Background
‘Tri-morbidity’ describes the complex comorbidity of chronic physical illness, mental illness, and alcohol and/or drug misuse within the homeless population. Poor health outcomes of homeless people are reflected by the higher rate of unplanned hospital admissions compared with the non-homeless population.
Aim
To identify whether tri-morbidity is a risk factor for unplanned hospital admissions in the homeless population.
Design and setting A case–control study of patients who were registered with a specialist homeless GP surgery in Brighton (72 cases and 72 controls).
Method
Cases were defined as those who had ≥1 overnight hospital admission within a 12-month period. Controls were matched for demographics but with no hospital admission. The primary care record was analysed, and tri-morbidity entered into binomial logistic regression with admission as the dichotomous dependent variable.
Results
The logistic regression analysis demonstrated that other enduring mental health disorders and/or personality disorder (odds ratio [OR] 3.84, 95% confidence interval [CI] = 1.56 to 9.44), alcohol use (OR 2.92, 95% CI = 1.42 to 5.98), and gastrointestinal disorder (OR 2.90, 95% CI = 1.06 to 7.98) were independent risk factors for admission. Tri-morbidity increased odds of admission by more than four-fold (OR 4.19, 95% CI = 1.90 to 9.27).
Conclusion
This study shows that tri-morbidity is an important risk factor for unplanned hospital admissions among the homeless population, and provides an interesting starting point for the development of a risk stratification tool to identify those at risk of unplanned admission in this population.
Background The most common obstacle to registration with a GP practice in the UK is difficulty presenting proof of address. NHS guidelines stipulate that inability to provide ID or proof of address is not reasonable grounds to refuse registration. Practices may ask patients to present ID/proof of address, but need a policy in case patients cannot.
Aim To find out how many London GP practice websites ask for documentation without a policy for where this cannot be provided and compare how GP practice websites describe the registration process in patient-facing material.
Design and setting Cross-sectional study of practices from 10 London boroughs (n = 100).
Method A proforma was piloted and then implemented, recording whether practices ‘demanded’, ‘requested’, or ‘mentioned’ photo ID or proof of address and whether there was a plan for patients without documentation. Text relating to documentation from all 100 practices for registration was subjected to thematic analysis.
Results Out of 100 practices 75% asked for documentation. The majority of these were ‘demanded’. A plan was included for people without documentation in 12% of practice websites. Five themes emerged from analysis of website content: reassuring people without documentation; diverse requirements between practices; conflating administration and treatment; withholding treatment; and immigration and ethnicity.
Conclusion Many practice websites breached NHS Standard Operating Principles and possibly the Equalities Act 2010. All practices should create a clear policy for patients who do not have photo ID/proof of address (for example, including a named receptionist), and update their websites accordingly.
Background: More than half of patients in the UK wait between 5 and 15 minutes before seeing the GP, and this time in the waiting room (WR) provides an ideal opportunity for patient education.
Aim: To assess patients’ perceptions of the usefulness, noticeability and attractiveness of health education materials (HEMs); and the variety, number, topics, design and accessibility of these HEMs.
Method: An anonymous questionnaire was distributed to patients in the WR to assess their use of health information and perceptions of HEMs. A survey measured the availability of HEMs in the WR and evaluated their quality against 16 accessibility and design criteria.
Results: A total of 556 questionnaires were completed (response rate 97.9%). On average, WRs contained 72 posters covering 23 topics, and 53 leaflets covering 24 topics. Multivariate analysis showed that patients’ perception of usefulness was significantly associated with reading in the WR, using written HEMs, and not having a university degree; whilst noticeability was associated with reading in the WR, and being female. Attractiveness was associated with not having a university degree and shorter waiting time.
Conclusion: This study suggests that a wide variety of HEMs are available, and that many patients find them useful and noticeable, however, fewer find them well-designed and attractive. Future research should focus on the effectiveness of generally available HEMs at changing knowledge, attitudes, intentions, and behaviours; and utilising technology to deliver innovative means of providing patient health information.
Background
Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission.
Aim
To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. Design and setting Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands.
Method
Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20).
Results
The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation.
Conclusion
Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.
Background: Significant health disparities between sexual minority individuals (i.e. lesbian, gay, bisexual or transgender (LGBT)) and heterosexual individuals have been demonstrated.
Aim: To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by lesbian, gay, bisexual and transgender (LGBT) adults in healthcare settings.
Design and setting: Mixed methods systematic review, including qualitative, quantitative and mixed methods papers following PRISMA guidelines.
Method: Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and then underwent a qualitative synthesis. Studies were included if their participants were ≥18 years who either identified as LGBT, had a same-sex sexual relationship or were attracted to a member of the same-sex.
Results: The review included 31 studies representing 2442 participants. Four overarching themes were identified as barriers or facilitators to SO disclosure, the moment of disclosure, the expected outcome of disclosure, the HCP, and the environment or setting of disclosure. The most prominent themes were the perceived relevance of SO to care, the communication skills and language used by HCPs and the fear of poor treatment or reaction to disclosure.
Conclusion: The facilitators and barriers to SO disclosure by LGBT individuals are widespread but most were modifiable and could therefore be targeted to improve HCP awareness of their patient’s SO. HCPs should be aware of the broad range of factors that influence SO disclosure and the potential disadvantageous effects of non-disclosure on care. The environment in which patients are seen should be welcoming of different SOs as well as ensuring HCP communication skills, both verbal and non-verbal, are accepting and inclusive.
Background: Up to 20% of women experience anxiety and depression during the perinatal period. In the UK, management of perinatal mental health falls under the remit of general practitioners (GPs).
Aim: This review aimed to synthesise the available information from qualitative studies on GPs’ attitudes, recognition and management of perinatal anxiety and depression.
Design & Setting: Meta-synthesis of the available published qualitative evidence on GPs recognition and management of perinatal anxiety and depression.
Method: A systematic search was conducted on Embase, Medline, PsycInfo, Pubmed, Scopus and Web of Science, and grey literature was searched using Google, Google Scholar and British Library EThOS. Papers and reports were eligible for inclusion if they reported qualitatively on GPs’ diagnosis or treatment of perinatal anxiety or depression. The synthesis was constructed using meta-ethnography.
Results: Five themes were established from five eligible papers: Labels: diagnosing depression; clinical judgement versus guidelines; care and management; use of medication; and Isolation: The role of other professionals. GPs considered perinatal depression as a psychosocial phenomenon, and were reluctant to label disorders and medicalise distress. GPs relied on their own clinical judgement more than guidelines. They reported helping patients make informed choices about treatment, and inviting women back regularly for GP visits. GPs felt isolated when dealing with perinatal mental health issues.
Conclusion: GPs often do not have timely access to appropriate psychological therapies and use several strategies to mitigate this shortfall. Training needs to focus on these issues and needs to be evaluated to consider if this makes a difference to outcomes for women.
Background: Major depressive disorder (MDD) is often a chronic disorder with relapses usually detected and managed in primary care using a validated depression symptom questionnaire. However, for individuals with recurrent depression the choice of which questionnaire to use and whether a shorter measure could suffice is not established.
Aim: To compare the nine-item Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory, and the Hospital Anxiety and Depression Scale against shorter PHQ-derived measures for detecting episodes of DSM-IV major depression in primary care patients with recurrent MDD.
Design and setting: Diagnostic accuracy study of adults with recurrent depression in primary care predominantly from Wales.
Method: Scores on each of the depression questionnaire measures were compared with the results of a semi-structured clinical diagnostic interview using Receiver Operating Characteristic curve analysis for 337 adults with recurrent MDD.
Results: Concurrent questionnaire and interview data were available for 272 participants. The onemonth prevalence rate of depression was 22.2%. The area under the curve (AUC) and positive predictive value (PPV) at the derived optimal cut-off value for the three longer questionnaires were comparable (AUC = 0.86-0.90, PPV = 49.4-58.4%) but the AUC for the PHQ-9 was significantly greater than for the PHQ-2. However, by supplementing the PHQ-2 score with items on problems concentrating and feeling slowed down or restless, the AUC (0.91) and the PPV (55.3%) were comparable with those for the PHQ-9.
Conclusion: A novel four-item PHQ-based questionnaire measure of depression performs equivalently to three longer depression questionnaires in identifying depression relapse in patients with recurrent MDD.
Background: Better self management could improve quality of life (QoL) and reduce hospital admissions in chronic obstructive pulmonary disease (COPD), but the best way to promote it remains unclear. Aim: To explore the feasibility, effectiveness and cost effectiveness of a novel, layperson-led, theoretically driven COPD self-management support programme. Design and setting: Pilot randomised controlled trial in one UK primary care trust area. Method: Patients with moderate to severe COPD were identified through primary care and randomised 2:1 to the 7-week-long, group intervention or usual care. Outcomes at baseline, 2, and 6 months included self-reported health, St George’s Respiratory Questionnaire (SGRQ), EuroQol, and exercise. Results: Forty-four per cent responded to GP invitation, 116 were randomised: mean (standard deviation [SD]) age 69.5 (9.8) years, 46% male, 78% had unscheduled COPD care in the previous year. Forty per cent of intervention patients completed the course; 35% attended no sessions; and 78% participants completed the 6-month follow-up questionnaire. Results suggest that the intervention may increase both QoL (mean EQ-5D change 0.12 (95% confidence interval [CI] = –0.02 to 0.26) higher, intervention versus control) and exercise levels, but not SGRQ score. Economic analyses suggested that with thresholds of £20 000 per quality-adjusted life-year gained, the intervention is likely to be cost-effective. Conclusion: This intervention has good potential to meet the UK National Institute for Health and Clinical Excellence criteria for cost effectiveness, and further research is warranted. However, to make a substantial impact on COPD self-management, it will also be necessary to explore other ways to enable patients to access self-management education.
E-Letter in relation to the article: A further dimension to general practitioners’ (GP) limited knowledge of the Chief Medical Officer’s (CMO) advice on physical activity described by Savill et al. lies in the health of primary care physicians themselves. As a sedentary profession with long office hours, this finding indicates that GPs may be at increased risk of the very same physical and psychological consequences they seek to prevent in their patients. Such a conclusion could have wider implications for the public because patients’ perceptions of GP health are reported to influence their facilitation of advice given.1 This effect is not simply based on physical appearance of health and weight; one of the key determinants is the disclosure of the GP’s own health behaviours.1 While growing attention has been paid to burnout in general practitioners,2-3 the impact of working conditions on the physical health of general practitioners needs to be considered further. Opportunities should be created within annual appraisals to promote greater discussion of this, in particular strategies to address physical inactivity.
Street-level bureaucracy (SLB) is a sociological theory that seeks to explain the working practices and beliefs of frontline workers in public services and the ways in which they enact public policy in their routine work. Developed by an American, Michael Lipsky, it examines the workplace in terms of systematic and practical dilemmas that must be overcome by employees, with a particular focus on public services such as welfare, policing, and education. The theory is based on the notion that public services represent ‘the coal mines of welfare where the “hard, dirty and dangerous work” of the state’ is done.’
Background: 'Expert patient' programmes have been introduced in the UK as a new approach to chronic disease management for the 21st century. The average survival age of those with cystic fibrosis (CF) has steadily increased such that the majority of those with the condition now live into adulthood. Currently, specialist CF centres deliver the core of medical care, with primary care providing access to prescribed medicines, referral to other services, and care of non-CF needs, however, it is necessary to provide a more comprehensive service for adult CF patients, involving both specialist centres and primary care. To date, little is known about these expert patients' experiences of primary care. Aim: To investigate how young adults with CF perceive and experience primary healthcare services. Design of study: Qualitative study. Setting: One specialist CF centre in southeast England. Method: Inter view study of 31 patients with CF, aged 18 years or over. Results: Adults with CF consult in primary care on two distinct levels: as lay and expert patients. When consulting as experts, patients tend to operate as consumers of health care and perceive a satisfactory doctor-patient relationship to be influenced by three factors: GPs' understanding of how people live with CF, GPs' ability to prescribe certain specialist medications, and sensitive management of the cost of health care for adults with CF. A doctor-patient relationship based on trust and understanding is seen as desirable, but requires that these factors are addressed both by the GP and the patient. Conclusion: Exper t patient policy has focused on the role of patients with common chronic conditions in secondary and tertiary care, with little consideration of how adults with rare chronic illness and their GPs manage health problems that can be addressed in primary care. Enabling easy access to holistic care, as well as establishing successful trusting relationships with people with long-term rare conditions, is a necessary foundation for expert patients to take an active role in their care. ©British Journal of General Practice 2006.
Background The rate of new HIV infections in the UK continues to rise, with one-quarter of cases undiagnosed. Opt-out HIV testing — in which tests are routinely offered to all patients, with the offer to decline — have proved effective in antenatal care. Pilot studies of HIV opt-out testing at GP registration and acute medical admission to hospital have described service-level issues and the clinician’s perspective, but not the views of the general public.
Aim To further understand the public’s perspective on opt-out testing for HIV in England.
Design and setting Focus groups (n = 9) with a total of 54 participants in Brighton, England, where HIV prevalence is high.
Method Quota sampling on sexual orientation, age, sex, and testing experience was applied to groups with high and low HIV prevalences, and analysed using framework analysis.
Results Opt-out testing for HIV was acceptable. Testing on GP registration was regarded as a more appropriate setting than acute medical admission. Participants from groups in which HIV has a higher prevalence felt HIV testing required consideration that may not be possible during acute hospital admission. However, there was concern that screening would still be targeted at groups in which HIV prevalence is higher, based on clinicians’ judgement of patients’ behaviours, sexuality, or ethnicity.
Conclusion The opt-out method of testing for HIV must be routinely offered to all who are eligible, to increase test uptake and to prevent communities feeling targeted. Any pressure to test is likely to be poorly received. Inaccurate concerns about medical records being shared with financial services are a disincentive to test. Primary care should be an active setting for opt-out HIV testing.
BACKGROUND
Earlier studies have suggested a link between asthma and severe headache, and also between migraine and wheezing illness. Recent analysis have also shown an increase of asthma among cases with a prior history of migraine but without a history of hay fever, allergic rhinitis or eczema.
AIM
To examine whether there is an association between migraine and asthma in the United Kingdom.
DESIGN OF STUDY
Matched case-control study using the General Practice Research Database (GPRD).
SETTING
Practices in the United Kingdom providing data on 5,110,619 patients to the GPRD.
METHOD
The subjects were the patients with one or more diagnoses of migraine plus treatment for migraine. Each case was matched by general practice, sex, and age, with one control who had never been given a diagnosis of migraine. Case and control groups were compared for prevalence of asthma, chronic obstructive pulmonary disease, respiratory symptoms treated with inhalers or hay fever. Investigations were carried out to determine whether the association between migraine and asthma was stronger among patients with hayfever or those without hayfever, and whether patients with migraine had an increased prescription of other (non-migraine and non-asthma) medications.
RESULTS
Among 64 678 case-control pairs, the relative risk of asthma in patients with migraine was 1.59 (95% CI = 1.54 to 1.65) among definite cases, and 0.75 (95% CI = 0.67 to 0.83) among those whose selection as case included beta-blocker prophylaxis. Among definite migraine cases, relative risks of chronic obstructive pulmonary disease, respiratory symptoms, eczema, and hay fever (pollinosis), were all raised (at 1.22, 1.85, 1.55, and 1.67, respectively). The association between migraine and asthma was stronger in patients without a diagnosis of hay fever, than in those with hayfever (relative risk = 1.32 and 1.19, respectively). The relative risk of prescription for a range of non-migraine, non-asthma medications was raised, the exception being anti-diabetic medication.
CONCLUSION
This large case-control study provides evidence for an association between migraine and asthma. Frequent attendance at a general practice surgery may confound this association. However, if the association is real, its elucidation may help the understanding of disease mechanisms shared by migraine and asthma.
BACKGROUND:
Since the introduction of highly active antiretroviral therapy (HAART) in the late 1990s, individuals with HIV are living longer and beginning to experience the chronic diseases of ageing. Alongside side effects of HAART therapy, these may be better managed in the community by generalists rather than by HIV specialists.
AIM:
To explore GPs' current perceptions of barriers to their involvement in managing patients with HIV.
DESIGN OF STUDY:
Postal questionnaire.
SETTING:
Practices within a primary care trust in the south of England.
METHOD:
The questionnaire included 24 statements relating to potential structural and attitudinal barriers to GPs' involvement in the care of patients with HIV.
RESULTS:
Seventy-one per cent (124/174) of GPs responded; 93% (n = 115) of responders were comfortable managing other illness in HIV patients, and 60% (n = 74) agreed that GPs rather than specialists should manage common chronic problems such as hypertension or diabetes. Specialist prescribing was commonly identified as a barrier, specifically: difficulty keeping up to date, knowledge of HAART side effects, and drug interactions. The majority of responders (67% [83]) viewed patients as preferring their HIV illness to be managed by specialists.
CONCLUSION:
There is now the opportunity and potential to relocate the management of chronic disease in patients with HIV to GPs. Factors such as lack of time, experience, and training were identified as barriers to caring for patient with HIV in the pre-HAART era; these factors continue to challenge some GPs. Additional barriers are the complexity of HAART regimes and inadequate reimbursement. Addressing these barriers is necessary if services are to be reconfigured for people with HIV.
Background
Urinary tract infection (UTI) is one of the commonest acute infections presenting to primary care. Little is known of women's experiences of UTI; self-care strategies and key triggers for their consulting behaviour are also little known.
Aim
To explore women's experiences of self-care and their journey to GP care, when faced with symptoms of a UTI.
Design of study
Qualitative semi-structured interview study with women recruited to a larger UK trial of different management strategies for UTI.
Setting
General practices across four counties in southern England.
Method
Twenty-one women were interviewed about the experiences they had prior to their GP visit, self-care strategies, and triggers for help seeking. Interviews were analysed thematically, using principles of analytic induction.
Results
Women reported a process of evaluation, monitoring, re-evaluation, and, finally, consulting in order to meet their needs. Four key triggers for consulting were identified: failure to alleviate symptoms through self-care; symptom duration and escalation; impeding normal functioning and the fulfilment of social roles; and concern that it may be or become a serious illness.
Conclusion
Although UTI is often self-limiting, when taking patient histories and formulating their management strategies clinicians need to take into account women's often painful experience, their efforts to resolve symptoms prior to consulting, and their fears that the symptoms may indicate something more serious than a UTI.
Background Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines. Aim To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines. Design of study Cohort study. Setting UK general practices contributing to the General Practice Research Database (GPRD). Method Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management. Results A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period. Conclusion These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions.
Background Epididymo-orchitis is a common urological presentation in men but recent incidence data are lacking. Guidelines for management recommend detailed investigation and treatment for sexually transmitted pathogens, such as Chlamydia trachomatis. Data from secondary care indicate that these guidelines are poorly followed. It is not known how epididymo-orchitis is managed in UK general practice. Aim To estimate the incidence of cases of epididymo-orchitis seen in UK general practice, and to describe their management. Design of study Cohort study. Setting UK general practices contributing to the General Practice Research Database (GPRD). Method Men, aged 15-60 years, consulting with a first episode of epididymo-orchitis between 30 June 2003 and 30 June 2008 were identified. All records within 28 days either side of the diagnosis date were analysed to describe the management of these cases (including location) and to compare this management with guidelines. Results A total of 12 615 patients with a first episode of epididymo-orchitis were identified. The incidence was highest in 2004-2005 (25/10 000) and declined in the later years of the study. Fifty-seven per cent (6943) of patients were managed entirely within general practice. Of these, over 92% received an antibiotic, with ciprofloxacin being the most common one prescribed. Only 18% received a prescription for doxycycline. Most men, including those under 35 years, had no investigation recorded and fewer than 3% had a test for chlamydia. Conclusion These results indicate low rates of specific testing and treatment for sexually transmitted infections in males who attend general practice with symptoms of epididymo-orchitis. There is a need for further research to understand the pattern of care delivered in general practice.
BACKGROUND: Case studies from the US suggest that Advanced Access appointment systems lead to shorter delays for appointments, reduced workload, and increased continuity of care. AIM: To determine whether implementation of Advanced Access in general practice is associated with the above benefits in the UK. DESIGN OF STUDY: Controlled before-and-after and simulated-patient study. SETTING: Twenty-four practices that had implemented Advanced Access and 24 that had not. METHOD: Anonymous telephone calls were made monthly to request an appointment. Numbers of appointments and patients consulting were calculated from practice records. Continuity was determined from anonymised patient records. RESULTS: The wait for an appointment with any doctor was slightly shorter at Advanced Access practices than control practices (mean 1.00 day and 1.87 days respectively, adjusted difference -0.75; 95% confidence interval [CI] = -1.51 to 0.004 days). Advanced Access practices met the NHS Plan 48-hour access target on 71% of occasions and control practices on 60% of occasions (adjusted odds ratio 1.61; 95% CI = 0.78 to 3.31; P = 0.200). The number of appointments offered, and patients seen, increased at both Advanced Access and control practices over the period studied, with no evidence of differences between them. There was no difference between Advanced Access and control practices in continuity of care (adjusted difference 0.003; 95% CI = -0.07 to 0.07). CONCLUSION: Advanced Access practices provided slightly shorter waits for an appointment compared with control practices, but performance against NHS access targets was considerably poorer than officially reported for both types of practice. Advanced Access practices did not have reduced workload or increased continuity of care.
Background Suspected urinary tract infection (UTI) is one of the most common presentations in primary care. Systematic reviews have not documented any adequately powered studies in primary care that assess independent predictors of laboratory diagnosis. Aim To estimate independent clinical and dipstick predictors of infection and to develop clinical decision rules. Design of study Validation study of clinical and dipstick findings compared with laboratory testing. Setting General practices in the south of England. Method Laboratory diagnosis of 427 women with suspected UTI was assessed using European urinalysis guidelines. Independent clinical and dipstick predictors of diagnosis were estimated. Results UTI was confirmed in 62.5% of women with suspected UTI. Only nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) independently predicted diagnosis (adjusted odds ratios 6.36, 4.52, 2.23 respectively). A dipstick decision rule, based on having nitrite, or both leucocytes and blood, was moderately sensitive (77%) and specific (70%); positive predictive value (PPV) was 81% and negative predictive value (NPV) was 65%. Predictive values were improved by varying the cut-off point: NPV was 73% for all three dipstick results being negative, and PPV was 92% for having nitrite and either blood or leucocyte esterase. A clinical decision rule, based on having two of the following: urine cloudiness, offensive smell, and dysuria and/or nocturia of moderate severity, was less sensitive (65%) (specificity 69%; PPV 77%, NPV 54%). NPV was 71% for none of the four clinical features, and the PPV was 84% for three or more features. Conclusions Simple decision rules could improve targeting of investigation and treatment. Strategies to use such rules need to take into account limited negative predictive value, which is lower than expected from previous research.
The general medical services (GMS) contract Quality and Outcomes Framework (QOF) awards up to 70 points for measuring patient satisfaction with either the Improving Practices Questionnaire (IPQ) or the General Practice Assessment Questionnaire (GPAQ). The usefulness of data collected depends crucially on the validity and reliability of the measurement instrument. The literature was reviewed to assess the validity and reliability of these questionnaires. The literature was searched for peer-review publications that assessed the reliability and validity of the IPQ and GPAQ, using online literature databases and hand-searching of references up to June 2006. One paper claimed to assess the validity and reliability of the IPQ. No paper reported the reliability and validity of the GPAQ, but three papers assessed an earlier version (the GPAS). No published evidence could be found that the IPQ, GPAQ, or GPAS have been validated against external criteria. The GPAS was found to have acceptable reliability and test–retest reliability. Neither of the instruments mandated by the GMS contract has been formally assessed for reliability: their reproducibility remains unknown. The validation of the two questionnaires approved by the QOF to assess patient satisfaction with general practice appears to be suboptimal. It is recommended that future patient experience surveys are piloted for validity and reliability before being implemented widely.
Background Guidelines for depression management have been developed but little is known about GP and patient goals, which are likely to influence treatment offers, uptake, and adherence. Aim To identify issues of importance to GPs, patients, and patients' supporters regarding depression management. GP and patient goals for depression management became a focus of the study. Design of study Grounded theory-based qualitative study. Setting GPs were drawn from 28 practices. The majority of patients and supporters were recruited from 10 of these practices. Method Sixty-one patients (28 depressed, 18 previously depressed, 15 never depressed), 18 supporters, and 32 GPs were interviewed. Results GPs described encouraging patients to view depression as separate from the self and ‘normal’ sadness. Patients and supporters often questioned such boundaries, rejecting the notion of a medical cure and emphasising self-management. The majority of participants who were considering depression-management strategies wanted to ‘get out’ of their depression. However, a quarter did not see this as immediately relevant or achievable. They focused on getting by from day to day, which had the potential to clash with GP priorities. GP frustration and uncertainty could occur when depression was resistant to cure. Participants identified the importance of GPs listening to patients, but often felt that this did not happen. Conclusion Physicians need greater awareness of the extent to which their goals for the management of depression are perceived as relevant or achievable by patients. Future research should explore methods of negotiating agreed strategies for management.
Background: Acute infective conjunctivitis is a self-limiting condition that commonly presents to primary care. Patients' understanding of conjunctivitis, their reasons for attendance, and their responses to different management strategies, are unknown.
Aim: To explore patients' understanding of conjunctivitis and its management.
Design of Study: Qualitative study using semi-structured one-to-one interviews.
Setting: Three general practices in Hampshire and Wiltshire.
Method: Twenty-five patients presenting with conjunctivitis at their general practices were interviewed. Main outcome measures were patients' perceptions of conjunctivities, their experience and knowledge of the disease, beliefs regarding treatment, and their responses to different management strategies and a patient information leaflet.
Results: Patients regarded conjunctivitis as a minor illness, although some considered it might become more serious if not treated. Nearly all were confident at recognising conjunctivitis. They stated a preference for not taking medication, but believed that conjunctivitis would not clear up without treatment. However, they were open to alternative management approaches; for example, the delayed prescription approach, because they trusted their general practitioners' (GPs') judgement. Once they were aware of the self-limiting nature of conjunctivitis, patients felt they would prefer to wait a few days to see if the condition improved before seeking medical advice, even if this resulted in a few more days of symptoms.
Conclusion: Patients who attend their general practices with conjunctivitis present for treatment because they are not aware of its self-limiting nature. Providing patients with this information may enable patients, enhance self-management, and reduce the use of topical antibiotics and the demand for urgent general practice appointments.
The general medical services (GMS) contract Quality and Outcomes Framework (QOF) awards up to 70 points for measuring patient satisfaction with either the Improving Practices Questionnaire (IPQ) or the General Practice Assessment Questionnaire (GPAQ). The usefulness of data collected depends crucially on the validity and reliability of the measurement instrument. The literature was reviewed to assess the validity and reliability of these questionnaires. The literature was searched for peer-review publications that assessed the reliability and validity of the IPQ and GPAQ, using online literature databases and hand-searching of references up to June 2006. One paper claimed to assess the validity and reliability of the IPQ. No paper reported the reliability and validity of the GPAQ, but three papers assessed an earlier version (the GPAS). No published evidence could be found that the IPQ, GPAQ, or GPAS have been validated against external criteria. The GPAS was found to have acceptable reliability and test-retest reliability. Neither of the instruments mandated by the GMS contract has been formally assessed for reliability: their reproducibility remains unknown. The validation of the two questionnaires approved by the QOF to assess patient satisfaction with general practice appears to be suboptimal. It is recommended that future patient experience surveys are piloted for validity and reliability before being implemented widely.
Background: The number of out-of-hours calls to general practitioners (GPs) has increased steadily during the past 20 years. The proportion of inappropriate calls are reportedly increasing but we know very little about how GPs judge a call to be appropriate or inappropriate.
Aim: To determine the factors that influence GPs' perceptions of the appropriateness or inappropriateness of out-of-hours calls.
Design of Study: Postal questionnaire survey.
Setting: GP members of the Wessex Primary Care Research Network (WReN) and the Northern Primary Care Research Network (NoReN).
Method: General Practitioners were asked to write down what they meant by an 'appropriate' and 'inappropriate' out-of-hours call. The free text was subjected to content analysis.
Results: Detailed responses were received from 146 (73%) GPs. General practitioners appear to have a well developed classification of the appropriateness of out-of-hours calls. Factors that make calls appropriate include not only the nature of patients' symptoms and illness but also non-medical factors such as patients' compliance and politeness.
Conclusion: The inclusion by GPs of non-medical factors in their conceptualisation of the appropriateness of out-of-hours calls may contribute to patients' confusion about what is and is not appropriate and also to the apparent failure of patient education initiatives designed to decrease inappropriate demand.
Background: The Department of Health's review of continuing professional development in general practice advocates setting team and individual goals.
Aim: To explore how general practitioners (GPs) share learning experiences with colleagues, focusing on how GPs choose courses as one factor influencing sharing.
Method: Interviews were conducted with 21 GPs using grounded theory methodology. The responses were coded by six researchers from psychology, education, and general practice.
Results: Much sharing with colleagues took place, though not always immediately following a course. GP explanations revealed four reasons for course selection that influenced the degree of sharing: 1. Attendance to meet group needs encouraged rapid sharing and could involve course attendance with colleagues. 2. Attendance to enhance 'special interests' could either encourage or inhibit sharing. 3. Attendance in pursuit of 'personal interests' peripheral to general practice did not result in sharing within the primary care team. 4. Attendance to meet personal learning needs did not involve sharing when needs were not currently shared with colleagues.
Conclusion: Course selection and subsequent sharing have implications for course providers and those writing personal and practice professional development plans.
General practitioners receive a large and increasing number of unsolicited requests to participate in research. This study describes the volume and nature of research requests received by 18 primary care teams in a three-month period. On average, each practice receives 16 to 24 research requests each year. The most frequent request is to complete a questionnaire (32%). Only one-fifth of studies originate from academic or service general practice. Remuneration for participating in a study was only offered for 15% of studies. Although general practice teams feel swamped by research requests, this sensation may be exaggerated by invitations to participate in non-scientific surveys as well as true research projects. Practice teams would welcome help in distinguishing quality research proposals from the remainder.
There is no evidence to support the practice of screening consultations that include general physical examinations and batteries of tests; however, many patients may choose, or be sent by their employers, to have private full health screening (FHS). General practitioners (GPs) are routinely sent the results of these screening examinations and are expected to deal with any subsequent care required. GPs recognize some positive aspects of FHS, but in our survey there was a groundswell of dislike for these examinations because of uncertainty about patient benefit (raised anxiety or false assurance) and a potential to irritate the GP. The implications for workload were minimal but resented. GPs would welcome a precise summary of significant findings and for the screening doctor to take greater responsibility for follow-up.
Background: General practitioners’ (GPs’) attendance at continuing medical education (CME) events has increased since the introduction of the Post Graduate Educational Allowance (PGEA) in 1990. However, few studies have examined doctors’ perceptions about their continuing education, and explored their views in depth.
Aim: To investigate general practitioners’ experience of CME events, what personal impact they had, and how the GPs perceived the influence of CME in their professional practice and patient care.
Method: A qualitative study, with in-depth semi-structured interviews, of a purposive sample of 25 general practitioners in Dorset was conducted. Content analysis was used to identify major themes from the transcripts.
Results: GPs perceived CME events as beneficial. Confidence levels rose, and the events provided a break from practice that refreshed and relaxed, thus indirectly benefiting patients. The opportunities provided by formal events for informal learning and exchange of ideas, with both peers in general practice and consultant colleagues, were highly valued. The relevance of the subject to general practice, and the appropriateness of the educational format, were considered of paramount importance. Few responders identified major changes in their practice as a result of formal CME events, and information was seldom disseminated among practice colleagues.
Conclusion: The results of this study challenge GP educators to provide CME that is relevant, to recognize the value of peer contact, and to facilitate the incorporation of new information into practice.