down9s syndrome. Results Complications such as hypothyroidism, coeliac disease, and obesity occur more frequently in adults with Down9s syndrome than previous paediatric prevalence studies suggest. Surveillance of common complications that occur in individuals with Down9s syndrome is infrequent. In this study, 48% of adults with Down9s syndrome had not seen a doctor in the previous 12 months and 33% had not had a medical assessment in the previous 3 years. Conclusion Many individuals with Down9s syndrome do not have access to regular healthcare checks, despite the high frequency of common medical complications in adult life. Debate regarding the practicality and relevance of introducing regular health checks is warranted.

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework.

Abstract: Background The existence of health inequalities between least and most socially deprived areas is now well established. Aim To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities. Design of study Two-year study. Setting Primary care in England. Method QOF data were obtained for each practice in England in 2004–2005 and 2005–2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004–2005 and 8264 practices in 2005–2006. Comparisons were made between practices in the least and most deprived quintiles. Results The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004–2005 (mean score, all practices, 959.9) and 30.4 in 2005–2006 (mean, 1012.6). In 2005–2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening ≥45 hours/week (90 versus 74%), practices conducting ≥12 significant event audits in previous 3 years (93 versus 81 %), proportion of epileptics who were seizure free ≥12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices. Conclusions Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.

More time for complex consultations in a high-deprivation practice is associated with increased patient enablement.

Abstract: Background Evidence of the beneficial effects of longer consultations in general practice is limited. Aim To evaluate the effect of increasing consultation length on patient enablement in general practice in an area of extreme socioeconomic deprivation. Design of study Longitudinal study using a ‘before and after’ design. Setting Keppoch Medical Centre in Glasgow, which serves the most deprived practice area in Scotland. Method Participants were 300 adult patients at baseline, before the introduction of longer consultations, and 324 at follow-up, more than 1 year after the introduction of longer consultations. The intervention studied was more time in complex consultations. Patient satisfaction, perceptions of the GPs9 empathy, GP stress, and patient enablement were collected by face-to-face interview. Additional qualitative data were obtained by individual interviews with the GPs, relating to their perceptions of the impact of the longer consultations. Results Response rates of 70% were obtained. Overall, 53% of consultations were complex. GP stress was higher in complex consultations. Patient satisfaction and perception of the GPs9 empathy were consistently high. Average consultation length in complex consultations was increased by 2.5 minutes by the intervention. GP stress in consultations was decreased after the introduction of longer consultations, and patient enablement was increased. GPs9 views endorsed these findings, with more anticipatory and coordinated care being possible in the longer consultations. Conclusion More resource to provide more time in complex consultations in an area of extreme deprivation is associated with an increase in patient enablement.

Prognostic factors of disability in older people: a systematic review

Abstract: Aim To systematically review the evidence on the influence of sociodemographic, lifestyle, and (bio)medical variables on the course of prevalent disability and transition rates to different outcome categories in community-dwelling older people. Method Articles were identified through searches of PubMed, EMBASE, and PsycINFO databases and reference lists of relevant articles. Prospective population studies that assessed disability at baseline and reported on associations between potential prognostic variables and disability were included. Methodological quality of studies was assessed by standardised criteria, after which relevant data were extracted. A synthesis of the available evidence was carried out. Results Nine cohort studies reported transition rates and eight cohort studies presented multivariate analyses on prognostic factors. There was some heterogeneity among studies in definition and assessment of disability. There is moderate to strong evidence that higher age, cognitive impairment, vision impairment, and poor self-rated health are prognostic factors of disability. Conclusion Prognostic factors, partly modifiable, are identified that should be taken into account in targeting treatment and care for older people with disabilities. Further conceptual and methodological standardisation is required in order to enable a meta-analysis and obtain higher levels of evidence.

Triadic communication in the primary care paediatric consultation: a review of the literature.

Abstract: Background Children aged 6–12 years are usually seen in primary care with an adult carer. It is a government and professional priority for doctors to try and involve these children in their medical consultations. Aim To ascertain the evidence available on the amount and type of involvement that children in the 6–12 year age group have in their primary care consultations when the consultation was held with a child, a GP, and an adult. Design of the study Literature review. Method Data sources included MEDLINE, CINAHL, EMBASE, and ERIC, The Cochrane library, PsychINFO, Web of Science and Wilson9s Social Science abstracts, hand searching for references, and contact with authors. Results Twenty-one studies were selected for inclusion in the study. Children were found to have little quantitative involvement in their own consultations. They may take part during information gathering but are unlikely to participate in the treatment planning and discussion parts of the consultation. Conclusion Children in the 6–12 year age group have little meaningful involvement in their consultations.

A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people.

Abstract: Background Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. Aim To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. Design of study Randomised controlled trial with 16-weeks follow up. Setting A primary care trust in Manchester. Method Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. Results The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. Conclusion A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.

Exercise participation, body mass index, and health-related quality of life in women of menopausal age

Abstract: Background Menopausal symptoms can affect women9s health and wellbeing. It is important to develop interventions to alleviate symptoms, especially given recent evidence resulting in many women no longer choosing to take hormone replacement therapy. Exercise may prove useful in alleviating symptoms, although evidence on its effectiveness has been conflicting. Aim To examine the association between exercise participation, body mass index (BMI), and health-related quality of life in women of menopausal-age. Design of study Survey of women of menopausal age. Setting West Midlands, England. Method Women aged 46–55 years ( n = 2399) registered with six general practices in the West Midlands were sent a questionnaire containing items relating to demographics, lifestyle factors, weight, height, exercise participation, menopausal bleeding patterns, and health-related quality of life (including vasomotor symptoms). Results One thousand two hundred and six (50.3%) women replied. Women who were regularly active reported better health-related quality of life scores than women who were not regularly active ( P P P P Conclusion The data suggest a positive association between somatic and psychological dimensions of health-related quality of life and participation in regular exercise. Women with BMI scores in the normal range reported lower vasomotor symptom scores and better health-related quality of life scores than heavier women. Further evidence from high-quality randomised controlled trials is required to assess whether exercise interventions are effective for management of menopausal symptoms.

The Quality and Outcomes Framework: what have you done to yourselves?

Abstract: Six years ago we were asked to write an accompanying editorial to a paper by Julia Hippisley-Cox and Mike Pringle from Nottingham University looking at the time requirements to implement the National Service Framework for cardiovascular disease.1,2 At that time we raised concerns that the content of the consultations was at risk of being taken over by the agendas of well-meaning single disease interest groups, and that there were potential opportunity costs of this change. The 2004 Quality and Outcomes Framework (QOF) contract, based on 146 outcome indicators, links income to performance on a scale never before seen in the UK. To outsiders it seems that UK general practice has moved from having an internal framework of professionalism that supports it, to an external framework that holds it up and embraces a market model of healthcare with performance linked bonuses and its own acronym: P4P (pay for performance). New Zealand looks set to follow the same path. On reading through the QOF indicator list, our concerns have deepened. The mix of indicators looks like a hotchpotch of intermediate clinical and practice based ‘outcomes’. The list has the hallmark of those who think in terms of contracts, numbers, and linear production- line performance targets. This all purports to be in the name of evidence-based care, but we have looked in vain for evidence underpinning this radical, risky, and very expensive policy. The issue at the core of the relationship between QOFs and general practice is not the indicators chosen nor whether GPs should be paid what they are worth. The fundamental issue is a philosophical one that centres on the nature of professionalism, professional values, and the concept of good care. State-driven clinical priorities are risking general practice's disciplinary identity. By allowing ourselves to be coerced into persuading …

Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes

Abstract: Background Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance. Aim This study aimed to compare outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis. Design of study Analysis of hospital records. Setting One hospital trust in England Method The records of 889 patients diagnosed in 2000–2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays. Results For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes ( P = 0.035) and poorer survival ( P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals. Conclusion For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.

Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care

Abstract: Background Knowledge of predominant pathogens and their association with outcome are of importance for the management of lower respiratory tract infection (LRTI). As antibiotic therapy is indicated in pneumonia and not in acute bronchitis, a predictor of pneumonia is needed.