Systematic review: prognosis of angina in primary care

BACKGROUND: Angina is a common chronic condition, largely managed in primary care in the UK. Mortality data are predominately from population or hospital studies with little known about the prognosis of angina in general practice settings. OBJECTIVE: To describe the prognosis of angina in patients identified in primary care. METHODS DESIGN: Systematic review of cohort studies of angina in primary care. Data sources. Medline, PsycINFO, EMBASE, CINAHL, HMIC, WOS, IBSS, UK National Research Register, notification via JISC, CHAIN. REVIEW METHODS SELECTION CRITERIA: Cohort studies of patients with angina, with >12 months of follow-up, recruited within primary care. VALIDITY ASSESSMENT: Database searches and abstracts were reviewed independently by two authors. Papers were assessed according to criteria derived from the cohort methodological literature. DATA ABSTRACTION: Data were abstracted by two reviewers. DATA SYNTHESIS: Narrative summary. A quantitative synthesis was planned. MAIN OUTCOME MEASURES: Total and cardiovascular death; non-fatal myocardial infarction (MI). RESULTS: Six studies fulfilled our selection criteria. The annual total mortality rate is 2.8-6.6%, an annual cardiovascular death rate of 1.4-6.5% and an annual non-fatal MI rate of 0.3-5.5%. A quantitative synthesis was not possible, because the studies were clinically heterogeneous. CONCLUSIONS: The primary studies have value in determining the prognosis of patients with angina recruited in general practice; however, the studies are old, have small numbers of events and are clinically heterogeneous. The contemporary prognosis of angina in primary care remains a key question, and further research is, therefore, required to estimate the prognosis of angina in this setting and its determinants.     

Physical health care of patients with schizophrenia in primary care: a comparative study

BACKGROUND: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care. OBJECTIVE: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia. METHODS: Design: Case-matched retrospective case note review. Setting: Twenty-two general practices in the Birmingham area (UK). Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients. Main outcome measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups. RESULTS: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 1.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05). CONCLUSIONS: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.     

Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey

A prior national survey of one in eight randomly selected general practices in England estimated that 39% of general practices [95% confidence interval (CI) 35-43%] provided some access to complementary or alternative medicine (CAM) therapies in 1995. A repeat survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs (95% CI 46-52%). The change was due to increased provision in-house; the proportion of practices making NHS referrals remained unchanged. The proportion of services supported by patient payments rose from 26 to 42%.     

Health-related quality of life in carers of patients with dementia

BACKGROUND: Carers of patients with dementia experience high levels of stress that can adversely affect their health and well-being. OBJECTIVE: Our aim was to assess the health-related quality of life of carers of patients with dementia compared with an age- and gender-matched sample from the general population. METHODS: A cross-sectional study was conducted in 37 primary health care centres in Catalonia, Spain. Carers (n = 181; 78% females, mean age 63 years) of patients with dementia together with a random sample of 543 individuals from the general population, matched for age and gender, were assessed with the SF-36 questionnaire, which is a generic measure of health status. RESULTS: With the exception of physical function category, seven of the scales showed lower scores for females in the carer group. The most important differences were observed in the emotional role [95% confidence interval (CI) -37.7 to -3.6], mental health (95% CI -21.0 to -1.6) and bodily pain (95% CI -37.7 to -8.6) categories. In contrast, male carers had higher scores in the physical function category (95% CI 2.2-19.4), and no differences were observed on the other scales. CONCLUSION: Female carers of patients with dementia experienced a seriously decreased quality of life level compared with their contemporaries in the general population.     

Depression in terminal illness: the need for primary care-specific research

BACKGROUND: Palliative care research highlights depression as a common, treatable condition in patients with terminal cancer. Guidance from the European Association for Palliative Care calls for proactive screening and treatment of the disease. However, prevalence of depression among primary care patients with advanced cancer is unknown and it remains uncertain whether existing guidance is appropriate for use by GPs. OBJECTIVE: To estimate the prevalence of depression in a primary care population with terminal cancer. METHODS: A two-stage community prevalence survey conducted in primary care practices in Merseyside, UK. Adult patients with advanced metastatic cancer were invited to join the study. In phase 1, a depression screening tool (the Edinburgh Depression Scale [EDS]) was used to categorize patients as being high or low risk of depression. In phase 2, samples from each group underwent a diagnostic assessment using the revised Clinical Interview Schedule. Weighted prevalence estimates were calculated. RESULTS: In a final sample of 70 (response rate 47.9%), the prevalence of depression was 4.1% (95% confidence interval 0-8.8%). The sensitivity and specificity of the EDS were poorer than predicted. CONCLUSION: The prevalence of depression in our sample was lower than expected given findings from previous studies. Screening tools also performed differently in this population. The limitations in our study are discussed; however, our findings raise questions about whether depression guidance from palliative care studies can be directly applied to a primary care setting. We propose the need for development of a primary palliative care evidence base to underpin appropriate clinical care.     

Six month outcomes after emergency admission of elderly patients to a community or a district general hospital

BACKGROUND: Emergency admissions account for 40% of National Health Service bed usage. Recent policy is to increase the role of intermediate care, which includes the use of community hospitals (CHs). However, the proposed expansion presumes that CH care is as effective as acute hospital care. No direct comparison of outcomes between CHs and district general hospitals (DGHs) has been undertaken. OBJECTIVES: The aim of this study was to compare patient-based outcomes at 6 months following emergency admission to a DGH or CH. METHODS: We designed a prospective cohort study, with strict eligibility criteria. The study was set in one DGH and five CHs in Devon, UK. Study participants were people aged >70 years with an acute illness requiring hospital admission, but whose condition could have been treated in either hospital setting. A cohort of people admitted to each setting was identified and followed-up for 6 months. The primary outcome measure was change in quality of life 6 months after admission, as measured by SF-36 and EuroQol. Secondary outcome measures were death, readmission and place of residence at 6 months. The use of drugs and investigations during the hospital stay were also measured. RESULTS: A total of 376 patients were recruited and completed baseline measures, 254 of whom were followed-up at the 6-month stage (136 CH, 118 DGH). There were no differences in outcome between settings, with a small increase in quality of life scores at 6 months in both cohorts: the mean change in EuroQol 5D in CH was 6.6 points (95% confidence interval, 2.8-10.4) and in DGH was 6.5 (2.4-10.7); P = 0.97. Mortality and place of residence at 6 months were similar in the two groups. The numbers of investigations (median CH four investigations, DGH 22; P < 0.001) and of prescribed medications during the hospital stay (median CH eight drugs, DGH 11; P < 0.001) were significantly higher in the DGH. CONCLUSIONS: The quality of life and mortality in the CH cohort was similar to those in the DGH cohort. CH care can be used as an alternative to DGH care for a wide range of conditions requiring emergency admission.     

Which GP deals better with depressed patients in primary care in Kastamonu, Turkey: the impacts of 'interest in psychiatry' and 'continuous medical education'

BACKGROUND: Little is known about the reasons behind Turkish GPs' limited ability to diagnose and treat major depression. OBJECTIVE: The aim of this preliminary study is to evaluate the impact of a GP's level of interest in psychiatry and participation in previous continuous medical education (CME) on their ability to recognize and treat major depression. METHODS: Thirty-eight GPs from an underdeveloped city in Turkey participated in the study. A survey consisting of questions about their demographic characteristics, self-reported capacity for recognition and antidepressant management of depression, presence of previous CMEs and self-ratings of their interest in psychiatry was given to all GPs. Comparisons were made using hierarchical multiple regression analyses and SPSS software. RESULTS: Almost half of the GPs had participated previously in at least one CME course on depression, and these were significantly more involved with the treatment of depressed patients (P = 0.02). Hierarchical multiple regression analysis indicated that 'interest in psychiatry' was an important factor in predicting the GPs' confidence in recognizing and treating depression even after controlling for other variables such as age, gender (P = 0.01) and participation in previous CME (P = 0.05). CONCLUSION: Our findings suggest that personal characteristics, including a GP's interest in psychiatry, should be considered when planning education and other interventions to improve the detection and treatment of depression in primary care.     

Developing a standard short questionnaire for the assessment of patient satisfaction with out-of-hours primary care

BACKGROUND: Governmental reviews of out-of-hours services in England and Scotland have recommended that a standard questionnaire should be used to assess patient satisfaction. This is important because of the rapid introduction of new forms of care. OBJECTIVE: To produce a brief, reliable and valid measure of patient satisfaction for use by a wide variety of providers of out-of-hours primary care. METHODS: The Short Questionnaire for Out-of-Hours care was designed and compared with a longer questionnaire which had been validated and used in earlier research. Questionnaires were sent to 1906 people contacting an out-of-hours GP co-operative. Three versions of the short questionnaire were used with different formats. Analysis compared the response rates, measurement properties, concurrent and construct validity of the short and long questionnaires, and of different versions of the short questionnaire. RESULTS AND CONCLUSIONS: There was no significant difference in the overall response rates obtained from the short or long questionnaires (45.7% versus 41.9%; P = 0.17). The effective response rate of questionnaires from which all satisfaction scales could be calculated was higher for the short questionnaire (43.0% versus 36.4%; P = 0.01). There were no significant differences in response rates or distribution of responses between different versions of the short questionnaire. There was moderate agreement between items on the short questionnaire and corresponding scales on the long questionnaire. Scores using the short questionnaire showed anticipated relationships with the age and sex of patients and with characteristics of how the service was delivered. The SQOC is valid and reliable for routine service use.     

The relationship between primary care physicians' adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study

BACKGROUND: Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician's interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care. OBJECTIVE: The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics. METHODS: The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. RESULTS: Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient's ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation. CONCLUSION: Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.     

Diagnosis of colorectal cancer in primary care: the evidence base for guidelines

BACKGROUND: Colorectal cancer is common, causing approximately 11% of cancer deaths in the UK. However, a GP would only expect to see one new presentation each year. Referral guidelines outlining clinical scenarios of high risk have been published. These aim to help GPs select patients for rapid investigation. OBJECTIVES: The purpose of this study was to review the presenting features of colorectal cancer in primary care, using the basic structure of the UK Referral Guidelines for Suspected Cancer. METHODS: A structured literature review was carried out. RESULTS: Two symptoms have a high predictive value for cancer: rectal bleeding and change in bowel habit towards increased looseness or increased stool frequency. Other symptoms, such as abdominal pain, are so prevalent in the community that they have little predictive value. There is little published evidence on abdominal or rectal masses and iron deficiency anaemia as presenting features for colorectal cancer. However, these are so likely to have an important cause, investigation is mandated. Two areas in the Referral Guidelines are questioned: the need to defer investigation of change in bowel habit towards increased looseness or increased stool frequency for 6 weeks, and the low risk nature of constipation. CONCLUSION: The Referral Guidelines have a reasonable evidence base.     

Dyspnea in elderly family practice patients. Occurrence, severity, quality of life and mortality over an 8-year period

BACKGROUND AND OBJECTIVES: This study examined the prevalence and severity of dyspnea in patients >/=70 years of age and its impact on the quality of life. We also examined the prognostic significance of dyspnea for mortality. METHODS: The cohort study started with a mailed questionnaire, supplemented with an interview. From the population of elderly patients in a family practice health center, a one in five sample (n = 124) was randomly selected, similar in age and sex distribution to those not in the sample. Demographic and other relevant variables were examined for their association with dyspnea. Cox proportional hazards ratio analysis was done with dyspnea (MRC, BDI scores) as independent and mortality as dependent variable. RESULTS: Baseline data indicated that 23% (MRC) to 37% (BDI) of the patients had moderate to severe dyspnea. Shortness of breath was associated with older age, poor perceived health, more anxiety and depressive symptoms, impaired daily functioning, and lower happiness. Moderate and severe dyspnea measured with BDI and MRC was a significant predictor of death within eight years due to cardiovascular or lung disease. Selective participation did not appear to have biased this outcome. CONCLUSIONS: Dyspnea occurs frequently in the elderly, is associated with poor health, and interferes with daily functioning. Results suggest that dyspnea contributes to mortality. Development and implementation of guidelines would be highly desirable. Early diagnosis is valuable because this provides opportunities to positively influence the patient's functional condition.     

Quality of life and objective disease criteria in patients with intermittent claudication in general practice

BACKGROUND: The quality of life (QoL) of patients with chronic diseases is an important decision criterion for medical treatment, especially in primary care settings. It is known that subjective sickness feelings often cannot be correlated with objective disease criteria. OBJECTIVE: The aim of the study was to determine the QoL of patients with intermittent claudication with the arterial morphology, haemodynamic parameters and functional disability of peripheral arterial occlusive disease (PAOD). METHODS: In 150 patients with stable intermittent claudication, the health-related QoL was compared with the angiogram score, the resting Doppler pressure values, and the initial claudication distance (ICD) and absolute claudication distance (ACD) with treadmill exercise. RESULTS: The QoL did not correlate significantly with either the angiogram score or the ankle systolic blood pressure and ankle brachial index. ICD and ACD correlated significantly with the QoL activity subscales of pain, complaints and functional status (P < 0.001). In a multiple regression analysis, ACD and body mass index were the most predictive variables for the QoL. CONCLUSION: The QoL of PAOD patients is independent of the peripheral Doppler pressure and the angiographic severity of the disease. The most important criterion for the QoL is the patient's functional disability.     

Engaging the reluctant GP in care of the opiate misuser: Pilot study of change-orientated reflective listening (CORL)

BACKGROUND: The GP is central to plans for improved general health care and increased availability and delivery of addiction treatment to drug misusers in the UK. Attention to the actual quality of overall primary care, rather than just the treatment of dependence, has, however, been limited. OBJECTIVES: The purpose of this study was to test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting the quality of primary care given to opiate misusers by GPs. METHOD: This study had an observational 'before and after' design with follow-up assessment after 2-3 months. The target population was all GPs in two Primary Care Groups who had neither attended training events nor were involved in the treatment of drug dependence (n = 66), who were then approached via a telephone-administered change-orientated reflective listening intervention, based on principles of motivational interviewing, with informational adjunct. Outcome measures for the study sample (n = 29) were overall therapeutic commitment and motivation to follow up and actual clinical activity and willingness to deliver specified general health care interventions for drug misusers. RESULTS: Across the study sample, therapeutic commitment improved over time, whilst motivation did not. Change among individual practitioners in receipt of the intervention was observed in both positive and negative directions, and in four of the positive changers, this was judged attributable to the intervention. Positive changes were more than twice as frequent as negative changes. CONCLUSIONS: The direction and extent of change detected were encouraging. Further initiatives are needed to influence practitioner motivation, based on improved understanding of GPs' views on the delivery of primary care for drug misusers.     

The association between culture, climate and quality of care in primary health care teams

BACKGROUND: Culture and climate represent shared beliefs and values that may influence quality of care in health care teams, and which could be manipulated for quality improvement. However, there is a lack of agreement on the theoretical and empirical relationships between climate and culture, and their relative power as predictors of quality of care. This study sought to examine the association between self-report measures of climate and culture in primary care teams and comprehensive measures of quality of care. METHODS: The data were derived from a cross-sectional survey of 492 professionals in 42 general practices in England. Self-report measures of culture (the Competing Values Framework) and climate (the Team Climate Inventory) were used, together with validated measures of quality of care from medical records and self-report. RESULTS: The majority of practices could be characterized as 'clan' culture type. Practices with a dominant clan culture scored higher on climate for participation and teamwork. There were no associations between culture and quality of care, and only limited evidence of associations between climate and quality. CONCLUSIONS: The current analysis would not support the hypothesis that culture and climate are important predictors of quality of care in primary care. Although larger studies are required to provide a definitive test, the results may suggest the need for a more complex model of the associations between culture, climate and outcomes, and further research may be required into the interaction between culture and climate with other determinants of behaviour such as internal and external incentives.     

Practice and patient characteristics related to blood pressure in patients with type 2 diabetes in primary care: a cross-sectional study

BACKGROUND: Good blood pressure control reduces the risk of long-term complications of diabetes; however, most people with diabetes do not achieve recommended blood pressure targets. OBJECTIVE: To quantify the relationships between patient and practice factors and blood pressure in patients with type 2 diabetes. METHODS: A cross-sectional study was carried out in 42 general practices in Nottingham. Participants were 1534 people with type 2 diabetes. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by questionnaire. The outcome measures were systolic and diastolic blood pressure. RESULTS: In all, 46% of participants had well-controlled blood pressure (or= 25 kg/m(2), and increased with alcohol consumption. Systolic blood pressure increased whereas diastolic blood pressure decreased with increasing age and duration of diabetes. Current smokers and ex-smokers had a significantly lower diastolic blood pressure than those who had never smoked. Patients from practices where blood pressure targets were negotiated with most patients had significantly lower mean systolic and diastolic blood pressure than those where targets were negotiated with few patients. CONCLUSIONS: A number of patient characteristics are associated with blood pressure. Negotiating individual goals for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore the process of negotiating targets.     

Understanding variation in quality improvement: the treatment of sore throats in primary care

BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.     

The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland

OBJECTIVE: To assess the prevalence of ear, nose and throat (ENT) symptoms experienced by individuals living in Scotland, and their use of GP or hospital services for these problems. METHODS: A cross-sectional postal self-completed questionnaire was sent to a random sample of 12,100 households throughout Scotland. 15,788 individuals aged 14+ years living in the 7244 households who returned the questionnaire (adjusted response rate 64.2%) participated in the study. RESULTS: Roughly a fifth of respondents reported currently having hearing difficulties, including difficulty following conversations when there is background noise and hearing problems causing worry or upset; few wore a hearing aid regularly. A fifth reported noises in head or ears (tinnitus) lasting more than five minutes. In the previous year, between 13 and 18% of respondents reported persistent nasal symptoms or hayfever, 7% sneezing or voice problems and 31% had at least one episode of severe sore throat or tonsillitis. Nearly 21% of all respondents reported ever having had dizziness in which things seemed to spin around the individual; 29% unsteadiness, light-headedness or feeling faint; 13% dizziness in which the respondent seemed to move. Important gender, age, occupation and deprivation differences existed in the occurrence of these ENT symptoms. There was considerable variation in the proportion of individuals consulting their GP or being referred to hospital for different problems. CONCLUSIONS: ENT problems occur frequently in the community, and most are managed without consulting medical services. Whilst reasonable for many problems, there are likely to be important groups in the community with ENT problems that might benefit from modern interventions.     

The GPs' Experiences Questionnaire (GPEQ): reliability and validity following a national survey to assess GPs' views of district psychiatric services

BACKGROUND: The measurement of patient and professional views of quality are important components in the evaluation of health care delivery. OBJECTIVE: To describe the development and evaluation of the GPs' Experiences Questionnaire (GPEQ) for assessing the quality of community mental health clinics in Norway. METHODS: Design: Literature review, GP interviews, pre-testing of questionnaire items and a cross-sectional national survey. Setting: Postal survey of GPs in Norway evaluating 73 community mental health clinics in the five health regions in Norway during spring of 2006. Subjects: Three thousand four hundred and sixty-three GPs were sent a postal questionnaire with the GPEQ and were asked to assess their community mental health clinic responsible for general adult psychiatric services. RESULTS: Two thousand one hundred and thirty (61.5%) GPs returned a completed questionnaire. Low levels of missing data suggest that the questionnaire is acceptable. Factor analysis identified five scales: workforce situation (four items), discharge letter (three items), competence (four items), guidance (three items) and emergency situations (two items). All scales met the criterion of 0.7 for Cronbach's alpha and test-retest correlations were 0.72-0.87. The results of validity testing were as hypothesized with scale scores significantly related to knowledge of the community mental health clinic, overall satisfaction, negative experiences with the clinic, waiting time and acceptance of referrals. CONCLUSIONS: The GPEQ is a self-administered questionnaire that includes the most important aspects of the GPs' experience of quality at community mental health clinics. All scales have good evidence for internal consistency, test-retest reliability and validity.