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.     

Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs

OBJECTIVES: The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs. METHODS: A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs. RESULTS: The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15-2.82] and waiting time (OR = 1.96, 95% CI 1.20-3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29-0.83). Satisfaction with doctor-patient interaction was not associated with CAM use. Being 'very satisfied' on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14-0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the 'chronic disease triad' (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45-6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14-0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07-3.31). CONCLUSION: CAM use in Asian patients is prevalent and associated with the 'chronic disease triad' (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor-patient interaction.     

Anticoagulant treatment of patients with chronic atrial fibrillation in primary health care in Sweden--a retrospective study of incidence and quality in a registered population

BACKGROUND: The number of patients receiving anticoagulant treatment is increasing. Chronic atrial fibrillation is the most common treatment diagnosis. The literature indicates a variable level of treatment control. Estimates of time within the therapeutic range have been recommended as a measurement of quality. Electronic patient records are providing clinical data that are useful for audits concerning anticoagulant treatment in real-life practice. OBJECTIVE: Our aim was to assess warfarin treatment for chronic atrial fibrillation in primary health care with regard to prevalence, incidence and quality. METHODS: A 2 year retrospective study was carried out of electronic patient records up to April 2002 in primary health care in Stockholm, including 12 primary health care centres with a registered population of 203 407. Main outcome measures were the number of new patients on wafarin treatment for chronic atrial fibrillation, and time within the therapeutic prothrombin range in the first 90 days of treatment using a linear interpolation method. RESULTS: In total, 827 patients were on warfarin treatment for chronic atrial fibrillation, giving a prevalence of 0.41%. Of these, 144 patients (study group) started treatment with warfarin for chronic atrial fibrillation during the study period, giving a yearly incidence of 0.07%. Their mean age was 73.1 years and 61.1% were men. There were 1721 prothrombin monitoring episodes registered in the first 90 days of treatment, on average once a week per patient. The average proportion of time within the therapeutic range was 54.1% (95% confidence interval (CI) 50.1-58.1), and the proportion of therapeutic tests was 50.2% (95% CI 47.8-52.6). CONCLUSIONS: During the first, second and third months of warfarin treatment for chronic atrial fibrillation, patients were outside the therapeutic range time nearly half the time. There was a gender difference favouring men regarding initiation of treatment.     

An evaluation of prompt access to physiotherapy in the management of low back pain in primary care

BACKGROUND: Disability arising from low back pain (LBP) is a growing problem. Current primary care management of LBP has been criticized for its mechanistic basis and for delays in gaining access to specialist advice. Among recent recommendations made for improved management are functional explanatory models, a rehabilitative approach and early access to physical therapy. It is not known if these recommendations can be implemented in mainstream primary care. OBJECTIVE: The purpose of our study was to examine the feasibility, acceptability and component costs of providing a prompt access physiotherapy service for new episodes of LBP in primary care; to describe outcomes and compare them with other published interventions; and to explore the influence of the service on GPs' approach to LBP. METHODS: Back pain clinics staffed by a physiotherapist were established in a group of demographically representative practices in a typical UK health authority. Adult patients with a new episode of LBP referred by their GPs were managed in accordance with recent recommendations. Data on pain, disability and well-being were collected at recruitment and some 12 weeks later. Patient diaries and interviews with GPs before and after the study provided qualitative data. Comparative costings were derived from national and local sources. RESULTS: A total of 614 patients, representing 3.2% of the adult population, were referred, of whom 522 (85%) were seen at the back pain clinics within 3-4 days, the majority within 72 h. Although this represents less than half the adult patients thought to be presenting to their GPs with LBP, patients exhibited levels of pain and disability comparable with those described in other studies of LBP in primary care. More than 70% of patients required only a single clinic visit and <5% were referred on to specialist orthopaedic or back pain rehabilitation services. At follow-up, levels of improvement were comparable with and time taken off work superior to those seen in other intervention studies of LBP in primary care. Prompt access to physiotherapy in primary care costs less per episode of LBP than conventional management. Qualitative data suggest that patients valued early access to the physiotherapist, particularly for the reassurance provided. Interviews with GPs revealed strong support for the service, in large part based on favourable feedback from patients. CONCLUSIONS: For primary care patients with a new episode of LBP referred by their GP, prompt access to a dedicated physiotherapy service is both feasible and acceptable. Comparison with other published interventions suggests that it is also cost-effective and that a typical Primary Care Trust (PCT) would rapidly recoup the cost of additional physiotherapists. However, questions remain about the availability of sufficient physiotherapists to make such a service available nationally. The influence of the service upon GPs' own approach to the management of LBP is likely to be gradual and to come about largely through positive feedback from patients.     

Preconception care: practice and beliefs of primary care workers

BACKGROUND: A number of lifestyle modifications and medical interventions can be of benefit to maternal and neonatal health, when applied prior to conception. These include smoking cessation, supplementation with folic acid, cessation or moderation of alcohol intake and improvement of diabetic control. However, preconception care (PCC) is not widely practised in the UK, despite being apparently acceptable to health professionals and to women of childbearing age. OBJECTIVES: The aims of the study were to describe the current practice of PCC in Barnsley and to assess the beliefs and attitudes of primary health care practitioners. This information would help direct appropriate educational and clinical governance intervention to this service in the locality in the light of other evidence about the effectiveness of PCC. METHODS: A questionnaire was devised to explore the beliefs about, and practice in providing, PCC in primary care in the Barnsley Health Authority area and sent to all known GPs, practice nurses (PNs), health visitors (HVs) and midwives (MWs) in practices in the area in July 2000. A total of 163 completed questionnaires were received (one reminder, response rate 60.1%). RESULTS: Few practices had a written policy on PCC. Most respondents were providing it mainly on an opportunistic basis and had done so less than five times in the previous 3 months; GPs and PNs were most commonly involved. They agreed that advice about smoking, drug use, folic acid, genetic counselling, chronic disease, alcohol, and maternity care and screening for rubella, genital infections, hepatitis, human immunodeficiency virus and cervical cytology were important. They felt that advice about diet, exercise, supplements, food safety, occupational hazards and State benefits, and screening for nutritional status were less important. Although respondents felt that PCC was effective, and important to women of childbearing age, it was not a high priority in their workload. They indicated that this care was best provided in general practice and that they had the appropriate skills. Barriers to providing PCC included lack of resources and lack of contact with women planning to conceive. Few had received any training on PCC since qualifying in their discipline. CONCLUSIONS: The practitioners who responded to this survey agreed to a large extent about the importance of the subject, and about the content and effectiveness of PCC. Factors hindering the delivery of this service include resource constraints, lack of training and practice policies and procedures, and difficulty in targeting couples planning conception. Further research is needed into ways to increase the provision and uptake of PCC.     

Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people

BACKGROUND: Although it is known that only a small minority of people experiencing sexual problems seek treatment for these, barriers to treatment seeking remain relatively unexplored. This is particularly true for older people, whose perceived "asexuality" has led to them being excluded from sexual health research. OBJECTIVE: The aim of the present study was to identify barriers experienced by older people in seeking treatment for sexual problems. METHODS: Semi-structured interviews were conducted with 22 women and 23 men aged 50-92 years recruited from the age/sex register of a Sheffield general practice. A central component of the interviews involved exploring participants' attitudes towards, and experiences of, seeking help for sexual problems. Interviews were analyzed using the "framework" approach. RESULTS: The GP was seen as the main source of professional help if sexual problems were experienced. However, several barriers were identified as inhibiting help being sought. These included the demographic characteristics of the GP, GP attitudes towards later life sexuality, the attribution of sexual problems to "normal ageing", shame/embarrassment and fear, perceiving sexual problems as "not serious" and lack of knowledge about appropriate services. Twenty-five participants had experienced recent sexual problems which informed their responses. CONCLUSION: These findings indicate that many older people have sexual problems that they would like to discuss with their GP, but they feel unable to do so. GPs may need to be more proactive in raising sexual health issues in consultations if these needs are to be met.     

Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece

BACKGROUND: Musculoskeletal disorders (MSDs) account as a reason for frequent consultations in primary care. However, the magnitude of the problem at the GP's clinic, the patterns of pain and the consulting behaviour has not been sufficiently explored. OBJECTIVES: The aim of this study was to report on patterns of pain relevant to MSDs and explore the co-morbidities and consulting behaviour in rural primary care settings in Crete. METHODS: Three primary care centres (PCCs) of Crete were selected for a study period of 2 weeks. Every visitor, aged 20-75 years, regardless of the reason for visiting the facility was invited to participate. The Greek version of the general Nordic questionnaire for the analysis of musculoskeletal disorders (NMQ) was used for data collection. RESULTS: A total of 455 subjects answered the NMQ. Three hundred and seventy-six (82.6%) of the study population reported having one or more symptoms during the previous year. Low back (56.9%), neck (34.1%), shoulder (29.9%) and knee (27.9%) were the commonest sites of pain. In almost half cases (48.6%), the complaints about pain were accompanied by activity restrictions. Multivariate statistical analysis showed significant correlations with increasing age and female gender (P < 0.05). Common chronic conditions were associated with co-morbidities from the musculoskeletal system. Only one-third of those who reported MSDs had consulted their GPs for the same problems within the previous year. CONCLUSIONS: MSDs are highly prevalent among rural population in Crete but fewer patients seek care than those who report symptoms.     

Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic

BACKGROUND: Rapid Access Chest Pain Clinics have recently been introduced to assist in the management of primary care patients experiencing suspected cardiac chest pain. OBJECTIVE: To study the longer term outcome for patients referred to a Rapid Access Chest Pain Clinic and then given a non-cardiac diagnosis. METHODS: The study collected retrospective data from a cohort of all patients attending the Rapid Access Chest Pain Clinic based in the cardiorespiratory Department at the York District Hospital, England. Questionnaires were sent to all patients who attended the Rapid Access Chest Pain Clinic during the previous 14 months and were diagnosed with non-cardiac chest pain. Participants reported on their chest pain, subsequent episodes of primary and secondary care and their beliefs about causation of pain. RESULTS: Of the patients referred to the Rapid Access Chest Pain Clinic, 235 (52%) did not have cardiac chest pain. Of these patients, 161 (69%) returned the questionnaire, nearly half of whom reported ongoing chest pain. The mean time since Clinic attendance was approximately 8 months and the median duration of ongoing chest pain was 5.4 months. Women were twice as likely as men to continue to be experiencing pain but did not report more frequent or severe pain on average. More than 50% of the non-cardiac group were not convinced by their negative cardiac diagnosis. CONCLUSION: There is an ongoing challenge to support patients with non-cardiac chest pain, including the provision of reassurance that their pain is very unlikely to be caused by their heart.     

The needs of patients dying of chronic obstructive pulmonary disease in the community

BACKGROUND: Ninety percent of the last year of life of a terminally ill patient is spent at home, but possible drawbacks to domicillary terminal care have been suggested. Most previous studies have taken place in secondary care settings, and have often obtained relatives' views of patients' needs rather than those of the patient. OBJECTIVES: Our aim was to determine the needs of patients dying in primary care from chronic obstructive pulmonary disease (COPD). METHODS: Semi-structured interviews were undertaken with 16 patients who were having maximal therapy for COPD, who were thought likely to die in the year following the commencement of the study. RESULTS: Five themes were identified. (i) Patients' information needs and the future course of their illnesses. Information needs were often variable and patients were sometimes unwilling to contemplate the future. (ii) The impact of symptoms on patients' lives. Dyspnoea was a particular problem. (iii) Attitudes towards and opinions on smoking, which many acknowledged as being causal. (iv) Attitudes to help received. Many patients relied on their family; most patients felt their doctors were helpful although some expressed reservations. (v) Patients' expressed needs. These usually focused on mobility, and many patients would not express needs even when prompted. CONCLUSION: Poor symptom control remains an important cause of distress. The low number of expressed needs may reflect patients' unwillingness to appear ungrateful, but the variability of information needs emphasizes the importance of an individual approach to patients with an apparently homogenous disease     

Diagnosis of lung cancer in primary care: a structured review

BACKGROUND: Lung cancer has the highest cancer incidence and mortality in the UK. Despite this, an individual GP encounters only one new presentation approximately every 8 months, so gains relatively little experience of its diagnosis. This is partly addressed by referral guidelines which aim to help GPs in selection of patients for chest X-ray or referral for specialist investigation. OBJECTIVE: The purpose of this study was to review the primary care presenting features of lung cancer, in the light of the UK Referral Guidelines for Suspected Cancer. METHODS: A structured literature review was carried out. RESULTS: Little research has been undertaken in primary care, and the predictive values for most symptoms are unknown. Approximate likelihood ratios could be calculated for six symptoms or signs: haemoptysis 13; fatigue 5.7; cough 5.3; finger clubbing 3.9; weight loss 2.9; and dyspnoea 1.5-5.7, but none of these figures derived from single primary care studies. Three recommendations for urgent investigation of possible lung cancer in the UK Referral Guidelines are questioned: for unexplained dyspnoea, hoarseness or cervical lymphadenopathy. For all these presentations, other serious diagnoses are more likely. CONCLUSION: The UK Guidelines for referral of suspected lung cancer have a weak evidence base.     

A comparison of two methods of collecting economic data in primary care

BACKGROUND: There have been few attempts to assess alternative methods of collecting resource use data for economic evaluations. OBJECTIVE: This study aimed to compare two methods of collecting resource use data in primary care: GPs' case records and a self-complete postal questionnaire. METHODS: 303 primary care attenders were sent a postal survey, incorporating a questionnaire designed to collect service utilisation information for the previous six months. Data were also collected from GP case records. The reporting of GP visits between the two methods, and estimates of costs associated with those visits, were compared. RESULTS: There was good agreement between the number of GP visits recorded on GP case records (mean 3.03) and on the CSRI (mean 2.99) (concordance correlation coefficient = 0.756). In contrast, estimates of average costs of visits from CSRI data were higher and had greater variance compared to case record-based costs (54.63 pound sterling versus 42.37 pound sterling; P = 0.003). This may be explained by differences in average visit length (11.66 versus 9.36 minutes). CONCLUSIONS: This study shows good agreement between GP case records and a self-complete questionnaire for the reporting of GP visits. However, differences in costs associated with those visits arose due to differences in the method used for calculating length of visit.     

The needs of children of depressed mothers in primary care

BACKGROUND: Maternal depression has a number of adverse effects on children. Although most depression is treated in primary care, assessment or support is rarely given to children of depressed mothers on a routine basis. OBJECTIVE: Our aim was to examine the needs of children, aged 5-11 years, whose mothers are being treated for depression in primary care. METHODS: Mothers being prescribed antidepressants by their GP (n = 30) and mothers not being prescribed antidepressants (n = 30) were interviewed, and comparisons were made between their children (n = 48 and 50). RESULTS: The mothers who were prescribed antidepressants were more depressed than the other mothers, and their children had more dysfunctional symptoms. CONCLUSIONS: The needs of children must be considered when depressed mothers are being treated in primary care.     

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.     

Health status and health care utilisation of patients in complementary and conventional primary care in Switzerland--an observational study

BACKGROUND: The study is part of a nationwide evaluation of complementary and alternative medicine (CAM) in primary care in Switzerland. OBJECTIVES: Patient health status with respect to demographic attributes such as gender, age, and health care utilisation pattern was studied and compared with conventional primary care. METHODS: The study was performed as a cross-sectional survey including 11932 adult patients seeking complementary or conventional primary care. Patients were asked to document their self-perceived health status by completing a questionnaire in the waiting room. Physicians were performing conventional medicine and/or various forms of complementary primary care such as homeopathy, anthroposophic medicine, neural therapy, herbal medicine, or traditional Chinese medicine. Additional information on patient demographics and yearly consultation rates for participating physicians was obtained from the data pool of all Swiss health insurers. These data were used to confirm the survey results. RESULTS: We observed considerable and significant differences in demographic attributes of patients seeking complementary and conventional care. Patients seeking complementary care documented longer lasting and more severe main health problems than patients in conventional care. The number of previous physician visits differed between patient groups, which indicates higher consumption of medical resources by CAM patients. CONCLUSIONS: The study supports the hypothesis of differences in socio-demographic and behavioural attributes of patients seeking conventional medicine or CAM in primary care. The study provides empirical evidence that CAM users are requiring more physician-based medical services in primary care than users of conventional medicine.     

Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care

BACKGROUND: The long-term effects of disease management programmes for coronary heart disease on health status are unknown. In a randomized trial of nurse-led secondary prevention clinics, we found significantly improved health status at 1 year. Participants were followed-up again at 4 years to determine if improvements had been sustained. OBJECTIVE: Our aim was to evaluate the effects on health of nurse-led clinics for the secondary prevention of coronary heart disease in primary care. METHODS: A total of 1343 patients with coronary heart disease were randomized to nurse-led secondary prevention clinics or usual care, with follow-up at 1 and 4 years by review of medical case notes and national data sets, and postal questionnaires. The study involved a stratified, random sample of 19 general practices in north-east Scotland. Health status was measured by the SF-36 questionnaire, chest pain by the angina TyPE specification and anxiety and depression by the hospital anxiety and depression scale. RESULTS: At 1 year, there were significant improvements in five of eight SF-36 domains (all functioning scales, pain and general health) in patients randomized to clinics. Role limitations attributed to physical problems improved the most [adjusted difference 8.52, 95% confidence interval (CI) 4.16-12.9]. At 4 years, the intervention group scored higher than control in all domains, but differences were no longer significant. At 1 year, fewer patients in the intervention group reported worsening chest pain (odds ratio 0.59, 95% C1 0.37-0.94). At 4 years, there were no significant differences between the proportion of intervention or control group patients who reported chest pain in the last week or who reported worsening chest pain. No significant effects were observed on anxiety or depression at 1 or 4 years. CONCLUSION: We have demonstrated previously a significantly greater survival in attendees at nurse-led secondary prevention clinics. Despite this, improvements in health status achieved in the first year of the study were reduced at 4 years. The case for nurse-led clinics remains strong, but further research is required on ways to optimize current health status.