Better Prescribing Project: a randomized controlled trial of the impact of case-based educational modules and personal prescribing feedback on prescribing for hypertension in primary care

OBJECTIVE: The purpose of this study was to assess the impacts of individualized prescribing feedback and interactive small group education aimed at encouraging evidence-based prescribing in family/general practice. METHODS: A two-by-two factorial randomized controlled trial was carried out involving 200 family physicians in British Columbia, Canada. The physicians met monthly in 28 peer learning groups within the Practice-Based Small Group (PBSG) learning programme. Personalized prescribing feedback related to hypertension was provided through 'prescribing portraits' which graphically displayed comparative rates of individual and peer group prescribing, together with a concise guide for evidence-based prescribing. A case-based educational module, containing the same evidence-based message, was discussed in small groups. Groups were matched and randomized into four arms of seven groups each: control (n = 56), prescribing portrait only (n = 48), educational module only (n = 47), both portrait and module (n = 49). The main outcome measure was changes in 'prescribing preferences' to new patients among those medications used to treat hypertension (i.e. probability that a patient would receive the evidence-based medication as first-line therapy). RESULTS: Using data from the provincial pharmacy registry (PharmaNet), prescribing preferences for antihypertensive agents were determined for all groups for a 6 month period before and after the interventions, based on 4394 patients receiving a first-line antihypertensive. Significant absolute increases in prescribing preference for thiazides were documented for both the module +0.068 (confidence interval [CI] 0.022-0.115) and the portrait +0.065 (CI 0.018-0.111). Preference in the group receiving both module and portrait increased by +0.115 (CI 0.040-0.189). CONCLUSIONS: Evidence-based educational interventions combining personalized prescribing feedback with interactive group discussion can lead to modest but meaningful changes in physician prescribing. Clear messages, proper trial design and sensitive outcomes are necessary to demonstrate these changes.     

An analysis of factors that predict patient consent to take part in a randomized controlled trial

BACKGROUND: Recruitment targets of patients to multi-centre primary care-based randomized controlled trials (RCT) are often not met. A critical step in the pathway is whether an eligible patient will give consent. OBJECTIVE: To assess whether patient, practice or practitioner characteristics are associated with a patient's likelihood of giving consent to participation in a large primary care-based RCT. METHODS: A cross-sectional study of patients from 260 practices in England and Wales who met the eligibility criteria for an RCT of aspirin versus warfarin for stroke prevention and attended an appointment with their GP to consider trial participation. Logistic regression analysis was used to determine which patient and practitioner factors independently predicted whether or not a patient would give consent to take part in the trial. RESULTS: Of the 1740 patients, 973 (55.9%) gave consent. On multivariable analysis, patient factors associated with increased likelihood of giving consent were younger age, current use of warfarin and year of recruitment to the trial. Patients with a history of transient ischaemic attack, angina or valve disease were less likely to give consent. Practice/practitioner factors that were associated with increased likelihood of consent were smaller practice size (practices with greater than eight GPs as compared with those with one to two GPs, odds ratio 0.40, 95% confidence interval 0.21-0.75) and older GPs. CONCLUSIONS: The strong association of consent with year of recruitment may be due to changes in trial procedures and investigator training. If so, this has important implications for the conduct of future trials.     

A randomized controlled trial of the effect of providing information on accidental injury admissions and their costs to Primary Care Groups and Trusts

BACKGROUND: Primary Care Groups and Trusts (PCG/Ts) are responsible for improving the health of local populations, but there is little evidence of their strategic involvement in accident prevention. OBJECTIVE: To determine the effect of providing information on local accidental injuries to PCG/Ts on the development of accident prevention strategies. METHODS: The study is a randomized controlled trial in PCG/Ts in the former Trent Region. Intervention PCG/Ts were sent profiles containing PCG/T specific information on hospital admissions for accidental injury and their costs and on accident prevention interventions. Health promotion leads were surveyed at baseline and three and fifteen months. The primary outcome was whether the PCG/T had a written accident prevention strategy. Secondary outcome measures included other accident prevention activities, prioritization of accident prevention, and knowledge and attitudes towards accident prevention. RESULTS: At three months 38% of PCG/Ts in the intervention arm had a written accident prevention strategy, compared with 42% in the control arm [difference -4%, 95% confidence interval (CI) -31% to 25%]. At fifteen months these values were 55% in the intervention arm and 50% in the control arm (difference 5%, CI -24% to 33%). There were no statistically significant differences between the groups for any outcome measures. CONCLUSIONS: Providing profiles containing information on accidental injuries to PCG/Ts did not significantly increase the development of accident prevention strategies, however this study only had sufficient power to detect substantial changes. Larger national studies would be required to detect moderate effects of tailored packages in changing PCG/T behaviour.     

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals

BACKGROUND: Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals. OBJECTIVE: The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s). METHODS: Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups. RESULTS: For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40). CONCLUSIONS: Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.     

Assessing the feasibility of proactive recruitment of smokers to an intervention in general practice for smoking cessation using computer-tailored feedback reports

BACKGROUND: Specialist National Health Service clinics for smoking cessation have increased in number, but most smokers prefer less intensive self-help and many smokers have no serious intentions to attempt to quit. Computer-tailored self-help materials can be adapted to provide advice to less motivated smokers, and can also take into account features such as level of education and socio-economic circumstance. OBJECTIVE: To assess the feasibility of delivering tailored feedback to a large population by identifying smokers from general practice records, with the aim of informing a large-scale trial of effectiveness. METHOD: Questionnaires were sent to a random sample of smokers (n = 876) aged between 18 and 65 years, identified from records in four practices. Smokers returning the questionnaire (n = 78) were randomized to receive standard information, or to receive standard information plus computer-tailored feedback reports. Follow-up questionnaires were sent 3 months after the return of the baseline questionnaire. RESULTS: The recruitment strategy yielded a response rate of 8.9%, and a 66.7% follow-up rate. There were no significant differences in outcome between the two conditions, and no significant differences in outcome between practices. In the Intervention group significantly more of those who remembered receiving the tailored advice letter had made a quit attempt (6[60%]/3[21.4%], P < 0.05). CONCLUSION: This pilot study demonstrated the feasibility of carrying out such a trial to evaluate the effectiveness of delivering an intervention for smoking cessation in primary care, and highlighted issues that should be addressed in considering the design of a large-scale trial.     

Implementing guidelines on acute maxillary sinusitis in general practice--a randomized controlled trial

BACKGROUND: Management of acute maxillary sinusitis (AMS) is not optimal; antibiotics are often prescribed for viral sinusitis, which leads to many problems including those with antimicrobial resistance. Guidelines have been proposed as a means to change the professional practices. OBJECTIVE: Our aim was to study whether a nationwide guidelines implementation programme has an effect on the management of AMS in primary care. METHODS: A multi-centre randomized controlled trial was conducted in 30 health centres (HCs) covering a population of 819 777 people from 1998 to 2002. The participating HCs were randomized to implement guidelines either according to a problem-based learning (PBL) or an academic detailing (AD) method facilitated by local GPs. Data were gathered during 1 week in November in all study years and also from external control HCs in 2002. The main outcome measure was compliance with the key points of AMS management in national Current Care guidelines. RESULTS: Implementation of guidelines produced minor changes towards the recommended practices in the management of AMS. Use of the first-line drug amoxicillin increased slightly (from 39% to 48% in AD centres and from 33% to 45% in PBL centres, controls 40%). Proportion of courses of antibiotics with recommended duration increased in MIKSTRA study centres (from 34% to 40% in AD centres and from 32% to 47% in PBL centres, controls 43%). CONCLUSIONS: A nationwide guidelines implementation project produced modest changes in the management of AMS. There were no significant differences between AD and PBL education methods. Less than half the HCs were able to realize the project as intended, which decreases the internal validity of the study. The guidelines implementation might have benefited of more focussed targets and approaches that took into account the problems and practices of each HC.     

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.     

Effects of educational outreach visits on prescribing of benzodiazepines and antipsychotic drugs to elderly patients in primary health care in southern Sweden

BACKGROUND: Different methods have previously been tested to affect GPs' prescribing habits. Attention has been drawn to benzodiazepines and antipsychotic drugs that are associated with several adverse effects in the elderly. OBJECTIVE: To evaluate if educational outreach visits to GP practices can affect the prescribing of benzodiazepines and antipsychotic drugs to the elderly and to evaluate the opinions of the participating GPs on such education. METHODS: In the county of Sk?ne, Sweden, 41 GP practices were invited to participate in educational outreach visits. Fifteen GP practices accepted the invitation. Practices were randomised to active (8 practices, 23 physicians) and control group (7 practices, 31 physicians). After the educational outreach visits prescribing of benzodiazepines and antipsychotic drugs to patients 65 years or older were measured for 1 year. The control group participated in the education after the study period. The opinions of GPs on educational outreach visits were evaluated. RESULTS: One year after the educational outreach visits there were significant decreases in the active group compared to control group in the prescribing of medium- and long-acting benzodiazepines and total benzodiazepines but not so for antipsychotic drugs. CONCLUSIONS: Educational outreach visits can be effective in modifying GPs' prescribing habits. We have shown this to be so for prescribing of benzodiazepines to elderly patients in primary health care. Educational outreach visits are also very well appreciated by participating GPs.     

The use of text messaging to improve attendance in primary care: a randomized controlled trial

BACKGROUND: Non-attendance is common in primary care and previous studies have reported that reminders were useful in reducing broken appointments. OBJECTIVE: To determine the effectiveness of a text messaging reminder in improving attendance in primary care. DESIGN: Multicentre three-arm randomized controlled trial. SETTING: Seven primary care clinics in Malaysia. Participants. Patients (or their caregivers) who required follow-up at the clinics between 48 hours and 3 months from the recruitment date. Interventions. Two intervention arms consisted of text messaging and mobile phone reminders 24-48 hours prior to scheduled appointments. Control group did not receive any intervention. Outcome measures. Attendance rates and costs of interventions. RESULTS: A total of 993 participants were eligible for analysis. Attendance rates of control, text messaging and mobile phone reminder groups were 48.1, 59.0 and 59.6%, respectively. The attendance rate of the text messaging reminder group was significantly higher compared with that of the control group (odds ratio 1.59, 95% confidence interval 1.17 to 2.17, P = 0.005). There was no statistically significant difference in attendance rates between text messaging and mobile phone reminder groups. The cost of text messaging reminder (RM 0.45 per attendance) was lower than mobile phone reminder (RM 0.82 per attendance). CONCLUSIONS: Text messaging reminder system was effective in improving attendance rate in primary care. It was more cost-effective compared with the mobile phone reminder.     

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     

Effect of preventive health screening on long-term primary health care utilization. A randomized controlled trial

BACKGROUND: Regular preventive health screenings are a feature of primary health care in several countries. Studies of the effect of regular preventive health checks have reported different results regarding primary health care utilization. OBJECTIVE: To analyse the effect of preventive health screening and health discussions on contacts to general practice. METHODS: A randomized controlled trial with all GPs in the district of Ebeltoft, Denmark. All middle-aged residents registered with a GP in the district of Ebeltoft were included (n = 3464). A random sample of 2030 subjects was selected for invitation to participate in health screening or health screening and discussions. The remaining 1434 subjects were never contacted and served as an external control group. Main outcome measure was number of daytime consultations in general practice. RESULTS: The annual rate ratios for daytime consultations showed a very clear time trend (P < 0.0001) with a high rate of contacts among invited compared with non-invited subjects during the first year (P = 0.001) followed by a gradual decrease to a lower level after eight years (P = 0.037). The total rate ratio for daytime consultations was 1.01 (95% CI 0.93 to 1.10). CONCLUSION: We observed no differences between the invited group and the non-invited group in any type of contact to general practice when the entire follow-up period was considered. There was a significant trend in rate ratios for daytime consultations with an initial rise followed by a gradual decrease in rate ratios. More investigations are needed to confirm and explore reasons for this trend.     

Frequency and diagnostic utility of cognitive test instrument use by GPs prior to memory clinic referral

BACKGROUND: Previous studies have indicated not only that cases of dementia are missed in primary care but also that many non-demented patients are referred for evaluation to secondary care. OBJECTIVES: To measure frequency of cognitive test instrument use in primary care prior to patient referral to secondary care and to assess the relationship between instrument use and ultimate diagnosis. METHODS: This was a prospective study conducted in a Cognitive Function Clinic, Regional Neuroscience Centre setting. The referral letters for all patients seen in the clinic over a 2-year period (n = 231) were examined for mention of cognitive test instrument use. Patients were evaluated by standard clinical, neuropsychological and neuroimaging methods and diagnoses were made according to widely accepted diagnostic criteria for dementia and dementia subtype. Primary care cognitive test use and final diagnosis were then compared. RESULTS: Evidence of cognitive test use in primary care was found in 20% of referrals. Patients evaluated with cognitive test instruments in primary care were more likely to receive a diagnosis of dementia, whereas those not tested were more likely to receive a diagnosis of 'not demented'. CONCLUSIONS: Use of simple cognitive test instruments in primary care may improve dementia diagnosis and reduce the rate of referral of non-demented patients.     

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.     

Primary care practice a la carte among GPs: using organizational diversity to increase job satisfaction

BACKGROUND: Primary care revival in Canada and elsewhere is viewed by many as conditional to the introduction of new organizational models. Endorsement by GPs is a key factor in the success of these models, and increasing GPs' job satisfaction is often one of the desired outcomes of the reforms currently underway. OBJECTIVES: The phenomenon of work satisfaction from the GP's perspective is not yet fully understood. The objectives of this study were to elicit its different facets and to understand better how organizational factors affect it. METHODS: This is a case study carried out in the province of Quebec (Canada). We conducted semi-structured interviews with 28 GPs working in private clinics and community health centres (Centre local de services communautaires). RESULTS: The main themes uncovered are related to the relationship between time management and quality of care, variation in work, autonomy in day-to-day practice, team 'orientedness' and social rewards. We also found that some GPs prefer to combine work in different organizations and models in order to increase their job satisfaction and to better cope with an increasingly complex task environment. CONCLUSION: Our study provides a comprehensive view of the various dimensions that GPs consider important in their professional life. Our findings suggest that, for many GPs, the perfect practice is tailor made and implies a combination of organizational models in order to fulfil their multiple professional goals. This has important implications for decision makers who are promoting new primary care models.     

A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes

BACKGROUND: Somatising patients frequently present in primary care but GPs often express frustration in dealing with them. A negative attitude may result in missed diagnoses and ineffective treatment. OBJECTIVE: This study aimed to evaluate the effect of a novel, multifaceted training programme on GPs' attitudes towards somatisation. METHODS: The study was performed as a cluster randomised controlled trial with practices as randomisation unit and with a follow-up period of 12 months. Forty-three GPs from 27 practices in Vejle County, Denmark participated. The intervention consisted of a cognitive-oriented educational programme on assessment, treatment and management of somatisation (The Extended Reattribution and Management Model). Outcome measures were GPs' attitudes toward somatoform disorder and somatisation in general measured by the means of questionnaires at baseline and follow-up. The primary outcome was a change in response. RESULTS: Baseline values confirmed previous findings that GPs find it difficult to deal with somatising patients. Compared with the control doctors, intervention doctors' attitudes towards patients with somatoform disorders had changed significantly 12 months after training on the parameters enjoyment (P = 0.008) and anxiety (P = 0.002). Doctors also felt more comfortable in dealing with somatising patients in general (P = 0.002). Attitudes about other parameters related to the doctors feelings, aetiology and course of somatisation changed in the expected direction, but these changes were not statistically significant. CONCLUSION: A brief multifaceted training programme focussing on somatisation was accompanied by a significant change in GPs' attitude towards patients with somatoform disorders.     

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.