National screening policies in general practice: a case study of routine screening for partner abuse

Internationally-recognised criteria for screening for a particular disorder require the following: availability of a clear diagnosis; a suitable validated screening test; acceptability of routine screening by patients and health providers; benefits of earlier detection and application of appropriate interventions to prevent the progression of a disorder, and hence reduction in incidence of morbidity and mortality; identification of possible harm from screening (false positives, false negatives, adverse effects of labelling, early diagnosis or unnecessary treatment of persons with true-positive test results with inconsequential disease) and weighing this against potential benefits; identification of possible sub-populations with the possibility of targeted screening of high-risk populations; good quality evidence of interventions effective in preventing or managing the disorder; and a cost-effectiveness assay. The New Zealand Ministry of Health have launched a best-practice guideline recommending all female general practice patients sixteen years and over be routinely screened for physical and sexual abuse by their partners. Inter-partner violence, especially against women by male partners and expartners, is a serious public health problem. However, review of existing research indicates that this guideline meets none of the criteria listed above. Considerable funding is invested in training health providers to implement this screening protocol, but, in the absence of effectiveness studies, cost-effectiveness cannot be assessed. Under current conditions, routine screening of adult women for partner abuse cannot be justified. However, GPs should be encouraged to learn about partner abuse and consider this possibility in patients presenting with physical injuries, psychological disturbance or social dysfunction, especially in high-risk patients. Research should be supported for the development and validation of effective, acceptable screening tools and randomised controlled trials of appropriate interventions. The desire to intervene for the public good should not dictate the implementation of a screening programme that disregards accepted screening criteria.     

Variations in the diagnosis of psychosocial disorders: a general practice observation study

The factors that influence the interpretation and treatment of psychosocial complaints by general practitioners are discussed. The assessment of complaints differs considerably from one GP to another, in the sense that one will attach significance to psychological and sociological factors in many more cases than another. We investigate the effect of physician characteristics and their styles of communication on their bias over psychosocial assessments and treatment, and the way these effects are interrelated. The interpretation and eventually the treatment of complaints by 30 GPs (complaints presented at approx. 50 consultations per GP) were studied. Data of treatment and communication were collected from observation of the videotaped consultations, data of interpretation were collected on questionnaires for each consultation; doctor characteristics were inventarized by questionnaire. The following results can be reported. When a doctor communicates with a patient in an open manner, more complaints are interpreted as 'non-somatic' and treated as such. The same is the case among doctor's with a 'general medical' approach, rather than a 'clinical' one, when we look at interpretation. The effect on treatment is less marked. Practice characteristics and a GP's subjective feeling of competence have greater consequences for treatment than for judgement. There is not much interaction between the discerned effects.     

Cervical screening in general practice

Abstract: This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.     

Group screening for cognition disorders in elderly persons

Prevalence rates of cognitive impairment in persons aged 75 to 85 years are in the range of 10 to 19 percent, and 20 to 47 percent after the age of 85 years. Screening for dementia in persons aged 75 years and older would therefore identify a significant number of impaired persons. When screening for dementia, group testing would be more cost-effective than individual testing. We modified the Folstein Mini-Mental State examination (MMSE) for screening in a group setting. Community volunteers were tested at a geriatric health fair and at a special exercise class for the elderly. Subjects were subsequently tested individually using the standard Folstein MMSE. Analysis using Pearson correlation and a paired t-test indicates a high degree of concurrent validity between the two methods of administering the MMSE. This pilot study suggests that when screening elderly persons for dementia, a group-administered instrument can be a useful method to obtain a preliminary sample of cognitively impaired individuals.     

Independent learning among general practice trainees: an initial survey

Self-directed learning is a natural way for adults to learn. Vocational training for general practice is a preparation for unsupervised clinical work that will be supported, in the main, by continuing medical education. This study uses the Self-Directed Learning Readiness Scale to investigate factors influencing readiness for such learning among a sample of general practice trainees. Three principal factors emerged from analysis: enjoyment and enthusiasm for learning; a positive self-concept as a learner and a factor suggesting the possibility of a 'reproducing' orientation to learning. These factors may reflect approaches to learning in general rather than these adopted for professional learning, but offer helpful pointers for the development of both vocational training and of continuing medical education.     

Cervical cancer screening for hospital inpatients: report of an intervention study

A pilot study of a cervical cancer screening service was carried out at a major teaching hospital in Perth. The service, for women inpatients aged 20 to 69 years, was staffed by a women's health nurse. The effect of providing the service (service) was compared with giving a leaflet on Pap smears to eligible women (education) and with no intervention (control). Of 517 women in the service group, 184 (36 per cent) needed a Pap smear and were well enough to be offered screening; only 29 of 184 (16 per cent) refused and 132 of 184 (72 per cent) were screened. Of those screened, 29 per cent had never had a Pap smear. Information on women in the education and control groups was obtained by mailed questionnaire. Of the eligible women in the service group, 72 per cent accepted screening in hospital, but only 24 per cent of eligible women in the education group and 20 per cent in the control group reported having a Pap smear in the four months since leaving hospital. The service group showed a very large effect relative to the control group (odds ratio (OR) 17.71, 95 per cent confidence interval (CI) 10.05 to 31.22), but there was no significant difference between the education and control groups. Other significant variables in the logistic regression model were age, marital status, and sex of the woman's general practitioner. The effect of offering the service was greater for women over 50 (OR 51.51, CI 19.01 to 139.60) A hospital-based cervical screening service provides an important opportunity for screening women who are not being reached by other services. (Aust J Public Health 1995; 19: 288–93)     

Opportunistic screening for Chlamydia in general practice: the experience of health professionals

Chlamydia trachomatis is the most common curable bacterial sexually transmitted infection in the UK. The infection is asymptomatic in up to 70% of women, and if untreated, can lead to pelvic inflammatory disease, ectopic pregnancy and infertility. Chlamydial infection can be diagnosed using urine testing and is easily treated with antibiotics. In 1999, the UK Department of Health funded a pilot opportunistic Chlamydia screening programme in two health authorities. All sexually active women between the ages of 16 and 24 years attending general practices and other healthcare settings, such as family planning clinics, antenatal clinics and genito-urinary medicine services, were offered the opportunity to be screened for Chlamydia, regardless of the purpose of their visit. This evaluation was funded to assess the feasibility and acceptability of opportunistic screening. The evaluation was conducted using both qualitative and quantitative methods. The present paper describes findings from the qualitative evaluation study arising from the health professionals' experience of opportunistic screening in general practice. Receptionists were central to the opportunistic screening model in general practice and it was this aspect of the model that raised most concerns. Whilst general practitioners reported that the involvement of receptionists saved them time, the receptionists themselves were sometimes drawn into discussions for which they felt ill equipped and unsuitably located. This research suggests that a call-recall national screening programme would provide a better model to undertake Chlamydia screening in general practice. The advantages of this model are threefold. First, each individual within the target age range can receive information about Chlamydia through the post. Secondly, the test and more detailed information can be managed by a practice nurse in a private and confidential setting. Thirdly, individuals are not repeatedly offered the test when visiting the surgery.     

Strategies used to increase chlamydia screening in general practice: a qualitative study

OBJECTIVES: To explore strategies used by chlamydia screening co-ordinators and practice staff to implement genital chlamydia screening within general practices. METHODS: Qualitative phenomenological study using individual semi-structured telephone interviews. Screening co-ordinators were selected purposively in Phase 1 and 2 areas of the Department of Health National Chlamydia Screening Programme in England, where there was significant screening in general practice. Open questions were asked about: the factors that determined high chlamydia screening rates; maintaining motivation for screening; and strategies to increase screening in general practices. RESULTS: Co-ordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalized screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time-saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. Chlamydia screening was sustained through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the 'at-risk' population from the screening team. Co-ordinators' enthusiasm and project management skills were as important as sexual health experience. Co-ordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public. CONCLUSIONS: All practice staff need to be encouraged to become champions of the chlamydia screening programme through education, especially aimed at older clinicians and receptionists. The National Health Service should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.     

Brief intervention for male heavy drinkers in routine general practice: a three-year randomized controlled study

The aim of this research was to evaluate the effectiveness of long-term brief intervention in routine general practice. In five primary care out-patient clinics in a Finnish town, 296 male early-phase heavy drinkers consulting a general practitioner (GP) for various reasons were identified. Control group C (n = 88) was informed of the risks of drinking after the screening and were advised at the subsequent feedback about 2 weeks later to reduce their drinking. Groups A (n = 109) and B (n = 99) were offered in addition seven and three brief intervention sessions, respectively. All GPs took part, whether or not they indicated a special interest. The main outcome measures were differences between beginning and end-point at 3 years in self-reported alcohol consumption, mean corpuscular volume (MCV), and serum carbohydrate-deficient transferrin, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase. There were no statistically significant differences between study groups A, B and C in mean changes in outcome measures. Within all the groups, MCV decreased. Depending on the outcome measure used and the study group analysed, clinically significant reduction of drinking was found in 25-53% of the subjects. In routine general practice, giving additional sessions of brief intervention may not be as effective as in special research conditions. Factors reducing the effectiveness of brief intervention programmes should be investigated, so that primary health care staff can be better supported in their efforts.     

Life style intervention in general practice: Effects on psychological well-being and patient satisfaction

The objectives of this study were to: (1) study if an opportunistic screening of coronary heart disease (CHD) risk factors among male attenders in general practice (GP) influenced the overall subjective satisfaction with life of persons labelled high risk compared to other screened persons; (2) compare psychological well-being and patient satisfaction in a patient centred and self-directive (PCSD) intervention with conventional care (CC); and (3) evaluate patient satisfaction and psychological well-being among subjects with high CHD risk during a one year intervention study. Effects of labelling were evaluated in 115 subjects with high CHD risk in comparison with a low risk reference population. The 22 participating GP centres were randomly allocated to follow either a PCSD intervention or a CC approach. An overall satisfaction with life question was employed and psychological well-being were measured using the General Health Questionnaire (20 item version). Satisfaction measures on health care aspects were also included. No difference of change between the high risk and the reference population was found concerning satisfaction with life after screening. No significant difference of change was found within or between the PCSD and the CC group concerning emotional well-being or overall satisfaction with life during one year intervention. Satisfaction with the care received was significantly better in the CC group as compared with the PCSD group (p=0.02). Satisfaction with own efforts for improving health was, however, more pronounced in the PCSD group (p=0.01). A substantial number (n=61) of the participants reported distaste of being reminded of the risk of heart disease and no more than 60 of the participants were satisfied with their own efforts for improving health. Although no significant change of satisfaction with life and emotional well-being due to screening or intervention could be detected, clinicians should be aware that encouraging patients to change life style may lead to patients' annoyance of being reminded of the risk of disease and dissatisfaction with their own efforts. Increasing patient responsibility and self-determination may improve their satisfaction with their own efforts, but reduce satisfaction with medical care.     

A pilot study of a computerized assessment (AGE-PC) for the elderly in general practice

A pilot project was undertaken in Liverpool UK, to investigatewhether data useful for both general practice and public healthpurposes could be collected by primary care personnel usinga computerized semi-structured interview (AGE-PC) for assessmentof patients aged 75 and over. A high degree of variation betweenpractices was found in the proportion of elderly assessed withAGE-PC largely related to motivation to undertake assessmentsand methods employed to approach patients. Considerable differencesbetween and within practices were evident in staff attitudesto the need for detailed formal assessments and the use of computers.Several aspects of the AGE-PC package itself were identifiedas requiring modification including streamlining data transfermethods, adding facilities for analysis and giving users a degreeof choice over content of the assessment. This technique doesoffer a potentially efficient means of collecting very detailedstandardized data for intra- or inter-practice analysis whileat the same time generating a comprehensive report for individualpatients. However, in the context of the over-75 assessmentsit was too time-consuming. Possible future strategies are discussedsuch as using an initial screening stage with a self-reportquestionnaire to reduce numbers needing full assessment andthe use of the package for the community care assessments. Thepilot project highlighted some of the potential advantages anddisadvantages of collecting data from primary health care forpublic health purposes. One of the most salient lessons learntwas the importance of involving the different team members inthe planning process so that there is agreement on: the essentialdata items required by both parties, the use of a uniform methodof approaching and sampling patients for assessments, the importanceof accuracy and obtaining a high response rate, and finallythat the whole procedure must be easy and not involve too muchtime or effort on the part of the overloaded primary care staff.     

The incidence and prevalence of pressure ulcers among elderly patients in general medical practice

PURPOSE: The objective of this study was to estimate the period prevalence and incidence of pressure ulcer among those 65 years of age and older. METHODS: We used a patient-record database called the General Practice Research Database (GPRD). Subjects were 65 years of age and older and cases were ascertained based on strict inclusion and exclusion criteria. The accuracy of the ascertainment strategy was estimated using mailed physician-answered questionnaires. Annual period prevalence and age-specific incidence were estimated per 100 person-years with exact 95% confidence intervals (CI). RESULTS: The accuracy of our ascertainment strategy was excellent, with a positive predictive value of 100% (95% CI: 92%,100%) and negative predictive value of 95% (85%, 95%). Over 200,000 person-years of data were analyzed. The annual period prevalence of pressure ulcer among those 65 years of age and older varied from 0.31% to 0.70%. The incidence varied significantly with advancing patient age from 0.18 to 3.36 per 100-person years (p < 0.001) but was not associated with gender (p = 0.95). CONCLUSIONS: Pressure ulcers are seen in the general practice setting. They are most likely to occur in those over 85 years of age. Preventative strategies within the general practice setting should concentrate on the oldest of the elderly.     

Implementation of chlamydia screening in a general practice setting: a 6-month pilot study

OBJECTIVE: To determine whether screening for asymptomatic Chlamydia trachomatis infection could be undertaken in the context of a smear clinic or other sexual health consultation in general practice. METHODS: A prospective, opportunistic, cohort study was undertaken in a general practice setting. The participants were asymptomatic women aged 16-24 years and men aged 16-34 years who were screened for Chlamydia trachomatis by testing endocervical swabs or first-voided urine samples. The main outcome measure was the uptake of the screening offer and the presence or absence of chlamydia infection as indicated by the test result. RESULTS: A total of 115 patients (109 women and six men) were offered screening. Eighty-one (70%) patients accepted, with five positive results, giving an overall prevalence of 6.2% (5/81, 95% CI 1-11%). Of those offered screening when having a smear, 8.3% (3/36, 95% CI 0-17%) were positive. CONCLUSION: Screening for chlamydia can be undertaken in the context of existing services offered in general practice (e.g. a smear clinic or consultation) where contraception/sexual health is discussed.     

Tailored physiotherapeutic intervention for musculoskeletal disorders among video display terminal users: a case-control study

Background:Musculoskeletal disorders represent one of the most common complains among video display terminal (VDT) users and are responsible for an important burden of disease in white collars.Methods:From May 2017 to March 2018, 69 VDT users working at Trieste hospitals were recruited for a training session aimed to reduce musculoskeletal disorders in white collars workers. Thirty-three were assigned to the intervention group, whereas 36 were included in the control group. The intervention group received three personalized 1-hour-one-to-one sessions with a physiotherapist and a thorough evaluation of their workstation. Data were collected at baseline (T0), at 2 months (T1) and at 6 months (T2) using a standardized questionnaire and analyzed with the software STATA.Results:Overall pain significantly decreased in cases at T1 and T2 (p < 0.05). Headache significantly decreased in cases at T1 (p < 0.05). Body awareness significantly increased in cases both at T1 and T2 (p < 0.05). Headache was positively correlated with an increased perception of pain (Coef 6.85, CI95% 3.2-10.5; p < 0.001), while the intervention determined a significant reduction of overall pain during the follow up (OR 0.97, IC 0.95-0.99, p = 0.013). Cases showed a significant increase of the cranial-vertebral angle at the 6 months follow up (p < 0.05).Conclusion:A tailored physiotherapeutic intervention has showed a statistically significant decrease in osteoarticular pain and an increased body awareness in VDT users undergoing a personalized training session.     

太原地区3 173名老年人睡眠障碍现况调查

目的 了解太原地区老年人各种睡眠障碍的流行病学特点及失眠的相关因素.方法 采用多级抽样方法,对太原地区3173名60～100岁的老年人进行人户调查,筛选出有睡眠障碍症状者,由专科医生复查并作出诊断.结果 (1)3173名老年人中,有各种睡眠障碍症状者2132例,患病率为67.2%;其中失眠症、多梦、习惯性打鼾、日间嗜睡的患病率均较高,分别为39.65%、38.58%、26.66%、34.32%.(2)随着年龄的增长,男性老年人早醒、起夜次数多、日间嗜睡、睡眠呼吸障碍及睡眠节律紊乱的患病率有明显上升趋势(P＜0.01);随着年龄的增长,女性老年人早醒、日间嗜睡及睡眠节律紊乱的患病率也有明显上升趋势(P＜0.01).(3)经logistic回归分析,独居、情绪障碍、躯体疼痛、夜尿次数多(P＜0.01)与男性老年人失眠的发病有关;独居及麻/瘙痒等感觉异常(P＜0.01)、情绪障碍(P＜0.05)与女性老年人失眠的发病有关.结论 太原地区老年人中各种睡眠障碍的患病率有上升趋势;应注重老年人情绪、躯体疾病对睡眠的影响.

Abstract：

Objective To investigate the prevalence rates of sleep disorders and the correlatives in the elderly from Taiyuan city.Methods All of the 3173 elderly (aged 60 years to 100 years) in Taiyuan city were investigated at home through questionnaires,regarding their sleep condition.Subjects with sleep disorders were then screened through questionnaires and reexamined/diagnosed by special doctors.Results (1) Among the 3173 elderly,2132 subjects complained of having sleep disorders.The total prevalence of sleep disorders was 67.2%.The prevalence rates of chronic insomnia,multi-dreams,habitual snoring and daytime drowsiness were 39.65%,38.58%,26.66% and 34.32% respectively.(2)In the male elderly,the prevalence rates of being awaken early,having more urination at night,daytime drowsiness,sleep-respiratory disturbance and indiscriminate sleep rhythm increased with age(P＜0.01).However,in the female elderly,the prevalence rates of being awaken early,having daytime drowsiness and indiscriminate sleep rhythm also had a tendency of increase (P＜0.01).(3) Living alone,emotional disorder,pain and nocturia (P＜0.01) were the risk factors of chronic insomnia in the male elderly while living alone,numbness/pruritus(P＜0.01),emotional disorder (P＜0.05),were the risk factors of chronic insomnia in the female elderly.Conclusion The prevalence rates of some sleep disturbances in the elderly in Taiyuan city were generally correspondent with prevalence rates reported elsewhere that called for more attention be paid to the effect of mood disturbance and diseases related to sleep condition among the eldexly.