Predicting prolonged duration of fever in children: a cohort study in primary care

Background

Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care.

Aim

To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.

Design and setting

A prospective cohort study at a GPs’ cooperative (GPC) out-of-hours service.

Method

Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact.

Results

Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that ‘sore throat’ (OR 2.8; 95% CI = 1.30 to 6.01) and ‘lymph nodes palpable’ (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01).

Conclusion

The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.     

Presenting symptoms of children with cancer: a primary-care population-based study

Background

Knowledge of how children with cancer present in general practice is sparse. Timely referral from general practice is important to ensure early diagnosis.

Aim

To investigate the presenting symptoms and GPs’ interpretations of symptoms of children with cancer.

Design and setting

A Danish nationwide population-based study including children (<15 years) with an incident cancer diagnosis (January 2007 to December 2010).

Method

A questionnaire on symptoms and their interpretation was mailed to GPs (n?=?363). Symptoms were classified according to the International Classification of Primary Care (ICPC)-2 classification.

Results

GPs’ response rate was 87% (315/363) and GPs were involved in the diagnostic process of 253 (80.3%) children. Symptoms were few (2.4 per child) and most fell into the category ‘general and unspecified’ (71.9%), apart from patients with tumours of the central nervous system (CNS), whose symptoms fell mostly in the category ‘neurological’ (for example, headache). Symptoms like pain, swelling/lump, or fatigue were reported in 25% of the patients and they were the most commonly reported symptoms. GPs interpreted children’s symptoms as alarm symptoms in 20.2%, as serious (that is, not alarm) symptoms in 52.9%, and as vague symptoms in 26.9%. GPs’ interpretation varied significantly by diagnosis (P<0.001).

Conclusion

Children with cancer presented with few symptoms in general practice, of which most were ‘general and unspecified’ symptoms. Only 20% presented alarm symptoms, while 27% presented vague and non-specific symptoms. This low level of alarm symptoms may influence the time from symptom presentation in general practice to final diagnosis.     

Users' reports and evaluations of out-of-hours health care and the UK national quality requirements: a cross sectional study

Background

National standards for delivery of out-of-hours services have been refined. Health service users'' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs.

Aim

To investigate NHS service users'' reports and evaluations of out-of-hours care in the light of UK national service quality requirements.

Design

Cross sectional survey.

Setting

Three areas (Devon, Cornwall, Sheffield) of England, UK.

Method

Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users'' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment (‘call back time’); the time waiting for a home visit; and the waiting time at a treatment centre.

Results

UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of ‘up to an hour’), only one-third of users reported this as ‘excellent’. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as ‘excellent’, this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes.

Conclusion

Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of ‘good’ quality by service users. Attaining ‘excellent’ levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users'' expectations as well as their experience of care.     

Risk taking in general practice: GP out-of-hours referrals to hospital

Background

Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.

Aim

To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.

Design of study

Cross-sectional comparison of admission rates; postal survey.

Setting

Three OOH providers in south-west England.

Method

Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.

Results

There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).

Conclusion

GPs'' threshold of risk is important for explaining variations in referral to hospital.     

Why do patients with cancer access out-of-hours primary care? A retrospective study

Background

Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care.

Aim

To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department.

Design and setting

A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011.

Method

Subjects were identified by filtering the OOH computer database using the Read Codes ‘neoplasm’, ‘terminal care’, and ‘terminal illness’. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s).

Results

Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication.

Conclusion

Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning.     

Case finding for chronic obstructive pulmonary disease in primary care: a pilot randomised controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.

Aim

To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.

Design and setting

Pilot randomised controlled trial in two general practices in the West Midlands, UK.

Method

A total of 1634 ever-smokers aged 35–79 years with no history of COPD or asthma were randomised into either a ‘targeted’ or ‘opportunistic’ case-finding arm. Respiratory questionnaires were posted to patients in the ‘targeted’ arm and provided to patients in the ‘opportunistic’ arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.

Results

Twenty-six per cent (212/815) in the ‘targeted’ and 13.6% (111/819) in the ‘opportunistic’ arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the ‘targeted’ and ‘opportunistic’ arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = –0.5% to 3.08%]). Over a 12-month period, the ‘opportunistic’ case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the ‘targeted’ and £242.20 in the ‘opportunistic’ arm.

Conclusion

Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this.     

Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

What happens when doctors are patients? Qualitative study of GPs

Background

Current evidence about the experiences of doctors who are unwell is limited to poor quality data.

Aim

To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.

Design of study

Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.

Setting

Two primary care trusts in the West of England.

Method

A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis

Results

Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.

Conclusion

Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.     

Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting

Background

Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.

Aim

To assess whether GPs prescribe antidepressants appropriately.

Design of study

Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.

Setting

Four practices in Grampian, Scotland.

Method

Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.

Results

A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.

Conclusion

There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.     

Verbal and non-verbal behaviour and patient perception of communication in primary care: an observational study

Background

Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours.

Aim

To explore the relationship of observer ratings of behaviours of videotaped consultations with patients’ perceptions.

Design and setting

Observational study in general practices close to Southampton, Southern England.

Method

Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains.

Results

In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), ‘back-channelling’ (for example, saying ‘mmm’) (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness (‘aloof’) was helpful and optimism unhelpful. Finishing with non-verbal ‘cut-offs’ (for example, looking away), being professionally cool (‘aloof’), or patronising, (‘infantilising’) resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication.

Conclusion

These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional ‘coolness’ at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end.     

Epilepsy and its effects on children and families in rural Uganda

Background

This report aims to assess the impact of childhood epilepsy in an isolated rural area in Western Uganda, with little access to medical care, via its effect on children and families. Basic information on 440 affected children, clinically examined at 19 rural centres, was collated and data on seizure pattern and duration analysed, together with information on school attendance of older children.

Objective

To publicise the consequences of undertreated illness, and to encourage improved management of this condition.

Results

Distribution by seizure type was: generalised 61%, focal 33%, and miscellaneous 6%. When information on all seizure types was combined, a ‘typical seizure’ lasted < 1 hour, followed by coma. The typical age of onset and duration of illness approximated 2½ and 4 years respectively. Modal frequency and duration of seizures suggested that ∼96 hours might be ‘lost’ to seizures over 4 years. Twenty four children had delayed global or motor development; a further 93 were reported to have ‘poor understanding’. Information on school attendance available on 162 of 231 school aged children indicated that 92 were attending and 70 not attending school. Fifty eight percent of children >10 yrs old attending school and 68% of non-attendees, had never progressed beyond the entry class.

Conclusion

The unexpected prevalence of apparent cognitive delay is discussed, together with strategies for prevention and management of epilepsy at community level.     

Factors associated with prevalence and types of ‘may be fit’ advice on fit notes: a cross-sectional primary care analysis

Background

The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.

Aim

To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.

Design and setting

Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.

Method

Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.

Results

The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.

Conclusion

Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers).     

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

Background

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.

Aim

The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.

Design and setting

Retrospective cross-sectional study in general practices in England.

Method

Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.

Results

GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.

Conclusion

Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’.     

Predicted 10-year risk of cardiovascular disease is influenced by the risk equation adopted: a cross-sectional analysis

Background

Validated risk equations are currently recommended to assess individuals to determine those at ‘high risk’ of cardiovascular disease (CVD). However, there is no longer a risk ‘equation of choice’.

Aim

This study examined the differences between four commonly-used CVD risk equations.

Design and setting

Cross-sectional analysis of individuals who participated in a workplace-based risk assessment in Carmarthenshire, south Wales.

Method

Analysis of 790 individuals (474 females, 316 males) with no prior diagnosis of CVD or diabetes. Ten-year CVD risk was predicted by entering the relevant variables into the QRISK2, Framingham Lipids, Framingham BMI, and JBS2 risk equations.

Results

The Framingham BMI and JBS2 risk equations predicted a higher absolute risk than the QRISK2 and Framingham Lipids equations, and CVD risk increased concomitantly with age irrespective of which risk equation was adopted. Only a small proportion of females (0–2.1%) were predicted to be at high risk of developing CVD using any of the risk algorithms. The proportion of males predicted at high risk ranged from 5.4% (QRISK2) to 20.3% (JBS2). After age stratification, few differences between isolated risk factors were observed in males, although a greater proportion of males aged ≥50 years were predicted to be at ‘high risk’ independent of risk equation used.

Conclusions

Different risk equations can influence the predicted 10-year CVD risk of individuals. More males were predicted at ‘high risk’ using the JBS2 or Framingham BMI equations. Consideration should also be given to the number of isolated risk factors, especially in younger adults when evaluating CVD risk.     

Slaying the dragon myth: an ethnographic study of receptionists in UK general practice

Background

General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful ‘gatekeepers’. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience.

Aim

To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work.

Design and setting

Ethnographic observation in seven urban general practices in the north-west of England.

Method

Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters.

Results

Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to ‘play’ the system.

Conclusion

Framing the receptionist–patient encounter as one between the ‘powerful’ and the ‘vulnerable’ gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings.