Ebeltoft project: baseline data from a five-year randomized, controlled, prospective health promotion study in a Danish population.

BACKGROUND. There is increasing political pressure on the medical profession to approach welfare diseases, such as coronary heart disease and diabetes, through prevention. General practitioners are required to offer regular health checks to healthy people, in spite of the lack of scientific evidence for the universal need, usefulness and side effects of such an intervention. Randomized controlled trials are needed. AIM. A study was carried out to investigate people's interest in participating in health checks and in discussions about health with their own general practitioner, participants' health status, the proportion who received health advice following health checks, and the lifestyle goals they set following discussion with their general practitioner. This study reports the baseline data from a five-year randomized, controlled, prospective, population-based study in general practices in Ebeltoft, Denmark. METHOD. All general practitioners from the four practices in Ebeltoft and a random sample of 2000 people aged between 30 and 50 years were invited to participate. Participants were randomly divided into three groups--one control group and two intervention groups. One intervention group were given a health check which included being screened for cardiovascular risk factors, lung and liver function, fitness, sight and hearing and an optional test for the human immunodeficiency virus (HIV); this group received written feedback from the general practitioner. The other intervention group were also given a health check and written feedback; in addition, they were given the opportunity to attend their general practitioner to discuss preventive health. RESULTS. A total of 1370 people participated in the study (69% response rate). Health advice was given to 76% of 905 participants following health checks. Almost all of the 456 participants (96%) who were offered the opportunity of discussing their health with their general practitioner took up the offer; 64% of the 456 participants reported that they had decided to undertake lifestyle changes. Eleven of those who discussed their health with the doctor were referred to a specialist (2%). CONCLUSION. There was considerable interest in participating in health promotion. Three out of four of those having a health check were given health advice. Two out of three of those offered a health talk with the general practitioner appeared willing to make relevant lifestyle changes. Long-term follow up is needed to determine effects and side effects of health checks and health talks.     

How useful is weight reduction in the management of hypertension?

A group of previously untreated obese hypertensive patients were started on a weight reduction programme supervised by two dietitians working in a general practice surgery. It was stressed from the beginning of the programme that reducing blood pressure was the purpose of the diet. The results of follow-up after six months are presented together with results for a control group of obese hypertensive patients not receiving dietary advice or drug therapy, but being followed by the general practitioner. The weight, systolic blood pressure and diastolic blood pressure of the dieting hypertensive group were significantly lower than those of the non-dieting group after six months. However, the drop-out rate was significantly higher for the dieting group than for the non-dieting group.

The results of a separate comparison between a control group of obese normotensive patients following the same dietary programme and the group of dieting obese hypertensive patients are also presented. Attendance rates and weight loss achieved were significantly better for the hypertensive group than for the normotensive group after 12 months.

Weight reduction appears to be an effective first-line therapy for approximately 50% of obese patients with mild to moderate hypertension, and raised blood pressure appears to provide motivation for such patients to attend a dietitian's clinic and to lose weight.

     

An appointment system in a teaching practice

Some patients have difficulty in achieving an appointment to see a doctor in a university teaching practice. Only five per cent of patients indicated serious difficulty. Patients who discriminate in favour of seeing a particular doctor have greater difficulty. It is suggested also that some patients have the same difficulty if they are making an appointment to see a particular doctor.

Clearly there is a need to explore the problem further to determine the nature of the difficulties which patients experience. It might then be expected that improvements can be made which will help patients to achieve appointments more easily. At the same time it has to be recognised that there may be some patients who will continue to have difficulty in achieving an appointment however much they are helped. Such patients may need access to community health care services in a manner entirely different from the appointment system.

Most patients prefer to see their general practitioner by appointment. Both open-access surgeries and appointment systems cause difficulties for patients. The former is associated with the difficulty of long waiting periods and the second with difficulties in achieving an appointment. As some form of appointment system is likely to be continued, particularly for group practices and health centres, it is probably timely to audit patients' experience of achieving appointments.

University teaching practices present general practitioners with unusual additional stresses on an appointment system. The full-time teacher's day is divided between service to patients and teaching or research. Any reduction in the availability of a particular doctor in a group may result in patients having difficulty in making an appointment. This argument could equally apply to any group of practitioners who have commitments other than to general medical services.

     

Group-based care: does it change problem behaviour?

As a result of disappointing experiences in managing problem behaviour presented by patients in general practice, a system of team or group-based care was developed at the Ommoord Health Centre in Rotterdam, the Netherlands.

However, despite all the care given by social workers, general practitioners, physiotherapists and other members of the primary health care team, the problem behaviour of about half the patients was unaltered.

This report concerns the aims and methods of our group meetings and the conditions such as empathy, sincerity and non-possessive warmth which we regard as essential in dealing with problem behaviour. The conditions necessary for improvement, such as independence and responsiveness by patients, are also considered. During our group meetings the team deals with the emotions which patients are experiencing at the time, and patients are encouraged to discover as much as possible about their own possibilities for both influencing and making choices in their lives. Some examples of this type of care are given.

Patients react positively to the group-based care approach and some reduction in the consultation rate and in the prescribing of tranquillizers by general practitioners has been shown.

     

Disinfection methods in general practice and health authority clinics: a telephone survey

Concern about the epidemic of the acquired immune deficiency syndrome led to discussions in one health district about the dangers of cross-infection from instruments in general practice and health authority clinics. In order to establish what current disinfection practices were in use a telephone survey was adopted as a quick and easy method of data collection. Information was collected on who was responsible for disinfection as well as details of how each instrument was disinfected. Results from 69 general practices and 21 health authority clinice in one health district are reported.

Some form of sterilizer was used in 63 general practices. These included water boilers (49%), dry heat sterilizers (41%), autoclaves (5%) and pressure cookers (5%). Sixty one practices were using metal vaginal specula and of these 29 were disinfecting by boiling, three were using pressure cookers, 18 dry heat, seven chemical methods, three autoclaves and one the central sterile department of the local hospital. Of those who were boiling after simple washing, three practices boiled for five to 10 minutes and reused instruments during the same clinic. Of the 29 using simple boiling 20 (69%) were boiling for less than 20 minutes.

The study highlights the fact that no formal advice has been given on disinfection practice by the DHSS, the health authorities or the family practitioner committees. The need to set up local guidelines and develop practical steps for their introduction are discussed.

     

Randomized trial of nurse-assisted strategies for smoking cessation in primary care.

BACKGROUND: Brief advice to stop smoking from general practitioners (GPs) has been repeatedly shown to increase smoking cessation by a small, but measurable amount. Some studies have suggested that adding more intensive interventions to brief advice may increase its effectiveness, but it is unclear whether this is true in general practice. AIMS: To determine whether brief advice from a doctor together with counselling and follow-up from a trained practice nurse is more effective than brief advice alone in helping people to stop smoking. METHODS: The design was a randomized controlled trial. Four hundred and ninety-seven general practice patients aged older than 18 years and smoking at least one cigarette per day in six general practices in Oxfordshire, Berkshire, and Buckinghamshire were randomized to one of two interventions: brief verbal or written advice from a GP plus extended counselling and follow-up from a trained practice nurse; brief advice from a GP alone. The primary outcome was sustained abstinence from smoking at three and 12 months. A secondary outcome was forward movement in the stages of change cycle. RESULTS: The proportion showing sustained abstinence was 3.6% in the extended counselling group, and 4.4% in the brief advice group (difference = -0.8%; 95% confidence interval = -4.3% to 2.6%). Seventy-four (30%) of those randomized to extended counselling actually took up this offer. No significant progression in stages of change was detected between the two groups. CONCLUSIONS: In unselected general practice patients who smoke, brief advice from a GP combined with intensive intervention and follow-up by a practice nurse is no more effective than brief advice alone.     

Smoking in pregnancy: is the message getting through?

In order to determine the current smoking habits of pregnant women and the success of anti-smoking advice, inpatient postpartum mothers were invited to complete a questionnaire on their smoking habits, their knowledge of the ill-effects of smoking .in pregnancy and their recollections and reactions to anti-smoking advice.

Over a third of the smokers replied that smoking in pregnancy had no harmful effects, compared with 1% of the non-smokers. Only 37% of the smokers said they knew of the risk of having a smaller baby as a result of smoking, compared with 63% of the non-smokers. A high proportion of both smokers and non-smokers did not recall receiving anti-smoking advice during pregnancy, 55% and 54% respectively. However, 48% of the smokers felt that anti-smoking advice was over-cautious, compared with 7% of the non-smokers.

It is concluded that many smokers are `blocking' the smoking advice given to them, and it is therefore ineffective. A different approach by health professionals is recommended and the emphasis of the advice given should be changed.

     

Implementation and effectiveness of a primary care based physical activity counselling scheme

The aim of the project was to reach inactive people through primary care offices and motivate them to become more active for health purposes. Physical activity questionnaires based on the transtheoretical model (TM) of behaviour change were handed out to every person entering one of five primary care offices. All inactive people were entered into a randomised controlled trial (RCT). Individuals assigned to the feedback group were given feedback from their physician concerning their physical activity level. In addition, the advice plus group received further advice and stage matched leaflets and was offered a 45-min counselling session. Changes in physical activity behaviour were measured 7 weeks as well as 14 months after the intervention. Physicians and patients alike reacted positively to the project. Ninety percent of patients entering the primary care offices were willing to participate. Ninety percent of inactive people agreed to be entered into the RCT. The follow-up rate in this trial was 82% at 14 months. At 7 weeks, 35% of patients in the feedback group were now classified as active and 38% of patients in the advice plus group. At 14 months, 47% of the subjects in both groups were active. Inactive people can be reached effectively through primary care offices. Patients receiving feedback from their physician concerning their physical activity level improved their behaviour to the same extent as patients who were given further advice and written materials, and were offered a counselling session.     

Imported malaria in the UK: advice given by general practitioners to British residents travelling to malaria endemic areas

General practitioners are in a key position to provide advice to those travelling to malaria endemic areas. A study of at-risk travellers revealed that 54% visited their general practitioner before their intended trip overseas and of these 79% were given advice about antimalarial precautions. Of those advised 98% carried antimalarial tablets with them on their trip but only 46% had any knowledge of other methods of personal protection against malaria. Fewer non-white than white British residents received information from their general practitioners.

It is suggested that general practitioners should be better informed about current malaria transmission and currently recommended chemoprophylactic drugs and dosages. It is also suggested that the major public health priority should be to stimulate a greater involvement of non-health service agencies in order to make the public aware of the risk of malaria and seek medical advice before travel.

     

Treating sexual dysfunction in general practice

A method of training general practitioners in the treatment of sexual dysfunction is described, using fortnightly seminars at which the doctors discussed the continuing care of their patients.

Doctors took on patients presenting in their practices and treated couples together, where possible, using a mixture of insight-directed and behavioural techniques similar to those used by Masters and Johnson (1970). Interviews were reported back to the group which gave advice and support. The doctors, all beginners in this type of work, were able to help substantially 72 per cent of 47 couples treated.

     

Developing and maintaining patients’ trust during general practice consultations: The case of smoking cessation advice

Objective

The aim of this paper is to describe how the process of developing and maintaining trust is related to how and if smoking cessation advice is given in general practice consultations.

Methods

The study consisted of interviews with six Danish GPs and with 11 of their patients, on the basis of observations of their consultations.

Results

According to the findings of this study, both the GPs and the patients expected GPs to demonstrate in interaction with the patients their intent to evaluate and possibly resolve the patient's health problem. The GPs were also expected to show that they recognized the patient's health problem. Both GPs and patients felt that this would help to develop patients’ trust in their GPs. Smoking cessation advice during consultations could negate these demonstrations of GPs intents. Smoking cessation advice, however, could demonstrate interest and a desire to help and so develop trust.

Conclusion

Smoking cessation advice has the potential both to put trust under strain and to strengthen trust. The outcome depends on whether the advice conforms to what both patients and GPs expect from the interaction in general practice consultations.

Practice implications

To develop and maintain patients’ trust GPs should consider the specific expectations from the interaction with patients during consultations when giving smoking cessation advice.     

High blood pressure and psychiatric disorder in general practice

A programme for the control of hypertension has been started in general practice with the principal aim of finding the most effective way of identifying and keeping patients with high blood pressure under continuing control. One objective is to determine the psychiatric state of hypertensive patients in the programme and this paper reports these results.

There was no significant difference between the percentage of psychiatric patients in a hypertensive group and a control group. There was no relationship between blood pressure recorded at the initial clinic and the psychiatric state. In both hypertensive and control groups, patients who were on hypertensive treatment at the initial clinic were more likely to be `psychiatric' than those who were not on treatment; this appears to be less likely to occur if the hypertension is controlled.

     

Sport and the asthmatic child: a study of exercise-induced asthma and the resultant handicap

A group of 111 asthmatic children was studied using a self-administered questionnaire to investigate exercise-induced asthma and how it affected their participation in sport.

Although selected to represent the severe end of the spectrum of general practice asthma, most children reported relatively mild asthma, with attacks less than once a week. Even so, 97 of the children (87%) experienced exerciseinduced bronchospasm, 74% fairly frequently. Just under one-half of those who suffered exercise-induced asthma did not treat it adequately and even more of them never used adequate prophylaxis.

Forty-three children occasionally had to miss sport because of asthma, 24 had received advice to avoid certain sports and 28 had at times been unable to complete a game involving exertion. Given the importance of sport the findings suggest that asthma can be a real social handicap.

     

Acute myocardial infarction: an easy diagnosis in general practice?

In the imminent myocardial infarction Rotterdam (IMIR) study, contacts by patients with their general practitioners for symptoms of potential coronary artery disease were registered. Those who had acute myocardial infarction were diagnosed on the basis of the modified World Health Organization criteria, and those with this definite diagnosis were then compared with the initial diagnosis made by the general practitioner at the moment of contact without laboratory assistance.

Of the 1,343 patients included in the study, 93 (seven per cent) had `definite' acute myocardial infarction and another 37 (three per cent) had `possible' acute myocardial infarction according to the diagnostic criteria used.

At the time of contact with the general practitioner 41 (44 per cent) of the 93 patients with definite myocardial infarction were recognized as such by the general practitioner, while in another 31 (33 per cent) the general practitioner diagnosed `imminent' myocardial infarction.

Of the 1,213 patients free of acute myocardial infarction at the time, 40 (three per cent) were incorrectly diagnosed by the general practitioner as having `acute' myocardial infarction.

In the 22 patients who in fact had acute myocardial infarction but in whom the general practitioner did not make this diagnosis at the time, it was found that there was an absence of physical signs and, similarly, in patients who subsequently did not have infarction the presence of physical signs was related to a falsepositive general practitioner diagnosis of myocardial infarction.

In view of the inaccuracy of the general practitioner's provisional diagnosis of acute myocardial infarction, we believe that electrocardiogram and enzyme tests should be carried out systematically in all patients who present to general practitioners with symptoms of potential coronary artery disease. Laboratory support should be readily available and we support the idea of having a special diagnostic service.

     

Users and non-users of doctors — implications for self-care

Sixty patients who visited their general practitioner were matched with 60 patients registered with the same doctor, who were of the same sex and in the same ten-year age group, and who had not visited the doctor for at least one year, but had recently experienced symptoms similar to those presented by the attending patients.

Comparison of the 60 pairs revealed the following differences, all substantial although not all statistically significant. The patients who visited the doctor perceived themselves as less healthy, fewer had attempted self-treatment, more reported serious personal problems, and fewer reported obstacles to visiting the doctor.

Differences between the pairs were negligible for total number of current ailments, effectiveness of self-treatment, if used, optimism about the healing powers of doctors, and fear of troubling their doctor with trivia.

     

First encounters

Some conclusions are reported from a series of seminars involving several experienced general practitioners over a period of three years. The aim was to examine first consultations in general practice.

We found that these were often handled superficially and that both doctors and patients seemed hesitant in their new relationship. We believe that the loss of a trusted family doctor can create a bereavement reaction in patients, especially where the relationship has been long and when the doctor leaves or dies suddenly.

We are investigating the possibility that the death rate is increased among patients who have recently lost their general practitioner suddenly.

     

Comparison of the work of a nurse practitioner with that of a general practitioner

The work of a nurse practitioner was compared with that of a general practitioner. Both were equally available to the same patient population over the same period. The nurse practitioner saw a similar age and sex distribution of patients to the doctor but saw different types of problems. More of the patients she saw were for followup of chronic diseases, health advice and screening measures while fewer were acutely ill. The doctor dealt with four times as many patients. The nurse practitioner managed 78% of her consultations without referral to a doctor, and 89% without resorting to prescribed drugs. There was a high level of patient satisfaction with her work and 97% of the patients who saw the nurse would choose to consult her again. The role of the nurse practitioner in our practice has developed differently from a similar post in another setting, thus emphasizing the need for flexibility when defining the role.

Nurse practitioners are a valuable extra resource for the development of new areas of care, rather than a cheaper substitute for a general practitioner.

     

The verbal Oxford Knee Score is not clinically different from the written score when assessed before or after total knee arthroplasty

BackgroundThe aim of this study was to assess the reliability of the Oxford Knee Score (OKS) collected verbally compared with the validated written score, using a population of patients who underwent total knee arthroplasty (TKR).MethodsNinety patients (mean age 70.6; (43–92), 56.7% female) undergoing TKR were prospectively assessed. One group (n = 45) completed written (standard) and verbal (over the telephone) OKS preoperatively, half (n = 23) performed the written questionnaire first followed by the verbal questionnaire, and the other half (n = 22) performed this in reverse. A separate group (n = 45) completed the same regime one year postoperatively.ResultsA mean difference of 0.63 (95% CI − 0.985–2.23) points between verbal and written OKS was observed preoperatively, and of 1.36 (95% CI − 0.942–3.65) points was observed at one year postoperatively. Excellent reliability was observed using ‘average measures’ intra-class coefficient for the OKS preoperatively (r = 0.848) and at one year postoperatively (r = 0.970) in both groups who had written scores performed first, and those who had verbal scores performed first (preoperative r = 0.780, one year r = 892).Bland and Altman plots demonstrated consistent correlation between patients reporting their preoperative score and one-year postoperative score verbally and written. There was no significant variation between groups who had written scores performed prior to verbal, compared with those who reported verbal scores prior to written.ConclusionsProspective written collection of OKS remains the benchmark. However, verbal recording of OKS is not clinically different to written score, and may be a useful alternative to OKS in patients who are unable to attend or complete written questionnaires.     

Promoting physical activity in Australian general practices: a randomised trial of health promotion advice versus hypertension management

A randomised controlled trial was conducted to determine if physicians' advice to promote physical activity to patients was more effective if the advice was tailored to the management of hypertension, compared with more general health promotion advice. Participants included inactive 40- to 70-year-old patients visiting the physicians' during study recruitment period. Physicians provided verbal physical activity advice and written materials, both tailored to either general health promotion messages or specifically as a means for treating or managing hypertension. Seventy-five physicians and 98% (767/780) of screened eligible patients participated in the study. Differences between intervention and control groups self-reported physical activity were assessed over 6 months. Follow-up response rates were 92 and 84% at the 2- and 6-month assessments. There were no consistent, significant differences between groups at the 2- or 6-month assessments. Thus, neither intervention strategy resulted in significant changes in patients self-reported physical activity, regardless of the whether the advice was tailored to hypertension management or general health promotion advice.