Showing papers in "British Journal of General Practice in 2008"

Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care

Abstract: Background The 2004 National Institute for Health and Clinical Excellence (NICE) guidelines highlight the importance of assessing severity of depression in primary care. Aim To assess the psychometric properties of the Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for measuring depression severity in primary care. Design of study Psychometric assessment. Setting Thirty-two general practices in Grampian, Scotland. Method Consecutive patients referred to a primary care mental health worker completed the PHQ-9 and HADS at baseline (n = 1063) and at the end of treatment (n = 544). Data were analysed to assess reliability, robustness of factor structure, convergent/discriminant validity, convergence of severity banding, and responsiveness to change. Results Both scales demonstrated high internal consistency at baseline and end of treatment (PHQ-9 α = 0.83 and 0.92; HADS-D α = 0.84 and 0.89). One factor emerged each for the PHQ-9 (explaining 42% of variance) and HADS-D (explaining 52% of variance). Both scales converged more with each other than with the HADS anxiety (HADS-A) subscale at baseline (P Conclusion The HADS-D and PHQ-9 demonstrated reliability, convergent/discriminant validity, and responsiveness to change. However, they differed considerably in how they catergorised severity. Given that treatment decisions are made on the basis of severity, further work is needed to assess the validity of the scales9 severity cut-off bands.

Evaluation of the Counterweight Programme for obesity management in primary care : a starting point for continuous improvement

Abstract: Background Evaluation for obesity management in primary care is limited, and successful outcomes are from intensive clinical trials in hospital settings. Aim To determine to what extent measures of success seen in intensive clinical trials can be achieved in routine primary care. Primary outcome measures were weight change and percentage of patients achieving ≤5% loss at 12 and 24 months. Design of study Prospective evaluation of a new continuous improvement model for weight management in primary care. Setting Primary care, UK. Method Primary care practice nurses from 65 UK general practices delivered interventions to 1906 patients with body mass index (BMI) ≥30 kg/m2 or ≥28 kg/m2 with obesity-related comorbidities. Results Mean baseline weight was 101.2 kg (BMI 37.1 kg/m2); 25% of patients had BMI ≥40 kg/m2 and 74% had ≥1 major obesity-related comorbidity. At final data capture 1419 patients were in the programme for ≥12 months, and 825 for ≥24 months. Mean weight change in those who attended and had data at 12 months ( n = 642) was −3.0 kg (95% CI = −3.5 to −2.4 kg) and at 24 months ( n = 357) was −2.3 kg (95% CI = −3.2 to −1.4 kg). Among attenders at specific time-points, 30.7% had maintained weight loss of ≥5% at 12 months, and 31.9% at 24 months. A total of 761 (54%) of all 1419 patients who had been enrolled in the programme for >12 months provided data at or beyond 12 months. Conclusion This intervention achieves and maintains clinically valuable weight loss within routine primary care.

Doctors as patients: a systematic review of doctors' health access and the barriers they experience.

Abstract: Background The need to improve doctors9 access to health care by reducing the barriers they experience has been regularly described in the literature, yet the barriers experienced are not well defined, despite the volume of expert opinion in this area. Aim To define what is known about doctors9 access to health care from the data within the current literature. Design of study A systematic review of studies of doctors9 health access. Method A systematic search of MEDLINE® and CINAHL, supplemented by citation searches and searches of the grey literature, identified both quantitative and qualitative studies. Two reviewers used specific criteria for inclusion of studies and quality assessment. The data were tabulated and analysed. Results Twenty-six articles met the inclusion criteria. The paucity of data and the overall poor quality of those data are highlighted. Despite this, many doctors appear to have a GP, but this does not ensure adequate health access. Systemic barriers to healthcare access (long hours and cultural issues) are more significant than individual barriers. Conclusion Expert opinion in this field is supported by poor-quality data. The current knowledge reveals important similarities between doctors and the general population in their healthcare access, especially with mental health issues. Understanding this may help the medical profession to respond to these issues of ‘doctors’ health9 more effectively.

Connecting for health.

Abstract: We are writing to you with severe concerns over the coverage that NHS Connecting for Health and the issue of confidentiality controls has received this week in the February edition of the BJGP . The Journal contains an editorial that argues against the current proposals for the summary care record with no attempt to balance the debate or explain the systems that are being proposed.1 It is irresponsible to publish commentary on such an important issue for patient safety and confidentiality without the necessary balance expected from an academic journal. To promote a single agenda in such a blatantly campaigning way without an accurate representation of the facts in our view does the Journal, the College, and our patients a great disservice. The editorial by Professor Ross Anderson seriously misrepresents the current consent model of the summary care model. Professor Anderson who …

Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis

Abstract: Background Prompt diagnosis of acute myocardial infarction or acute coronary syndrome is very important. Aim A systematic review was conducted to determine the accuracy of 10 important signs and symptoms in selected and non-selected patients. Design of study Diagnostic meta-analysis. Method Using MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies were sought out that described one of the 10 signs and symptoms on one or both conditions. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model. Results Sixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% CI = 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), namely 2.92 (95% CI = 1.97 to 4.23) for acute myocardial infarction. The other pooled LR+ fluctuated between 1.05 and 1.49. Negative LRs (LR-) varied between 0.98 and 0.23. Absence of chest-wall tenderness on palpation had a LR- of 0.23 (95% CI = 0.18 to 0.29). Conclusions Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.

Motivational interviewing for modifying diabetes risk: a randomised controlled trial.

Abstract: Background Around 10–15% of adults aged over 40 years have pre-diabetes, which carries a high risk of progression to type 2 diabetes. Intensive lifestyle intervention reduces progression by as much as 58%. However, the cost and personnel requirements of these interventions are major obstacles to delivery in NHS primary care. Aim To assess the effectiveness of a low-cost intervention, delivered in primary care by non-NHS staff, to reduce the risk of diabetes through weight loss and physical activity. Design of study Pragmatic single-blind randomised controlled trial with researchers and statistician blinded to group allocation. Setting UK primary care. Method One-hundred and forty-one participants with a body mass index of 28 kg/m2 or more, but without diabetes or heart disease, received either information leaflets or individual behavioural counselling using motivational interviewing techniques. The intervention was delivered by five counsellors recruited from the local community. The primary outcomes were the proportions of participants meeting predefined targets for weight loss (5%) and moderate physical activity (150 minutes/week) after 6 months. Results Using intention-to-treat analysis, more people in the intervention group achieved the weight-loss target (24% versus 7% for controls; odds ratio [OR] = 3.96; 95% confidence interval [Cl] = 1.4 to 11.4; number needed to treat [NNT] = 6.1 (95% Cl = 4 to 21). The proportion achieving the physical activity target did not increase significantly (38% versus 28% for controls; OR = 1.6; 95% Cl = 0.7 to 3.8). Conclusion Short-term weight loss, at a level which, if sustained, is clinically meaningful for reducing diabetes risk, is achievable in primary care, without excessive use of NHS monetary or personnel resources.

Tips and tricks in performing a systematic review

Abstract: ### Building a PICO search strategy After identifying keywords that reflect your topic of interest,1 you need to use them to search for articles by building a ‘query’ more commonly known as a search string/strategy. Successful search strategies are usually highly structured and built around a PICO framework. Population Intervention Comparison Outcome (PICO) frameworks help the searcher group search terms into thematic groups. PICO is very good at identifying medical literature where systematic reviewing is common, this is …

Improving the uptake of pulmonary rehabilitation in patients with COPD:: qualitative study of experiences and attitudes

Abstract: Background Pulmonary rehabilitation can improve the quality of life and ability to function of patients with chronic obstructive pulmonary disease (COPD). It may also reduce hospital admission and inpatient stay with exacerbations of COPD. Some patients who are eligible for pulmonary rehabilitation may not accept an offer of it, thereby missing an opportunity to improve their health status. Aim To identify a strategy for improving the uptake of pulmonary rehabilitation. Design of study Qualitative interviews with patients. Setting Patients with COPD were recruited from a suburban general practice in north-east Derbyshire, UK.

Strengthening primary care: addressing the disparity between vertical and horizontal investment.

Abstract: Recently we have seen an unprecedented increase of financial support to improve health care in developing countries estimated at 26% between 1997 and 2002, from $6.4 billion to $8.1 billion.1 While the magnitude of such an investment is a positive development, the vast majority of aid has been allocated towards disease-specific projects (termed ‘vertical programming’) rather than towards more broad-based improvements in population health, such as preventive measures, primary care services, and health workforce development (termed ‘horizontal programming’). For instance, the initiatives of the Bill and Melinda Gates and Clinton Foundations usually focus on specific communicable diseases: 60% address ‘big diseases’ (HIV/AIDS, malaria, and tuberculosis). Rwanda, for example, with an HIV prevalence rate of 3.1 %2 and an annual health budget of $37 million,3 received $187 million since 2003 exclusively for HIV/AIDS. Thirty years ago, in 1978, the Alma-Ata Declaration pointed to the importance of community-oriented comprehensive primary health care for all nations. Improving health required changes in economic, social, and political structures, in addition to access to health care. In this comprehensive or ‘horizontal’ healthcare concept, health care is also a basic human right that requires community participation. Some have argued that the Alma-Ata concepts were unattainable because of the costs and numbers of trained personnel required. From this perspective, a selective disease-oriented approach could address the greatest disease burden in the community in less developed countries.4 The two positions differ both …

The silence of patients with end-stage COPD: a qualitative study

Abstract: Background Patients with end-stage chronic obstructive pulmonary disease (COPD) experience poor quality of life and considerable problems in daily life. However, as they often do not actively express a wish for help, they do not get the help they need. Aim To gain insight into why patients with end-stage COPD tend not to express a wish for help. Design of study Prospective qualitative study with semi-structured interviews. Setting Outpatient clinics of four hospitals and one centre specialising in asthma and COPD in the Netherlands. Method Sixteen semi-structured interviews were conducted with 11 patients with end-stage COPD. Results To express a wish for help, patients should regard their limitations as abnormal and should realise that there are possibilities to improve their situation. However, this was not the case with the patients interviewed. They appeared to consider themselves ill at a time of acute exacerbation of their illness, but regarded their everyday life as normal. In addition, patients lived with the assumption that, as their lungs were damaged beyond repair, they could not get help. Conclusion Patients with end-stage COPD do not actively express a wish for help because they do not consider their limitations to be abnormal and because they do not realise that there are possibilities to improve their situation. These results suggest that care in this stage of the disease should focus on improving daily life instead of just aiming to improve the functioning of the lungs. Professionals in health care should actively explore what kind of practical help these patients might welcome in keeping up their daily activities. Future research should focus on studying whether such an approach applies to the needs of patients with end-stage COPD.

Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care.

Abstract: Background Little is known about patients' perceptions of newer hypnotics. Aim To investigate use, experience, and perceptions of Z drug and benzodiazepine hypnotics in the community. Design of study Cross-sectional survey of general practice patients who had received at least one prescription for a Z drug or benzodiazepine in the previous 6 months. Setting Lincolnshire, UK. Method Self-administered postal questionnaire. Results Of 1600 surveys posted, 935 (58.4%) responses were received, of which 705 (75.4%) were from patients taking drugs for insomnia. Of those 705 patients, 87.9% (n = 620) were first prescribed a hypnotic by their GP, and 94.9% (n = 669) had taken a sleeping tablet for 4 weeks or more. At least one side effect was reported in 41.8% (n = 295); 18.6% wished to come off hypnotic medication; and 48.5% had tried to stop treatment. Patients on Z drugs were more likely to express a wish to stop (22.7% versus 12.3%; odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13 to 2.49), or to have attempted to come off medication, than those on benzodiazepines (52.4% versus 41.0%; OR = 1.54, 95% CI = 1.12 to 2.12). The two groups did not differ significantly in respect of benefits or adverse effects. Conclusion There were no significant differences in patients' perceptions of efficacy or side-effects reported by those on Z drugs compared to patients taking benzodiazepines. Side-effects were commonly reported, which may have contributed to a high proportion of responders, particularly patients on Z drugs who were wishing to stop, or who had previously tried to stop taking this medication. Reported prescribing practices were often at variance with the licence for short-term use.

Interprofessional relationships and communication in primary palliative care: impact of the Gold Standards Framework

Abstract: Background High quality end-of-life care in the community is achieved with effective multidisciplinary teamwork, interprofessional communication between GPs and district nurses, and early referral of patients to district nurses. These aspects of palliative care are highlighted in the Gold Standards Framework, a programme recently established in UK primary care. Aim To investigate the extent to which the framework influences interprofessional relationships and communication, and to compare GPs' and nurses' experiences. Design of study Qualitative interview case study. Setting Fifteen participating practices from three primary care trusts in England. Method Thirty-eight semi-structured interviews were undertaken with GPs, district nurses, Macmillan nurses, and framework facilitators. Results Adoption of the framework often resulted in earlier referral of palliative care patients to district nurses. Multidisciplinary team meetings enabled communication for sharing knowledge, discussing management problems, and keeping colleagues informed; however, arranging and maintaining such meetings was often problematic. Nurses particularly valued formal meetings while GPs generally preferred informal ad hoc dialogue. GPs largely maintained control of the mode of multidisciplinary working. The best functioning teams used a mixture of formal and informal meetings with a relatively non-hierarchical working style. Conclusion Implementing the framework enabled processes of communication associated with high quality palliative care in general practice, but there was marked variation in how this worked in individual teams. In general, hierarchical doctor–nurse relationships persisted.

Healthcare assistants in general practice: practical and conceptual issues of skill-mix change.

Abstract: The emergence of healthcare assistants (HCAs) in general practice raises questions about roles and responsibilities, patients' acceptance, cost-effectiveness, patient safety and delegation, training and competence, workforce development, and professional identity. There has been minimal research into the role of HCAs and their experiences, as well as those of other staff working with HCAs in general practice. Lessons may be learned from their role and evidence of their effectiveness in hospital settings. Such research highlights blurred and contested role boundaries and threats to professional identity, which have implications for teamwork, quality of patient care, and patient safety. In this paper it is argued that transferability of evidence from hospital settings to the context of general practice cannot be assumed. Drawing on the limited research in general practice, the challenges and benefits of developing the HCA role in general practice are discussed. It is suggested that in the context of changing skill-mix models, viewing roles as fluid and dynamic is more helpful and reflective of individuals' experiences than endeavouring to impose fixed role boundaries. It is concluded that HCAs can make an increasingly useful contribution to the skill mix in general practice, but that more research and evaluation are needed to inform their training and development within the general practice team.

Asylum seekers' expectations of and trust in general practice: a qualitative study.

Abstract: Background The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems. Aim This study explored how migrants9 previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role. Design of study Two qualitative methods. Setting Glasgow, UK. Method Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders9 accounts with World Health Organization statistics. Results Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders9 accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience. Conclusion GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals9 expectations in a GPled system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.

Poor adherence with inhaled corticosteroids for asthma: can using a single inhaler containing budesonide and formoterol help?

Abstract: Background Poor adherence with inhaled corticosteroids is an important problem in asthma management. Previous approaches to improving adherence have had limited success. Aim To determine whether treatment with a single inhaler containing a long-acting β 2 -agonist and a corticosteroid for maintenance treatment and symptom relief can overcome the problem of poor adherence with inhaled corticosteroids. Design of study Randomised, parallel group, open-label trial. Setting Forty-four general practices in Nottinghamshire. Method Participants who used less than 70% of their prescribed dose of inhaled corticosteroid and had poorly controlled asthma were randomised to budesonide 200 μg one puff twice daily plus their own short-acting β 2 -agonist as required (control group), or budesonide/formoterol 200/6 μg one puff once daily and as required (active group) for 6 months. The primary outcome was inhaled corticosteroid dose. Results Seventy-one participants (35 control, 36 active group) were randomised. Adherence with budesonide in the control group was approximately 60% of the prescribed dose. Participants in the active group used approximately 80% more budesonide than participants in the control group (448 versus 252 μg/day, mean difference 196 μg, 95% confidence interval 113 to 279; P P Conclusion Using a single inhaler for both maintenance treatment and symptom relief approximately doubled the dose of inhaled corticosteroid taken, suggesting this could be a useful strategy to overcome the problems related to poor adherence with inhaled corticosteroids.

Does distance matter? Geographical variation in GP out-of-hours service use: an observational study.

Abstract: Background GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services. Aim To examine the effects of distance and rurality on rates of out-of-hours service use. Design of study Geographical analysis based on routinely collected data on telephone calls in June (n = 14 482) and December (n = 19 747), and area-level data. Setting Out-of-hours provider in Devon, England serving nearly 1 million patients. Method Straight-line distance measured patients9 proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004). Results Call rates decreased with increasing distance: 172 (95% confidence interval [CI] = 170 to 175) for the first (nearest) distance quintile, 162 (95% CI = 159 to 165) for the second, and 159 (95% CI = 156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0–4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas. Conclusion There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.

Predicting who will benefit from an Expert Patients Programme self-management course.

Abstract: Background In England, the Expert Patients Programme, a lay-led chronic disease self-management course, was developed to improve self-care support and skills. The course is designed for anyone with a self-defined long-term condition, and attracts a heterogeneous group of patients. A randomised controlled trial has demonstrated effectiveness in improving subjective health. However, it is not known whether particular patient characteristics predict the impact of the course. Aim To determine whether baseline characteristics predict clinical outcomes from attendance at a chronic disease self-management course; and to assess whether identification of such characteristics assists in targeting the course to individuals most likely to benefit. Design of study A post-hoc subgroup analysis of data from a randomised controlled trial to explore predictors of three trial outcomes: self-efficacy, energy, and health-related quality of life. Setting Participants with self-defined long-term conditions (n = 629) were recruited from community settings in all 28 strategic health authorities in England. Method Multiple regression was used to examine interactions between baseline variables and trial outcomes. Results The predictors demonstrating significant interactions were: age and general health, and baseline values for self-efficacy, energy levels, and health-related quality of life. Conclusion Participants with lower self-efficacy and health-related quality of life at baseline demonstrated more positive health outcomes. The Expert Patients Programme may have a protective effect on health-related quality of life for patients with poor health and low confidence. Younger people benefited substantially more than older people. Results suggest that positive outcomes associated with the course will be demonstrated with a wide variety of patients, although it may be worthwhile encouraging attendance of younger patients, those lacking confidence, and those coping poorly with their condition.

Content and outcome of usual primary care for back pain: a systematic review.

Abstract: Background Most patients seeking help for back pain are managed in primary care. Aim To describe the content and outcome of ‘usual care’ for low back pain in primary care trials. Design of study A systematic review of randomised controlled trials published since 1998. Setting Primary care. Method Randomised controlled trials of back pain in adults were scrutinised to obtain data on treatment and outcome measures in groups receiving usual primary care. A narrative review of the resulting heterogeneous data was undertaken. Results Thirty-three papers were identified for analysis. Overall the exact nature of the treatment received in the ‘usual’ primary care group was poorly recorded. Medication was frequently used, and there were suggestions that levels of opioid prescription were higher than might be expected from clinical guidelines. Requesting of plain-film X-rays occurred more often than recommended. There was very little information to suggest that doctors were promoting physical activity for patients with back pain. Disability scores (Roland–Morris Disability Questionnaire) and pain scores improved over time for patients with acute or subacute back pain, but not for those with chronic pain. Conclusion Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and X-ray investigation. The content of the ‘usual care’ arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the ‘usual care’ arm.

Patients' perspectives on foot complications in type 2 diabetes: a qualitative study

Abstract: Background Foot ulceration is a major health problem for people with diabetes. To minimise the risk of ulceration, patients are advised to perform preventive foot self-care. Aim To explore beliefs about diabetic foot complications and everyday foot self-care practices among people with type 2 diabetes. Design of study Qualitative study using one-to-one interviews. Setting A suburban primary care health centre. Method Semi-structured interviews with a purposive sample of adults with type 2 diabetes but with no experience of foot ulceration. Results Most participants were unsure of what a foot ulcer is and unaware of the difficulties associated with ulcer healing. Prevention of accidental damage to the skin was not considered a priority, as few participants knew that this is a common cause of foot ulceration. Although it was recognised that lower-limb amputation is more common in people with diabetes, this was perceived to be predominantly caused by poor blood supply to the feet and unrelated to foot ulceration. Therefore, preventive foot care focused on stimulating blood circulation, for example by walking barefoot. Consequently, some of the behaviours participants considered beneficial for foot health could potentially increase the risk of ulceration. In some cases the uptake of advice regarding preventive foot care was hampered because participants found it difficult to communicate with health professionals. Conclusion Patients with type 2 diabetes may have beliefs about foot complications that differ from medical evidence. Such illness beliefs may play a role in foot-related behaviours that have previously been unrecognised. Health professionals need to explore and address the beliefs underlying patients9 foot self-care practices.

GPs' and health visitors' views on the diagnosis and management of postnatal depression: a qualitative study.

Abstract: Background In the UK, 8–15% of women suffer from postnatal depression, with long-term consequences for maternal mood and child development. Previous literature suggests that health visitors struggle with their conflicting roles with respect to mother and infant. Current policy is redirecting the emphasis and organisation of health visitor work, but guidelines state that health visitors and GPs should continue to have a major role in the detection and management of postnatal depression. Aim To explore the views of GPs and health visitors on the diagnosis and management of postnatal depression. Design of study A qualitative study nested within a multicentre randomised controlled trial. Setting Nine primary care trusts in Bristol, Manchester, and London. Method In-depth interviews with GPs and health visitors from primary care trusts participating in a randomised controlled trial of antidepressants versus health visitor-delivered non-directive counselling. Interviews were audiotaped and fully transcribed. Thematic analysis with an iterative approach was used to develop conceptual categories from the transcripts. Results Nineteen GPs and 14 health visitors were interviewed. GPs and health visitors described their work in making and negotiating the diagnosis of postnatal depression, the value of a long-term relationship with the woman, and how labelling affects management of women with postnatal depression. Responders described how they viewed others9 roles in the management of postnatal depression, and how national policy and local organisational changes had an impact on patient care, so that no one health professional was assuming overall responsibility for the care of women with postnatal depression. Conclusion Ongoing organisational changes within primary care, such as the implementation of corporate working by health visitors, affect care provided to women after birth, which in turn has an impact on the diagnosis and management of postnatal depression.

Effect of the new contract on GPs' working lives and perceptions of quality of care: a longitudinal survey

Abstract: BACKGROUND: An ambitious pay-for-performance system was implemented in UK general practice in 2004 amid doubts that it could improve both the working lives of doctors and quality of care. AIM: To evaluate doctors' perceptions of their working lives and quality of care before and after the new contract. DESIGN OF STUDY: Longitudinal questionnaire survey. SETTING: England, UK. METHOD: A longitudinal postal survey of English GPs in February 2004 and September 2005. Measures included reported job satisfaction (7-point scale), hours worked, income, and impact of the contract. RESULTS: Responses were available from 2105 doctors in 2004 and 1349 in 2005. Mean overall job satisfaction increased from 4.58 out of 7 in 2004 to 5.17 in 2005. The greatest improvements in satisfaction were with remuneration and hours of work. Mean reported hours worked fell from 44.5 to 40.8. Mean income increased from an estimated 73,400 pounds in 2004 to 92,600 pounds in 2005. Most GPs reported that the new contract had increased their income (88%), but decreased their professional autonomy (71%), and increased their administrative (94%) and clinical (86%) workloads. After the introduction of the contract doctors were more positive than they had anticipated about its impact on quality of care. CONCLUSION: GPs' job satisfaction increased after the introduction of the new contract, despite perceptions of negative consequences for workload and autonomy. GPs reported working fewer hours with a higher income, and their expectations regarding the impact of the contract on quality of care had been exceeded.

GPs' classification of headache: is primary headache underdiagnosed?

Abstract: With a high economic, social, and personal burden, headache remains an important health problem. How UK GPs diagnose headache in the UK is unknown. In this study, a large primary care database was used and diagnostic categories were described for 91 121 adult patients with new-onset headache, that is, patients who had not consulted for headache in the previous year. Seventy per cent of headaches were not given a diagnostic label, 24% were diagnosed as primary, and 6% as secondary headaches. It is suggested that GPs' difficulty in diagnosing headache presentations contributes to the high level of morbidity and unmet need in this disease.

Feasibility of an exercise intervention for women with postnatal depression: a pilot randomised controlled trial

Abstract: Background Postnatal depression is a serious mental health problem that may be reduced by exercise. Aim This study examined the feasibility of an exercise intervention for women with postnatal depression, and assessed which methods of recruitment are most effective. Design of study Randomised controlled trial. Setting General practice and the community. Method Participants were recruited from various sources and randomised to an exercise intervention or usual care with follow-up at 12 weeks. As well as assessing feasibility, other trial outcomes included exercise participation and self-efficacy for exercise. Levels of depression were assessed but the study was not powered to show a difference in this. Results The recruitment rate of eligible patients was 23.1%. The highest recruitment rate was via referral from the psychiatric mother and baby unit (9/28; 32.1%), followed by invitation letters from GPs (24/93; 25.8%). Thirty-eight eligible participants were randomised. At follow-up there was no significant difference in exercise participation between groups. The intervention group reported significantly higher self-efficacy for exercise compared to usual care, but depression scores did not differ. Conclusion Exercise participation over the 12-week period was not significantly increased, possibly because it is difficult to motivate women with postnatal depression to exercise, or the intervention was not sufficiently intensive. Eligible patients were recruited into this study but response rates were low. Optimum methods of recruitment in this difficult-to-reach population are required prior to a substantive trial. Further research is imperative given poorly-evidenced recommendations by the National Institute for Health and Clinical Excellence to consider this treatment.

Schizophrenia in black Caribbeans living in the UK: an exploration of underlying causes of the high incidence rate

Abstract: The incidence of schizophrenia in black Caribbeans living in the UK is substantially higher than in the white British population. When first reported, these findings were assumed to be a first-generation migrant effect or merely the result of methodological artefacts associated with inconsistencies in the diagnosis of schizophrenia in black Caribbeans and doubts about population denominators. More recently, it has become clear that the incidence of schizophrenia, based on standardised diagnosis and sophisticated census methods, is higher still in second-generation black Caribbeans. The largest study to date has demonstrated a ninefold higher risk of schizophrenia in UK-resident black Caribbeans: findings that are of concern to black Caribbean communities, to their GPs, and to health service managers responsible for resource allocation. A literature search was carried in order to explore possible reasons for the reported excess incidence of schizophrenia in UK-resident black Caribbeans. Competing hypotheses are reviewed and the paper concludes with a summary of specific social and psychological risk factors of significance within the black Caribbean community. Awareness of the factors associated with the onset and presentation of schizophrenia in black Caribbeans may help early diagnosis and rapid access to appropriate treatment which, in turn, appear to be related to improved long-term outcomes.

Parents' experiences of universal screening for haemoglobin disorders: implications for practice in a new genetics era.

Abstract: Background England is the only country in the world that currently has universal population screening for haemoglobin disorders through linked antenatal and newborn screening. Little is known about the acceptability of such screening. Aim To explore parents9 experiences of, and attitudes towards, new universal genetic screening for haemoglobin disorders. Design of study Narrative interview study. Setting Primary and community care settings across England. Method Narrative interviews were undertaken with a maximum variation sample of 39 people who had experienced gene-carrier identification through antenatal and newborn screening for sickle cell, thalassaemia, and other haemoglobin variants within the previous 2 years. Results Most parents were unaware screening had occurred or had given it little consideration and so were surprised or shocked by results. However, they were glad to learn of their carrier status, reproductive genetic risk, or their newborn9s carrier status. Participants emphasised that antenatal screening should happen as early as possible. Many would rather have known their carrier status before pregnancy or before entering a relationship. Although most were satisfied with the information they received, significant misunderstandings remained. There were culturally diverse attitudes towards prenatal diagnosis and termination. These procedures were acceptable to some parents with strong religious beliefs, including Christians and Muslims. Conclusion Parents support screening for haemoglobin disorders but need to be better informed and better prepared for results and what they mean. Sensitivity to patient diversity in attitudes and choices is also required. Universal screening for genetic reproductive risk will increasingly involve generalists, particularly in primary care, presenting opportunities for screening before or earlier in pregnancy, which is likely to be welcomed by patients.

Recorded quality of primary care for osteoarthritis: an observational study.

Abstract: Background Osteoarthritis is the most common chronic disease in the UK, with greater prevalence in women, older people, and those with poorer socioeconomic status. Effective treatments are available, yet little is known about the quality of primary care for this disabling condition. Aim To measure the recorded quality of primary care for osteoarthritis, and assess variavariations by patient and/or practice characteristics. Design of study Retrospective observational study. Setting Eighteen general practices in England. Method Records of 320/393 randomly selected patients with osteoarthritis (response rate 81%) were reviewed. High-quality health care was specified by nine quality indicators. Logistic regression modelling assessed variations in quality by age, sex, deprivation, severity, time since diagnosis, and practice size. Results There was substantial variation in the recorded achievement of individual indicators (range 5% to 90%). The percentage of eligible patients whose records show that they received care in the form of information provision ranged from 17% to 30%. For regular assessment indicators the range was 27% to 43%, and for treatment indicators the range was 5% to 90%. Recorded achievement of quality indicators was higher in those with more severe osteoarthritis (odds ratio [OR] 1.38, 95% CI = 1.13 to 1.69) and in older patients (OR 1.14, 95% CI = 1.02 to 1.28). There were no significant variations by deprivation score. Conclusion This study has demonstrated the feasibility of using existing robust quality indicators to measure the quality of primary care for osteoarthritis, and has found considerable scope for improvement in the recording of high-quality care. The lack of variation between practices suggests that system-level initiatives may be needed to achieve improvement. One challenge will be to improve care for all, without losing the equitable distribution of care identified.

Factors associated with enablement in general practice: cross-sectional study using routinely-collected data.

Abstract: Background Quality-improvement activities are most often focused on clinical quality indicators. However, patient evaluations are important additional indicators of the quality of general practice consultations, including measures of satisfaction or enablement (that is, the extent to which the consultation enhances the patient9s feelings of confidence and ability to cope). There is limited evidence concerning factors associated with enablement in UK general practice. Aim To identify patient and practice characteristics associated with enablement scores following general practice consultations. Design of study Cross-sectional survey using a large routinely-collected dataset of patient evaluations of general practice (190 038 individual patient responses). Setting A total of 1031 UK general practices. Method Relationships between health, demographic factors, evaluations of general practice care, and patient self-reported enablement were estimated using multiple regression. Results The primary predictor of enablement was positive patient evaluation of the GPs9 communication. Reported continuity of care accounted for a lower proportion of the variance. Of the included patient demographic variables, ethnicity was a key predictor, with patients from minority ethnic groups reporting greater enablement once other factors were controlled. Conclusion The current results provide support for the construct validity of the enablement measure. However, if enablement is to become a valid and useful measure of quality, it is necessary to understand the mechanisms by which enablement is increased in certain patients and practices. Detailed qualitative research may also be required to explain the relatively high scores of ethnic minority responders, despite lower overall satisfaction scores, and to understand why some items included in the enablement measure are regarded as ‘not applicable’ by a substantial minority of patients.

Multimorbidity and risk among patients with established cardiovascular disease: a cohort study

Abstract: Background Most patients managed in primary care have more than one condition. Multimorbidity presents challenges for the patient and the clinician, not only in terms of the process of care, but also in terms of management and risk assessment. Aim To examine the effect of the presence of chronic kidney disease and diabetes on mortality and morbidity among patients with established cardiovascular disease. Design of study Retrospective cohort study. Setting Random selection of 35 general practices in the west of Ireland. Method A practice-based sample of 1609 patients with established cardiovascular disease was generated in 2000–2001 and followed for 5 years. The primary endpoint was death from any cause and the secondary endpoint was a cardiovascular composite endpoint that included death from a cardiovascular cause or any of the following cardiovascular events: myocardial infarction, heart failure, peripheral vascular disease, or stroke. Results Risk of death from any cause was significantly increased in patients with increased multimorbidity ( P <0.001), as was the risk of the cardiovascular composite endpoint ( P <0.001). Patients with cardiovascular disease and diabetes had a similar survival pattern to those with cardiovascular disease and chronic kidney disease, but experienced more cardiovascular events. Conclusion Level of multimorbidity is an independent predictor of prognosis among patients with established cardiovascular disease. In such patients, the presence of chronic kidney disease carries a similar mortality risk to diabetes. Multimorbidity may be a useful factor in prioritising management of patients in the community with significant cardiovascular risk.

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study.

Abstract: BACKGROUND: Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. AIM: To explore the influences on referrals within general and specialist community palliative care services. DESIGN OF STUDY: Qualitative, multiple-case study. SETTING: Three primary care trusts in the north-west of England. METHOD: Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. RESULTS: Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes. CONCLUSION: Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.

Continuing medical education and burnout among Danish GPs.

Abstract: Background There has been minimal research into continuing medical education (CME) and its association with burnout among GPs. Aim The aim of this study was to investigate the association between participating in CME and experiencing burnout in a sample of Danish GPs. Design of study Cross-sectional questionnaire study. Setting All 458 active GPs in 2004, in the County of Aarhus, Denmark were invited to participate. Method Data on CME activities were obtained for all GPs and linked to burnout which was measured using the Maslach Burnout Inventory – Human Services Survey. The relationship between CME activity and burnout was calculated as prevalence ratios (PR) in a generalised linear model. Results In total, 379 (83.5%) GPs returned the questionnaire. The prevalence of burnout was about 25%, and almost 3% suffered from ‘high burnout’. A total of 344 (92.0%) GPs were members of a CME group or a supervision group. Not being a member of either a CME group or a supervision group was statistically significantly associated with doubled likelihood of burnout (PR = 2.2). Among GPs not making use of a practice facilitator, a seven-fold higher likelihood of high burnout was found. Conclusion GPs who were not members of a CME group and did not take part in outreach visits had a higher likelihood of suffering from burnout and high burnout than those who were members of a CME group or received outreach visits. Therefore, not being a member of a CME group could indicate that the GP is more likely to suffer from burnout. Although the present study does not unequivocally establish causality, it would be interesting to see whether staying active in CME may also prevent burnout among GPs.