A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy

Background. Interventions to promote prescribing of preventivetherapies in patients with cardiovascular disease (CVD) or diabeteshave reported variable success. Objective. (i) To evaluate the effect of prescribing feedbackon GP practice using academic detailing compared to postal bulletinon prescribing of CVD preventive therapies in patients withCVD or diabetes at 3 and 6 months post intervention and (ii)to evaluate the intervention from a GP's perspective. Methods. Volunteer GP practices (n = 98) were randomized toreceive individualized prescribing feedback via academic detailing(postal bulletin plus outreach visit) (n = 48) or postal bulletin(n = 50). The proportion of CVD or diabetic patients on statinsand antiplatelet agents/warfarin pre- and post-interventionwas calculated for each GP practice. Multivariate regressionwith a random effects model was used to compare differencesbetween the groups adjusting for GP clustering and confoundingfactors. ß-Coefficients and 95% confidence intervals(CIs) are presented. Results. There was a 3% increase in statin prescribing in CVDpatients at 6 months post-intervention for both randomized groups,but there was no statistical difference between the groups (ß= 0.004; 95% CI = –0.01 to 0.02). Statin and antiplatelet/warfarinprescribing also increased in the diabetic population; therewas no significant differences between the groups. GPs participatingin the project expressed a high level of satisfaction with bothinterventions. Conclusion. Prescribing of preventive therapies increased inboth randomized groups over the study period. But academic detailingdid not have an additional effect on changing prescribing overthe postal bulletin alone. Keywords. Academic detailing, feedback, prescribing, primary care.     

General practitioners' views about the need for a stress support service

OBJECTIVES: We wished to determine general practitioners' (GPS') views regardingthe need for a stress support service. METHOD: A postal questionnaire survey of GPs' views (n = 274) aboutthe need for a stress support service, and what form such aservice might take, was undertaken on Tyneside. RESULTS: A response rate of 79.5% was achieved with one reminder. A majority(78.8%) were in favour of a stress support service for GPs,the most popular options for the service being independentlyaccessed counsellors and stress management groups. Over 90%of respondents thought that support should be available to anydoctor, and 65% that it should be available to all primary healthcare team members. The five most commonly mentioned causes ofstress were: time and workload problems; on call; expectationsand demands of patients; administration and paperwork; and complaintsand fear of litigation. CONCLUSIONS: The survey demonstrated widespread concern amongst GPs on Tynesideabout stress levels and considerable interest in the idea ofstress support. However, a variety of approaches would be requiredto meet the range of perceived needs, and any such servicesshould be made accessible to all practitioners regardless ofwhether they are actually suffering from stress, as well asto other members of the primary health care team. Keywords. General practitioners, stress support, counselling, primary health care teams.     

Effect of Helicobactor pylori eradication therapy on dyspeptic symptoms in primary care

OBJECTIVE: The aim was to explore the effect of eradication therapy ondyspeptic symptoms in patients with known peptic ulcer disease(PUD). METHOD: A total of 164 known dyspeptics and 147 non-dyspeptic attendersat six UK general practices were recruited. The Helisal RapidBlood test was performed in the practices and eradication therapyleft to the preference of the general practitioner. Patientswere followed prospectively by a Likert scaled symptom questionnaireand record review. The symptom questionnaire distinguished betweenpatients known to have dyspepsia and those not. RESULTS: There was a statistically significant decrease in dyspepticsymptoms in patients with known PUD who received eradicationtherapy (n = 43, Z = –2.63, P = 0.009). CONCLUSIONS: Eradication of Helicobacter pylori in primary care can leadto a reduction in consumption of H2 receptor antagonists andhence cost savings. This study demonstrates that dyspeptic symptomsalso decrease. The questionnaire could be used in further studiesto evaluate the effect of management on dyspeptic symptoms inthe primary care setting. Keywords. Dyspepsia, Helicobactor pylori, primary care, therapy, outcome measures.     

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

Relationship between antidepressant and anxiolytic/hypnotic prescribing: A mixed-methods study

Background: Antidepressant prescribing has dramatically increased in Scotland, and the cause is unknown. Objective: To investigate if the increase in antidepressant prescribing coincided with a reduction in prescribing of anxiolytics and hypnotics; to investigate this relationship at practice level; and to explore whether general practitioners (GPs) explain the increase by their increased use for anxiety. Methods: Study design: analysis of routine prescribing data and interviews with GPs. Setting: Scottish general practices. Participants: 942 practices included in the analysis. Sixty-three GPs in 30 practices completed interviews. Main outcome measures: Quantity of antidepressants, anxiolytics, and hypnotics prescribed. Relationship at practice level between anxiolytic/hypnotic and antidepressant prescribing. Spontaneous comments by GPs about prescribing antidepressants for anxiety. Results: Antidepressant prescribing increased from 28.9 million defined daily doses (DDDs) in 1992/3 to 128.3 million in 2004/5. Anxiolytic/hypnotic prescribing fell from 64.2 million to 55.1 million DDDs. There was a weak, positive correlation between levels of antidepressant and anxiolytic/hypnotic prescribing (+0.084, p=0.010). GPs treated anxiety with antidepressants, although many described an overlap between anxiety and depression. Some spontaneously identified a relationship with benzodiazepine prescribing when asked to explain the increase in antidepressant prescribing. Conclusion: A small part of the increase in antidepressant prescribing is due to substitution for benzodiazepines to treat anxiety.     

Anthelmintic Prescribing Patterns of a Sample of General Practitioners from Selected Areas in the Colombo District of Sri Lanka

General Practitioners (GPs) provide first contact care of children and pregnant mothers in the community. This study ascertained the prescribing pattern of anthelmintics to children and pregnant women by a sample of GPs from the district of Colombo. Two hundred medical practitioners engaged in full-time General Practice (100 urban and 100 rural), were selected randomly. A pre-tested interviewer-administered questionnaire was used to collect data. A total of 183 GPs aged between 26 and 72 years (median 38) participated with 94 coming from urban areas. Seventy percent of the GPs were male. Almost 13% of GPs from urban areas had a Postgraduate degree in comparison to 4.5% from the rural areas (P < 0.05). Over 50% of GPs had 6-20 years of service and over 30% treated 16-30 patients daily. Seventy-three percent of GPs from rural areas accessed health-related reading material either daily or weekly in contrast to only 40% from urban areas (P < 0.001). All GPs prescribed anthelmintics to children. Pyrantel pamoate was the preferred anthelmintic used for children by both groups. Approximately 55% and 64% of GPs from urban and rural areas, respectively, prescribed anthelmintics during pregnancy. A majority of GPs prescribed drugs after the first trimester. However, 25% from urban areas gave drugs during any trimester (P < 0.001). Regression analysis revealed that GPs with postgraduate qualifications, those having frequent access to health-related material and those seeing more than 30 patients daily, prescribed anthelmintics to pregnant women more often. Although routine de-worming of pregnant women and children should occur through government antenatal and well-baby clinics, and through the schools de-worming programme, it may not happen due to various reasons. Thus, GPs play a vital role in achieving good coverage of anthelmintics among children and pregnant women. Making available clear national guidelines on prescribing anthelmintics in Sri Lanka would improve the prescribing patterns of anthelmintics among GPs.     

General Practitioners and Hospital-Initiated Prescribing

Objectives: Prescribing costs have risen significantly over the past decade and this has led to increasing pressure on general practitioners (GPs) to control their prescribing budgets. This paper explores GPs' perceptions of the influences of hospital-initiated prescribing on how they manage their prescribing budget.

Method: 16 practices within Birmingham Health Authority were selected according to characteristics of their prescribing budget. Twenty-one GPs in these practices were interviewed in depth about their views on how they controlled their prescribing budget, including questions on hospital-initiated prescribing.

Results: GPs reported being influenced by the experience of seeing patients who had been prescribed particular drugs by a consultant and then following their example. However, GPs expressed dissatisfaction with some hospital-initiated prescribing. Sometimes they considered the choice of drugs for conditions commonly treated in primary care to be unnecessarily expensive. They were also concerned about more expensive and more specialist drugs. GPs found it difficult to change or refuse to prescribe medication which had been initiated in hospital because they felt it could be damaging to their relationship both with their patients and consultants.

Conclusions: Hospital prescribing can have a major impact on general practice budgets and GPs felt that their ability to contain costs was not always within their control. The GPs expressed a wide range of views on how to respond to prescribing initiated in hospital with which they did not feel comfortable.     

Screening for alcohol misuse

Aira et al.'s constructive paper¹ identifies seven categoriesinfluencing the physician:patient dialogue for alcohol consumption.We recently have completed a study of Senior House Officer (SHO)attitudes to screening for alcohol misuse in Accident and Emergency(A&E) (127 SHOs over 5 years)². Briefly, we compare theexperiences of GPs and A&E staff under the headings identified. Sensitive nature of alcohol drinking     

Drug prescribing in hospital as experienced by general practitioners: East versus West Germany

BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are oftenchanged during hospitalization. This study set out to test thehypothesis that the extent of drug change and the informationprovided by the hospital determines the GPs' assessment of hospitalco-operation. The perception of drug change and hospital co-operationmay also be influenced by the degree of institutional separationof primary and secondary care. Therefore we compared GPs' respectiveattitudes in ‘East’ and ‘West’ Germany. METHOD: In 1993, a representative sample of ‘eastern’ and‘western’ German doctors received a structured questionnaire;554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPsbelieved that their medication was changed in hospital in morethan 60% of their patients. Only a minority of eastern (10%)and western (15%) doctors described the information providedby the hospitals as more or less satisfactory. More westernthan eastern doctors (56% versus 32%) expressed dissatisfactionwith hospital co-operation. Respondents in eastern Germany whofelt sufficiently informed about hospital drug change were morelikely to express satisfaction with the hospital doctors' co-operation.In the former area of West Germany the judgement of co-operationwas significantly better if the extent of drug change and thefrequency of generic drug replacement by original brand-namedrugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matterof concern, especially for GPs who are working in an area witha tradition of strictly separated primary and secondary care. Keywords. Drug prescribing, family practice, interprofessional relations, health system.     

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

OBJECTIVE: The aim was to establish the potential efficacy, tolerabilityand side-effect profile of electromagnetic therapy as an adjunctto conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinicaltrial was carried out in a dedicated leg ulcer clinic basedin one urban general practice. Nineteen patients with leg ulcersof confirmed venous aetiology were assessed. The main outcomemeasures were rate and scale of venous leg ulcer healing, changesin patient-reported pain levels, quality of life, degree ofmobility, side effect profile and acceptability to patientsand staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinicachieved improvements in the size of their ulcer (4, 21%, healedfully) and in reduced pain levels (P < 0.05) during the trial,despite the chronicity of ulcer histories. Patients treatedwith electromagnetic therapy at 800 Hz were found at day 50to have significantly greater healing (P < 0.05) and paincontrol (P < 0.05) than placebo therapy or treatment with600 Hz. All patients reported improved mobility at the end ofthe study. The electromagnetic therapy was well tolerated bypatients, with no differences between groups in reporting adverseevents, and proved acceptable to staff. CONCLUSION: Despite the small numbers in this pilot study, electromagnetictherapy provided significant gains in the healing of venousleg ulcers and reduction in pain. Keywords. Electromagnetic therapy, RCT, leg ulcers, primary care.     

Influences on doctors’ prescribing: is geographical remoteness a factor?

Objective: To identify factors influencing the prescribing of medicines by general practitioners in rural and remote Australia. Design: A qualitative study using a questionnaire to determine attitudes about prescribing, specific prescribing habits and comments on prescribing in ‘rural practice’. Setting: General practice in rural and remote Queensland. Subjects: General practitioners practising in rural and remote settings in Queensland (n = 258). Main outcome measures: The factors perceived to influence the prescribing of medicines by medical practitioners in rural environments. Results: A 58% response rate (n = 142) was achieved. Most respondents agreed that they prescribe differently in rural compared with city practice. The majority of respondents agreed that their prescribing was influenced by practice location, isolation of patient home location, limited diagnostic testing and increased drug monitoring. Location issues and other issues were more likely to be identified as ‘influential’ by the more isolated practitioners. Factors such as access to continuing medical education and specialists were confirmed as having an influence on prescribing. The prescribing of recently marketed drugs was more likely by doctors practising in less remote rural areas. Conclusion: Practising in rural and remote locations is perceived to have an effect on prescribing. These influences need to be considered when developing quality use of medicines policies and initiatives for these locations. What is already known: Anecdotal and audit based studies have shown that rural general practice differs to urban‐based practice in Australia, including some limited data showing some variations in prescribing patterns. No substantiated explanations for these variations have been offered. It is known that interventions to change prescribing behaviour are more likely to be effective if they are perceived as relevant and hence increasing our knowledge of rural doctors’ perceptions of differences in rural practice prescribing is required. What this study adds: Rural doctors believed that they prescribe differently in rural compared with city practice and they described a range of influences. The more remotely located doctors were more likely to report the ‘rural’ influences on prescribing, however, most results failed to reach statistical significance when compared to the less remotely located doctors. These perceptions should be considered when developing medicines policy and education for rural medical practitioners to ensure it is perceived rurally relevant.     

"I know what to do, but it's not possible to do it"--general practitioners' perceptions of their ability to detect psychological distress

BACKGROUND: Accurate detection of psychological distress in patients isa prerequisite of specific diagnosis and active management.Studies have shown that improved detection is related to alteredmanagement and to improved patient outcomes: there may alsobe a link with improved patient satisfaction. OBJECTIVE: Many factors in the doctor, patient, and context of the consultationmay influence whether or not a GP identifies psychological distressin a patient; whatever the triggers to detection, it has beenshown that specific training in appropriate skills can alterclinician behaviour and improve detection rate. This study examinedthe GPs' own perceptions of the influences on their performanceas detectors of psychological distress. METHOD: A postal questionnaire yielded nineteen GPs who were personallyinterviewed for the study. RESULTS AND CONCLUSIONS: The study highlights GPs' sense of the difference between possessingthe necessary skills and employing them in daily practice. Thishas implications for training and clinical practice in thisarea. Keywords. Consultation style, general practitioners, literature, patient factors, psychological stress.     

Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

BACKGROUND: Many patients with asthma or chronic obstructive pulmonary diseaseuse their medication inhalers incorrectly. General practitioners,pharmacists and other health care providers do not always havethe opportunity to instruct patients in correct inhaler technique. OBJECTIVE: To find out whether the inhaler technique and respiratory symptomsof patients can be improved after instruction by practice assistants. METHODS: Single blind, randomized intervention study in which 48 patientswho had been using a dry powder inhaler for at least one monthtook part. Their inhaler technique was videotaped on two visitswith a two-week interval between visits. The inhaler techniqueon the videos was subsequently scored by two experts on ninecriteria. At both visits the patients completed a questionnaireabout their respiratory symptoms. After the first video, 25patients were randomly chosen to receive instruction from oneof six practice assistants who had followed a one evening courseabout inhaler instruction, and who had been issued an instruction-set. RESULTS: The patients who received instruction had a significantly greaterreduction in number of mistakes at the second visit than thepatients who did not (P = 0.01). The instructed patients alsoreported less dyspnoea at the second visit (P = 0.03). No effectof instruction was found on wheezing, cough and sputum production. CONCLUSION: The inhaler technique of patients can be improved significantlyby the instruction of patients by trained practice assistants,possibly resulting in less dyspnoea. Keywords. Administration-inhalation, obstructive lung diseases, airways symptoms, patient-education, general practice.     

General Practitioners’ intention to prescribe and prescribing patterns in selected European settings: The OTCSOCIOMED project

The aim of this paper is to explore general practitioners’ (GPs) prescribing intentions and patterns across different European regions using the Theory of Planned Behavior (TPB).A cross-sectional study was undertaken in selected geographically defined Primary Health Care areas in Cyprus, Czech Republic (CZ), France, Greece, Malta, Sweden and Turkey. Face-to-face interviews were conducted using a TPB-based questionnaire. The number of GP participants ranged from 39 to 145 per country. Possible associations between TPB direct measures (attitudes, subjective norms (SN) and perceived behavioral control (PBC)) and intention to prescribe were assessed by country.On average, GPs thought positively of, and claimed to be in control of, prescribing. Correlations between TPB explanatory measures and prescribing intention were weak, with TPB direct measures explaining about 25% of the variance in intention to prescribe in Malta and CZ but only between 3% and 5% in Greece, Sweden and Turkey. SN appeared influential in GPs from Malta; attitude and PBC were statistically significant in GPs from CZ. GPs’ prescribing intentions and patterns differed across participating countries, indicating that country-specific interventions are likely to be appropriate. Irrational prescribing behaviors were more apparent in the countries where an integrated primary care system has still not been fully developed and policies promoting the rational use of medicines are lacking. Demand-side measures aimed at modifying GPs prescribing behavior are deemed necessary.     

Local clinical guidelines: description and evaluation of a participative method for their development and implementation

BACKGROUND: National guidelines are rarely followed by immediate changein clinical behaviour. We present our experience of an activeeducational method for local development and implementationof a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method fordeveloping local clinical guidelines. METHODS: A trial in a district of the effect of guideline developmentincorporating active participation of intended recipients onsubsequent relevant prescribing. It was carried out in WirralFamily Health Services Authority district (the Wirral peninsula)comprising 69 general practices covering a population of 345763. An exemplar guideline on ‘hypertension in the elderly’was developed by the method described. The principal recommendeddrug was bendrofluazide 2.5 mg once daily. The differences inprescribed daily doses (PDD) of bendrofluazide 2.5 mg tabletsper quarter per 1000 prescribing units (age-weighted population)between the intervention district and England as a whole wasmeasured. RESULTS: Comparison of the intervention district with England data demonstratesa median difference of 122.49 PDD before and 206.34 PDD afterguideline production, this change is statistically highly significant(Mann-Whitney two-tailed P < 0.0001; 95% CL = 36.51–104.77).Grouped regression analysis shows no significant difference(0.89) in slope gradients before guideline production (P = 0.35,95% CL = –3.97–5.76), but the difference in slopegradients after (12.95) is statistically highly significant(P < 0.0001; 95% CL = 8.17–17.73). The data suggeststhat the change in clinical behaviour persisted for at leasttwo years. CONCLUSION: Participation of intended recipient general practitioners andlocal specialists in the development of a guideline by an activeeducational method as described was followed by a favourablechange in clinical behaviour which persisted for at least twoyears. Keywords. Clinical guidelines, development, evaluation, implementation, participation.     

Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices

Background: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later. Methods: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals’ nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive. Results: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at ‘high risk’ of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS. Conclusions: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention.     

Cross-sectional survey: Risk-averse French general practitioners are more favorable toward influenza vaccination

ObjectivesWe tested the following hypotheses: (i) risk-averse general practitioners (GPs) are more likely to be vaccinated against influenza; (ii) and risk-averse GPs recommend influenza vaccination more often to their patients. In risk-averse GPs, the perceived benefits of the vaccine and/or the perceived risks of the infectious disease might indeed outweigh the perceived risks of the vaccine.Patients/MethodsIn 2010–2012, we conducted a cross-sectional survey of a nationwide French representative sample of 1136 GPs. Multivariate analyses adjusted for four stratification variables (age, gender, urban/suburban/rural practice location and annual patient consultations) and for GPs’ characteristics (group/solo practice, and occasional practice of alternative medicine, e.g., homeopathy) looked for associations between their risk attitudes and self-reported vaccination behavior. Individual risk attitudes were expressed as a continuous variable, from 0 (risk-tolerant) to 10 (risk-averse).ResultsOverall, 69% of GPs reported that they were very favorable toward vaccination in general. Self-reported vaccination coverage was 78% for 2009/2010 seasonal influenza and 62% for A/H1N1 pandemic influenza. Most GPs (72%) reported recommending the pandemic influenza vaccination to at-risk young adults in 2009, but few than half (42%) to young adults not at risk. In multivariate analyses, risk-averse GPs were more often vaccinated against seasonal (marginal effect = 1.3%, P = 0.02) and pandemic influenza (marginal effect = 1.5%, P = 0.02). Risk-averse GPs recommended the pandemic influenza vaccination more often than their more risk-tolerant colleagues to patients without risk factors (marginal effect = 1.7%, P = 0.01), but not to their at-risk patients and were more favorable toward vaccination in general (marginal effect = 1.5%, P = 0.04).ConclusionIndividual risk attitudes may influence GPs’ practices regarding influenza vaccination, both for themselves and their patients. Our results suggest that risk-averse GPs may perceive the risks of influenza to outweigh the potential risks related to the vaccine.     

Sip feed prescribing in primary care: an audit of current practice in Greater Glasgow Health Board, Glasgow, UK

Background and aims: Prior to September 1995, prescribing of sip feeds had been increasing at a higher rate than any other part of the drugs bill. An increase in requests for information on the use of these products led the Prescribing Advisers Department to seek funding for a 1-year project to document current practice in this area and produce guidelines for GPs, their practice nurses and district nurses. Methods: Questionnaires were completed by GPs (n=52), district nurses (n=94) and dietetic departments (n= 8) concerning current practice. In addition, 90 patients were interviwed and in all but one instance case notes were also consulted. Results: The most significant findings were that Primary Care staff see palliative care as one of the main areas of usage of these products and that 40% of patients were found to have some degree of undernutrition. The majority of patients interviewed were elderly and 10% of patients interviewed were in nursing homes. A significant proportion of patients interviewed had commenced sip feeds whilst in hospital. The majority of patients reported receiving no advice on diet with only one GP making written dietary advice available to patients. Finally, district nurses view company representatives as the most useful source of information on these products. Conclusions: In response to these findings, the project included the development of a standard communication form from secondary to primary care, dietary information resource development, development of guidelines on oral nutrition support in Primary Care and GP and district nurse training