Feasibility and effectiveness of a pulmonary rehabilitation programme in a community hospital setting.

BACKGROUND: Pulmonary rehabilitation programmes run in secondary care have proved to be one of the most effective interventions for patients with chronic obstructive pulmonary disease (COPD). AIM: To assess whether a pulmonary rehabilitation programme, similar to that run in secondary care, could be established in a primary care-run community hospital and whether it could achieve similar benefits in patents with moderately severe COPD. DESIGN OF STUDY: Uncontrolled prospective intervention study SETTING: A primary care-run community hospital. METHOD: Thirty-four patients with COPD aged between 5 and 80 years of age (mean = 70years) with a forced expiratory volume (FEV1) of 30 to 50% (mean = 40%) predicted were enrolled in a programme established in the activities room at Honiton Community Hospital. Patients were assessed at the start, on completion of the programme, and six months after completion, using spirometry, shuttle-walking distance, and short form-36 (SF-36) and chronic respiratory questionnaire (CRQ) scores. RESULTS: All but one patient completed the programme. There were significant improvements in the walking distance (by a mean of 100 m), in the SF-36, and in all domains of the CRQ. There was no significant change in the FEV1 or forced vital capacity. CONCLUSION: Pulmonary rehabilitation programmes can be run in community hospitals. They appear to be as effective as those run in secondary care and patients may find them easier to access.     

Developing a training programme in patient-centred consulting for evaluation in a randomised controlled trial; diabetes care from diagnosis in British primary care

Aim: To develop a feasible/theoretically based training programme in patient-centred consulting, for evaluation in a randomised controlled trial of diabetes care from diagnosis. Methods: The programme was developed with four primary care teams and their patients in an action research framework, with observation of diabetes review consultations before and after training, and evaluated by questionnaire after each training session, among 23 general practitioners and 32 practice nurses from 21 practices in the trial. Results: The observation study identified opportunities and obstacles to introducing a patient-centred approach into daily practice, especially in relation to time management and skill needs. The modified training programme was rated highly by participating general practitioners and nurses. Conclusions: Developing training programmes with the help of participating primary care teams ensures relevance and feasibility. Patient-centred consulting demands a shift from habitual consulting patterns. Practitioners are implementing the approach in practice, and the impact on patients is now under evaluation in the randomised controlled trial.     

Social comparison and anxious mood in pulmonary rehabilitation: the role of cognitive focus

Objectives. Comorbid anxiety is highly prevalent in Chronic Obstructive Pulmonary Disease (COPD), and it is related to increased morbidity and mortality. It has consistently been found that social comparison has substantial impact on mood. However, despite the strong social component of pulmonary rehabilitation, the effect of social comparison processes on anxiety has not been explored in this context. Design. Participants were 43 COPD patients enrolled in a 3‐week pulmonary rehabilitation programme. We tested in a longitudinal design the relationship between social comparison and assimilation and contrast at the beginning of rehabilitation and anxious mood at the end of the programme. Methods. Using moderator analysis, we tested whether perceived similarities and differences to upward and downward social comparison standards influence the relationship between comparison direction at the beginning of the programme and anxious mood at the end of the programme. Results. The relationship between social comparison at the start of rehabilitation and anxious mood at the end of the programme was dependent on assimilation and contrast to upward and downward standards. Downward assimilation and upward contrast were related to a stronger relationship of upward and downward social comparison and anxious mood. Conclusion. This study demonstrates the important role of social comparison focus in moderating beneficial effects of pulmonary rehabilitation. Downward assimilation and upward contrast might be important targets in reducing anxiety in pulmonary rehabilitation.     

Identification of core competencies for primary care of allergy patients using a modified Delphi technique

Background  

The majority of allergy patients who seek medical advice are seen in primary care. In-service training of professionals in general practice is needed in order to increase knowledge among primary care clinicians about allergy. Therefore it is important to establish a consensus about what primary care professionals should be able to do, and what the public can expect. We sought to identify core competencies for good practice amongst primary care providers with respect to diagnosis and therapy of allergic diseases and to outline learning objectives for a postgraduate training programme in this field.     

An outreach programme for patients with an exacerbation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a common clinical condition characterised by airflow obstruction. The clinical course of the disease is characterised by intermittent exacerbations. In Ireland exacerbations of chronic obstructive pulmonary disease are a common cause of admission to acute medical hospitals. The Beaumont Hospital COPD Outreach Programme was designed to provide care at home for patients with an exacerbation of COPD that would otherwise require hospitalisation. Patients recruited to the programme were discharged home within 72 hours of admission and reviewed by the Outreach Team over a two week period. In addition to monitoring clinical progress the Team provided education, smoking cessation and medication advice. Analysis of the outcome of the first 100 patients recruited to the study show that one third of patients admitted to Hospital with an exacerbation of COPD are eligible for this programme and the average length of Hospital stay was 2.6 days. During the fourteen day follow up there was one death (non-respiratory) and six patients were re-admitted to hospital. Forty percent of smokers had abstained from smoking at the end of three months. In summary, the COPD Outreach programme is a safe and effective alternative to acute hospital care for selected patients with exacerbations of COPD.     

Carrier screening for cystic fibrosis in primary care: evaluation of a project in South Wales The South Wales Cystic Fibrosis Carrier Screening Research Team

Population carrier screening for cystic fibrosis (CF) was offered to all patients aged 16–45 in one general practice in South Wales, excluding those in couples with a current pregnancy. Out of 1553 patients in this group, 481 subjects were tested, giving an overall uptake rate of more than 30%. The rate of uptake varied with the mode of invitation. Twenty-six carriers were identified, giving a prevalence of identified carriers of 5.4% (1 in 18.5) for those with no family history of CF. A further 18 carriers were identified by cascade testing of these 26. We describe the practical difficulties encountered in setting up this programme in primary care in South Wales. Questionnaires were administered or distributed to all subjects before and after testing. The response rate for the pre-test questionnaire was 95%, and 40–50% for the post-test questionnaires. These showed that, at 3 months post-test, 1 in 4 screen-negative subjects did not appreciate that they had a residual risk of being a carrier. At the same time, 15% of this group thought that there was a 1 in 4 chance of a child being affected if one parent was screen-positive (carried an identified mutation) and the other was screen-negative, and 40% thought there was no risk. Anxiety in relation to testing did not appear to be a major problem, although individual patterns of response to carrier status varied widely and more sensitive indicators of psychosocial impact of genetic tests are required. A pilot study of couple screening showed that this approach is unlikely to be useful in primary care, although we did not assess couple testing during pregnancy. For any programme of CF carrier screening to be established in primary care, it will be necessary to involve the primary care team from the earliest planning stage, so that the opportunity costs, training needs and other costs of the programme can be fully resourced.     

Implications of process evaluation for clinical effectiveness and clinical practice in a trial on chronic shoulder complaints

OBJECTIVE: The intervention process was evaluated in a randomised clinical trial on the effectiveness of a behavioural Graded Exercise Therapy (GET) programme for patients with chronic shoulder complaints in primary care settings. This process evaluation was done for three reasons: first, to know whether the programme was performed as planned; second, to know whether or not this treatment is feasible in normal practice; third, to identify needs for improvement of the protocol to facilitate implication. METHODS: We evaluated the extent to which the programme is being applied according to protocol, patient adherence to the programme and the suitability of the programme according to patients and physiotherapists. Twenty participating physiotherapists and 87 patients allocated to GET were asked to evaluate the intervention process. Furthermore, a sample of 10 patients, taken from the total number of 87 patients allocated to GET, was invited to take part in a focus group interview at the end of the study. We evaluated the intervention process using a treatment registration form filled in by the physiotherapists during treatment, evaluation forms filled in independently by physiotherapists and patients 26 weeks after the start of the treatment period, and information gathered during the focus group interview at the end of the study. RESULTS: GET was applied according to protocol to an acceptable extent, and participating patients showed satisfactory adherence to the programme. CONCLUSIONS: Clinical effectiveness of GET in this trial is not influenced by flaws in the application of the programme or by lack of patient adherence. PRACTICE IMPLICATIONS: The programme could be improved in terms of the process of goal-setting, and the implementation of GET could be facilitated if the programme is embedded in a multidisciplinary approach in primary care.     

Is the promotion of physical activity in vulnerable older people feasible and effective in general practice?

There is convincing evidence about the benefits of exercise training in community dwelling frailer older people, but little evidence that this intervention can be delivered in general practice. In this prospective cohort study in 14 general practices in north London we assessed the feasibility and effectiveness of a tailored exercise referral programme for frail elderly patients delivered within a variety of inner city primary care settings. One hundred and twenty-six women and 32 men aged 75 years and older, deemed borderline frail by their GPs, took part in a two-phase progressive exercise programme (Stage 1--primary care setting; Stage II--leisure/community centre setting) using the Timed Up And Go (TUG) test as the primary outcome measure. Baseline TUG measures confirmed that the participants were borderline frail and that GP selection was accurate. Of those referred by their GP or practice nurse 89% took up the exercise programme; 73% completed Stage I and 63% made the transition to the community Stage II programme. TUG improved in Stage I with a mean difference of 3.5 seconds (P<0.001). An individually tailored progressive exercise programme following GP referral, delivered in weekly group sessions by specialist exercise instructors within general practices, was effective in achieving participation in exercise sessions and in improving TUG values in a significant number of frailer older citizens.     

Online communication in a rehabilitation setting: Experiences of patients with chronic conditions using a web portal in Denmark

ObjectiveTo gain insight into the experiences of patients with long-term conditions enrolled in an online rehabilitation programme using a web portal.MethodsDanish outpatients were recruited from a rehabilitation department and were granted access to a web portal which included an online rehabilitation programme with key information, clinical advice, and self-management activities. After two weeks, patients were invited to participate in focus groups. A topic guide was used to explore this new online rehabilitation programme in relation to participants’ experiences.ResultsFourteen participants, ranging from 42 to 72 years old, were allocated into three focus groups. Participants mainly reported negative experiences by the following four themes: ‘patients’ experiences’, ‘technical aspects’, ‘areas for improvement’, and ‘digitalization added value’.ConclusionParticipants mainly reported negative experiences and suggested combining both face-to-face consultations with online care by user-friendly web portals. This will ensure a positive contribution from digital communication tools to rehabilitation.Practice implicationsPatients’ experiences should be considered in the design of web portals in rehabilitation which could help healthcare organizations when developing online rehabilitation programmes.     

The control of hypertension, atherosclerotic diseases, and diabetes in a family practice

A community-orientated programme for the control of hypertension, atherosclerotic disease, and diabetes has been developed in a family practice in a neighbourhood of Jerusalem. Intervention is directed mainly towards the control of risk factors associated with these diseases.

The programme has specific objectives for diet, smoking, obesity, blood pressure, serum cholesterol, glucose intolerance, and diabetes mellitus, and the identification and treatment of patients with cardiovascular diseases. The survey seeks to identify the nature and extent of problems, intervention by medicinal and educational means, and continuing surveillance and evaluation.

The programme aims to test and demonstrate the feasibility of carrying out multifactorial community health care within the framework of a family practice, thereby developing a joint practice of primary health care and community medicine.

     

Patient participation during and after a self-management programme in primary healthcare – The experience of patients with chronic obstructive pulmonary disease or chronic heart failure

Objective

Patient participation is facilitated by patients’ ability to take responsibility for and engage in health issues. Yet, there is limited research as to the promotion of these aspects of patient participation in long-term healthcare interactions. This paper describes patient participation as experienced by patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF); the aim was to describe if and how a self-management programme in primary healthcare influenced patient participation.

Efficacy of pulmonary rehabilitation in an Irish population

This study evaluated the results after 8 and 52 weeks of a comprehensive pulmonary rehabilitation programme for patients with chronic obstructive pulmonary disease (COPD) in Ireland. 170 patients with clinical and physiological evidence of COPD (mean FEV1 43.1 +/- 17.0%pred.) were recruited into an 8 week programme. At the time of final evaluation 15 patients had died, 25 patients had not been compliant with required attendances and 1 patient had transferred to another programme. To date assessments of 106 of the remaining 129 patients were made after eight weeks and of 78 patients after 1 year. Assessment consisted of pulmonary function testing; exercise tolerance as measured by a progressive maximal walking test (shuttle walk test) and an endurance test (treadmill test); quality of life (QoL) as measured by the Chronic Respiratory Disease Questionnaire (CRDQ), the St. George's Hospital Questionnaire (SGHQ) and the Breathing Problems Questionnaire (BPQ); and perceived dyspnoea on the Borg scale. Significant improvements in exercise tolerance, (shuttle p<.001, treadmill p<.001), QoL, (BPQ p<.001, CRDQ p<.001, SGHQ p<.001) and dyspnoea (p<.001) were demonstrated after 8 weeks. These improvements were maintained at 1 year. These results suggest that pulmonary rehabilitation can increase exercise tolerance and improve QoL in patients with COPD.     

Regular planned respite admissions to a geriatric unit

A programme of regular planned respite admissions to the geriatric unit in Cork was established in 1984, for dependent elderly being cared for at home. Retrospective analysis of the respite programme sought to establish its bed utilisation, type of patients admitted, factors in their selection process, their outcome and any associated hospital morbidity. Twenty-four patients have used the scheme during the four years since its commencement, with an efficiency of bed utilisation in 1987 of 14 patients occupying a mean of 4.33 beds per month. The median number of medical problems per patients was five; their median age 77 years and the percentage over 80 years was 46%. Twenty-two patients were already receiving intensive rehabilitation before being placed on the programme, mobility problems dominated. Nine patients continue on the programme with a mean of 23.9 months of respites to date, eight were discharged and seven died. There was no significant difference between the number of respite stays in hospital and "at home" stays complicated by morbidity. The results suggest that even for a highly selected group of dependent elderly, a planned programme of respite admissions is an effective form of care, uses hospital beds efficiently without associated morbidity and may provide an alternative to long stay institutional care.     

An evidence-based programme for smoking cessation: effectiveness in routine general practice.

BACKGROUND: Smoking cessation clinical practice guidelines are based on randomised clinical trials reporting outcomes in persons who participate in these studies. However, many practitioners are sceptical about the effectiveness of these recommendations when applied to the general population in everyday routine consultation. AIM: To evaluate the results of a comprehensive smoking cessation programme in routine primary care practice. METHOD: All smokers consulting in 10 general practices during one year participated in a non-randomised controlled trial. The percentages of subjects in the intervention (n = 1203, seven practices) and control (n = 565, three practices) groups who reported sustained abstinence between six and 12 months follow-up and were validated biochemically were compared. The effect of the programme was adjusted to baseline differences in both groups by multiple logistic regression analyses. RESULTS: The programme resulted in an increase of five percentage points (95% CI = 3.1%-6.8%) in the validated and sustained one-year abstinence probability, with 7.1% for all of the intervention practices (adjusted OR = 3.7, 95% CI = 2.4-5.7). CONCLUSION: Programmes that combine advice to stop smoking to all smokers attending general practices with the offering of support, follow-up, and nicotine patches to those willing to stop are feasible and effective in routine practice, as primary care clinicians need only identify 20 smokers to get one additional success attributable to the programme.     

A cluster randomised trial to evaluate a nutrition training programme.

BACKGROUND: The need for training to equip primary care staff with the knowledge and skills to provide dietary advice to the public has been acknowledged. Little is known about the effectiveness of such training at improving the dietary counselling skills of multidisciplinary practice teams. AIM: To evaluate the effectiveness of a nutrition training programme, delivered to primary care teams by a dietitian. DESIGN OF STUDY: A paired-cluster randomised trial. SETTING: Twelve general practices in Sunderland, in the United Kingdom. METHOD: A nutrition training programme, aimed at improving the quality of dietary consultations, was developed and delivered to six primary care teams by a dietitian. Main outcome measures were patients' recall of seven key consulting behaviours. Data were collected from patients in intervention and control practices, pre- and post-intervention. Change in knowledge and attitude of practitioners was also measured. RESULTS: All 12 practices completed the trial. Data were collected from 251 patients pre-intervention and 228 patients post-intervention. Of the seven consulting behaviours targeted in the training, only the proportion of consultations where written information (diet sheets) was provided to patients was significantly higher (13% higher, 95% confidence interval [CI = 4 to 21, P = 0.004) in the intervention practices post-training. Some evidence of improved practitioner knowledge and attitude was detected. CONCLUSION: This evaluation of a nutrition training intervention detected only a limited impact on the behaviour, knowledge, and attitudes of primary care practitioners in dietary consultations.     

The dynamics of illness perceptions: Testing assumptions of Leventhal's common‐sense model in a pulmonary rehabilitation setting

Objectives . Although Leventhal's common‐sense model (CSM) is proposed to represent a dynamic system, limited research has been conducted to investigate whether and how illness perceptions change. This study tested two hypotheses from the CSM about the dynamics of illness perceptions of patients with chronic obstructive pulmonary disease (COPD) in a pulmonary rehabilitation setting. Design and methods . The study employed a longitudinal design. Patients with COPD (N=87) who took part in a pulmonary rehabilitation programme filled out the Illness Perception Questionnaire – Revised (IPQ‐R) before and after treatment and rated the degree to which the rehabilitation had led to the achievement of desired outcomes. Clinical variables and quality of life (Chronic Respiratory Disease Questionnaire) data were obtained from medical records. Results . In line with expectations, results showed that, at baseline, longer time since diagnosis was associated to perceptions corresponding with a chronic illness model (longer illness duration, more experienced consequences, less perceived personal controllability), after correction for clinical variables. After completion of the rehabilitation programme, patients who were more convinced that their participation had led to the achievement of desired outcomes were less concerned about the negative consequences of COPD, had stronger perceptions about the variability in symptoms (cyclical timeline) and had stronger perceptions of personal controllability Conclusions . We conclude that, in accordance with Leventhal et al.'s CSM, coping with an illness is a continuous process and the achievement of desired outcomes during treatment is likely to enable patients to adopt a more positive representation of their illness.     

Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns.

PURPOSE: To assess obstetrician-gynecologists' perceptions of their residency training in primary care, document health issues assessed at annual visits, and identify practice patterns of both generalist and specialist obstetrician-gynecologists. METHOD: Questionnaires were mailed to a random sample of 1,711 American College of Obstetricians and Gynecologists Young Fellows in September 2005. Information was gathered on perceptions about adequacy of residency training, how well training prepared obstetrician-gynecologists for current practice, and typical practice patterns for various medical diagnoses. Data were analyzed using univariate analysis of variance, t tests, and chi-square tests. RESULTS: Of 935 respondents (55% response rate), physicians estimated that 37% of private, nonpregnant patients rely on them for routine primary care. Approximately 22% report that they needed additional primary care training, specifically for metabolism/nutrition and dermatologic, cardiovascular, and psychosexual disorders. A wide range of topics, except for immunizations, were typically discussed at annual visits. Patients with pulmonary diseases, vascular diseases, and nongenital cancers were most often referred to specialists, whereas patients with urinary tract infections, sexually transmitted infections, or who are menopausal are most often managed totally. Self-identification as a generalist or specialist was associated with some practice patterns. Respondents were neutral about the role of primary care in obstetrics-gynecology residency training. CONCLUSIONS: For several primary care issues, obstetrician-gynecologists assumed sole management for obstetric patients but deferred to a primary care physician for gynecological patients. There is a continuing need for primary care training in obstetrics-gynecology residency, although it is unclear whether current training is adequate to meet their needs.     

Ankle brachial index measurement in primary care: are we doing it right?

Background

The reference standard for diagnosing peripheral arterial disease in primary care is the ankle brachial index (ABI). Various methods to measure ankle and brachial blood pressures and to calculate the index are described.

Aim

To compare the ABI measurements performed in primary care with those performed in the vascular laboratory. Furthermore, an inventory was made of methods used to determine the ABI in primary care.

Design of study

Cross-sectional study.

Setting

Primary care practice and outpatient clinic.

Method

Consecutive patients suspected of peripheral arterial disease based on ABI assessment in primary care practices were included. The ABI measurements were repeated in the vascular laboratory. Referring GPs were interviewed about method of measurement and calculation of the index. From each patient the leg with the lower ABI was used for analysis.

Results

Ninety-nine patients of 45 primary care practices with a mean ABI of 0.80 (standard deviation [SD] = 0.27) were included. The mean ABI as measured in the vascular laboratory was 0.82 (SD = 0.26). A Bland–Altman plot demonstrated great variability between ABI measurements in primary care practice and the vascular laboratory. Both method of blood pressure measurements and method of calculating the ABI differed greatly between primary care practices.

Conclusion

This study demonstrates that the ABI is often not correctly determined in primary care practice. This phenomenon seems to be due to inaccurate methods for both blood pressure measurements and calculation of the index. A guideline for determining the ABI with a hand-held Doppler, and a training programme seem necessary.     

A decade of caring for drug users entirely within general practice.

BACKGROUND: The government encourages general practitioners (GPs) to become involved in caring for drug users. However, in some areas of the country, including Bedford, secondary care support is inadequate. GPs in these areas have to decide how to cope with such patients entirely within general practice. AIM: To assess the characteristics and quality of care given without secondary care support to drug users by one practice in Bedford over a decade. METHOD: A search was made of the practice computer for all patients with a problem title of 'addiction drug' between 1986 and 1995. The age, sex, social characteristics, and drug history were recorded. RESULTS: One hundred and ninety-two patients were found, of which 155 took part in the practice programme; i.e. they consulted more than three times. Forty-three patients (37%) who took part and were prescribed Methadone were prescribed this drug as ampoules. Sixty-three patients (40.6%) who took part in the programme stopped using drugs. Thirty-two (33.6%) of the Methadone users became abstinent. A higher proportion of women (13-48%) than men (19-27.7%) stopped using Methadone (P = 0.019). Among patients who had a stable lifestyle, a higher proportion had been prescribed ampoules than mixture (22 out of 28: 78.6%; P = 0.001). Similarly, of those who had a job, eight out of 11 (72%; P = 0.037) had been prescribed methadone ampoules. Two-thirds of all patients prescribed amphetamines stopped using drugs. CONCLUSION: Long-term care of drug users entirely within general practice is feasible. Among those prescribed methadone ampoules, a higher than average proportion had stable lifestyles and had a stable job.     

Impact of UK Colorectal Cancer Screening Pilot on primary care

BACKGROUND: The UK Colorectal Cancer Screening Pilot has recently been completed to evaluate the feasibility of screening using the faecal occult blood test. Screening will be phased in over the next several years, and it is important to consider the impact on the NHS workforce. AIM: To determine the impact of the UK Colorectal Cancer Screening Pilot on primary care workload. DESIGN OF STUDY: A retrospective survey and prospective audit of general practice staff. SETTING: General practice. METHOD: Workload impact was assessed using a postal questionnaire and a prospective audit of activity in participating practices. Questionnaires were sent to practices that had been involved in the Pilot between 6 weeks and 1 year previously. They were sent to a random sample of 59 practices in Scotland and 60 practices in England between February 2001 and March 2002. Audit forms were sent prospectively to 60 practices involved in the Pilot between May 2001 and September 2002. RESULTS: Sixty-seven per cent of GPs, 82% of practice managers, 69% of practice nurses, and 70% of receptionists responded to the questionnaire. Of 60 practices contacted to take part in the workload audit, 38 returned completed 'workload impact audit' forms. Most practice staff indicated they spent 2% or less of their time during the screening period on Pilot-related activities. Forty per cent of GPs thought that a national colorectal cancer screening programme would substantially impact on the workload in primary care. However, there were variations by country: practice staff in Scotland were more likely to think that it would substantially impact on workload than practice staff in England (44.7% versus 26.6%). CONCLUSIONS: The surveys and audit demonstrate that the Pilot has had a discernible, albeit modest, impact on workload in primary care. Workload of particular significance to primary care personnel includes increases in paperwork, administration, and information provision to patients. The majority of primary care staff support the introduction of a colorectal cancer screening programme. However, there is a strong perception, particularly among GPs, that a national programme of faecal occult blood test screening will impact significantly on workload in primary care, and that primary care-based activities generated through screening should be adequately resourced and remunerated.