Non-pharmacological intervention for gastro-oesophageal reflux disease in primary care

Background

Up to 50% of patients with gastro-oesophageal reflux disease (GORD) have persistent symptoms despite taking proton pump inhibitors (PPIs) regularly. Lifestyle advice is available to patients, but no previous UK study has tested a behavioural change intervention to help patients self-manage their symptoms.

Aim

To determine whether a primary care, nurse-led intervention to address behaviours that promote GORD symptoms results in symptom improvement, an increased sense of control, and a reduced requirement for prescribed medication.

Design of study

A group intervention focusing on diet and stress was delivered to patients with reflux symptoms, recruited in rural general practices.

Setting

General practice in England.

Method

Forty-two subjects (male 19, female 23) aged 31–86 years took part. Pre- and post-intervention data were gathered using the Brief Illness Perception Questionnaire (BIPQ), the GORD Impact Scale (GIS), and the Hospital Anxiety and Depression Scale (HAD).

Results

There was a significant improvement (BIPQ P<0.001, GIS P = 0.008) 3 months after the intervention. There was no reduction in PPI use or change in HAD score. The greatest improvements were demonstrated in domains measuring the patient''s sense of control, perception of symptoms, and understanding of reflux. Patients reported benefits including understanding relevant anatomy and physiology, learning behavioural techniques to change eating patterns and manage stress, identifying actual and potential triggers, and developing and executing action plans.

Conclusion

An education programme for GORD enhances self-management, brings perceived symptom improvement, and promotes a sense of control at 3 months. This type of behavioural intervention, alongside medical management, could improve symptom control for reflux patients with refractory symptoms and should be the subject of a controlled trial.     

Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database

Background

Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines.

Aim

To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines.

Design of study

Cohort study.

Setting

UK general practices contributing to the General Practice Research Database (GPRD).

Method

Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management.

Results

A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period.

Conclusion

These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions.     

Introducing genetic testing for cardiovascular disease in primary care: a qualitative study

Background

While primary care systematically offers conventional cardiovascular risk assessment, genetic tests for coronary heart disease (CHD) are increasingly commercially available to patients. It is unclear how individuals may respond to these new sources of risk information.

Aim

To explore how patients who have had a recent conventional cardiovascular risk assessment, perceive additional information from genetic testing for CHD.

Design and setting

Qualitative interview study in 12 practices in Nottinghamshire from both urban and rural settings.

Method

Interviews were conducted with 29 adults, who consented to genetic testing after having had a conventional cardiovascular risk assessment.

Results

Individuals’ principal motivation for genetic testing was their family history of CHD and a desire to convey the results to their children. After testing, however, there was limited recall of genetic test results and scepticism about the value of informing their children. Participants dealt with conflicting findings from the genetic test, family history, and conventional assessment by either focusing on genetic risk or environmental lifestyle factors. In some participants, genetic test results appeared to reinforce healthy behaviour but others were falsely reassured, despite having an ‘above-average’ conventional cardiovascular risk score.

Conclusion

Although genetic testing was acceptable, participants were unclear how to interpret genetic risk results. To facilitate healthy behaviour, health professionals should explore patients’ understanding of genetic test results in light of their family history and conventional risk assessment.     

The delivery of prevention programmes for cardiovascular disease and chronic obstructive pulmonary disease in Lodz by primary care physicians

Introduction

In Poland, the National Health Fund (NHF) has contracted preventative interventions in primary health care (PHC) delivered by family physicians, internists, paediatricians and other physicians. The aim of the study was determining whether there is a correlation between PHC physicians’ specialisation and the rate of interventions delivered for the prevention of cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD).

Material and methods

A retrospective observational study of the NHF 2005 data related to the delivery of prevention programmes using Spearman''s rank correlation coefficient (rho).

Results

Out of 133 PHC providers in Lodz, 25 participated in the cardiovascular disease (CVD) prevention programme, 22 in the chronic obstructive pulmonary disease (COPD) prevention programme at a basic level, and 20 at an extended level (with contract completion rates respectively of 55.2, 47.8 and 51.5%). When all three prevention programmes were analysed together, the correlation between the rate of preventative interventions by physicians with a particular specialisation and the contract completion rate was positive (rho > 0) only for family physicians.

Conclusions

Participation of primary health care providers in preventative programmes and the rates of their delivery of interventions were low despite additional funding. The correlation between the proportion of physicians with a particular specialisation, involved in CVD and COPD prevention interventions delivery, and the rate of the programme accomplishment was the strongest for family physicians.     

Recorded quality of primary care for osteoarthritis: an observational study

Background

Osteoarthritis is the most common chronic disease in the UK, with greater prevalence in women, older people, and those with poorer socioeconomic status. Effective treatments are available, yet little is known about the quality of primary care for this disabling condition.

Aim

To measure the recorded quality of primary care for osteoarthritis, and assess variavariations by patient and/or practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Records of 320/393 randomly selected patients with osteoarthritis (response rate 81%) were reviewed. High-quality health care was specified by nine quality indicators. Logistic regression modelling assessed variations in quality by age, sex, deprivation, severity, time since diagnosis, and practice size.

Results

There was substantial variation in the recorded achievement of individual indicators (range 5% to 90%). The percentage of eligible patients whose records show that they received care in the form of information provision ranged from 17% to 30%. For regular assessment indicators the range was 27% to 43%, and for treatment indicators the range was 5% to 90%. Recorded achievement of quality indicators was higher in those with more severe osteoarthritis (odds ratio [OR] 1.38, 95% CI = 1.13 to 1.69) and in older patients (OR 1.14, 95% CI = 1.02 to 1.28). There were no significant variations by deprivation score.

Conclusion

This study has demonstrated the feasibility of using existing robust quality indicators to measure the quality of primary care for osteoarthritis, and has found considerable scope for improvement in the recording of high-quality care. The lack of variation between practices suggests that system-level initiatives may be needed to achieve improvement. One challenge will be to improve care for all, without losing the equitable distribution of care identified.     

Seeking support after hospitalisation for injury: a nested qualitative study of the role of primary care

Background

In the UK, studies suggest that the transition from hospital to home after an injury can be a difficult time and many patients report feeling inadequately prepared. Patients often use primary care services after hospital discharge. These consultations provide opportunities to consider problems that patients experience and to facilitate recovery. Little is known, however, about how patients and service providers view care after hospital discharge and the role played by primary care services, specifically GPs.

Aim

To identify good practice and unmet needs in respect of post-discharge support for injured patients.

Design and setting

Qualitative study using semi-structured interviews at four sites (Bristol, Leicester/Loughborough, Nottingham, and Surrey).

Method

Qualitative interviews with 40 service providers and 45 hospitalised injured patients.

Results

Although there were examples of well-managed hospital discharges, many patients felt they were not provided with the information they needed about their injury, what to expect in terms of recovery, pain control, return to work, psychological problems, and services to help meet their needs. They also described difficulty accessing services such as physiotherapy or counselling. Service providers identified problems with communication between secondary and primary care, lack of access to physiotherapy, poor communication about other services that may help patients, GP service and resource constraints, and difficulties in providing information to patients concerning likely prognosis.

Conclusion

Discharge from hospital after an injury can be problematic for patients. Changes in both secondary and primary care are required to resolve this problem.     

Development and evaluation of a brief self-completed family history screening tool for common chronic disease prevention in primary care

Background

Family history is an important risk factor for many common chronic diseases, but it remains underutilised for diagnostic assessment and disease prevention in routine primary care.

Aim

To develop and validate a brief self-completed family history questionnaire (FHQ) for systematic primary care assessment for family history of diabetes, ischaemic heart disease, breast cancer, and colorectal cancer.

Design and setting

Two-stage diagnostic validation study in 10 general practices in eastern England.

Method

Participants aged 18–50 years were identified via random sampling from electronic searches of general practice records. Participants completed a FHQ then had a three-generational ‘gold standard’ pedigree taken, to determine disease risk category. In stage 1, the FHQ comprised 12 items; in stage 2 the shorter 6-item FHQ was validated against the same ‘gold standard’.

Results

There were 1147 participants (stage 1: 618; stage 2: 529). Overall, 32% were at increased risk of one or more marker conditions (diabetes 18.9%, ischaemic heart disease 13.3%, breast cancer 6.2%, colorectal cancer 2.2%). The shorter 6-item FHQ performed very well for all four conditions: pooled data from both stages show diabetes, sensitivity = 98%, specificity = 94%; ischaemic heart disease, sensitivity = 93%, specificity = 81%; breast cancer, sensitivity = 81%, specificity = 83%; colorectal cancer, sensitivity = 96%, specificity = 88%, with an area under the receiver operating characteristic curve of 0.90 for males and 0.89 for females.

Conclusion

This brief self-completed FHQ shows good diagnostic accuracy for identifying people at higher risk of four common chronic diseases. It could be used in routine primary care to identify patients who would be most likely to benefit from a more detailed pedigree and risk assessment, and consequent management strategies.     

Cancer diagnosis in primary care

Around a quarter of those in the developed world die of cancer. Most cancers present to primary care with symptoms, even when there is a screening test for the particular cancer. However, the symptoms of cancer are also symptoms of benign disease, and the GP has to judge whether cancer is a possible explanation. Very little research examined this process until relatively recently. This review paper examines the process of primary care diagnosis, especially the selection of patients for rapid investigation. It concentrates on the four commonest UK cancers: breast, lung, colon, and prostate as these have been the subject of most recent studies.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.     

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

Background

Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.

Aim

To explore processes underpinning the implementation of CKD management in primary care.

Design and setting

Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.

Method

Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.

Results

A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.

Conclusion

Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.     

Interpersonal continuity of care: a cross-sectional survey of primary care patients'' preferences and their experiences

BACKGROUND: Developments in primary care may make the provision of interpersonal continuity more difficult. AIM: To identify those patients who regard interpersonal continuity as important and determine what makes it difficult for them to obtain this. Design of study: Cross sectional survey. SETTING: Twenty-two practices and a walk-in centre in West London and Leicestershire, UK. METHOD: Administration of a questionnaire on preferences for and experiences of interpersonal and informational continuity. Interpersonal continuity was defined in three questions: choosing a particular person; choosing someone known and trusted; and choosing someone who knows the patient and medical condition. RESULTS: One thousand four hundred and thirty-seven (46.5%) patients responded. Consulting someone known and trusted was important to 766 (62.6%) responders, although 105 (13.7%) of these reported that they had not experienced it at their last consultation. Seven hundred and eighty-eight (65.2%) responders regarded being able to consult a particular person as important, but 168 (21.3%) of these were unable to. Being in work and consulting for a new problem were associated with failing to obtain interpersonal continuity. Ethnic group was associated with failing to see someone with time to listen when this was preferred. CONCLUSION: In view of the response rate, which was particularly low among young males, some caution is required in applying the findings. Most patients experience the aspects of care important to them, although interpersonal continuity is important to many and certain groups find difficulty in obtaining it. Practices should have flexible appointment systems to account for the difficulties some patients have in negotiating for the type of care they want.     

Hepatic sinusoidal macrophages in alcoholic liver disease

Lysozyme is a bacteriocidal enzyme which is a major stable secretory product of mononuclear phagocytes, including hepatic sinusoidal macrophages (HSM), and serves as a good marker for these cells. Patients with alcoholic liver disease (ALD) have decreased HSM function which is reflected in reduced clearance of microorganisms and endotoxin derived from the gut. The HSM population in 54 liver biopsies from patients with ALD was studied using immunoperoxidase staining of lysozyme and was compared with 15 histologically normal controls. In both groups lysozyme positive HSM were more numerous in periportal than perivenous parenchyma. In each zone there were significantly fewer positive HSM in cases of ALD than in controls, in alcoholic hepatitis than in ALD without hepatitis, and in cirrhosis than in ALD without cirrhosis. These findings suggest a decreased population of functionally active HSM in ALD which correlates with severity of liver damage. This might be due to decreased lysozyme content of the entire HSM population or to the existence of two populations, one positive and one negative for lysozyme. The observed decrease in HSM function explains many of the phenomena observed in ALD.     

Prevalence and factors associated with tuberculosis treatment outcome among hazardous or harmful alcohol users in public primary health care in South Africa

Background

Tuberculosis (TB) remains a chronic infectious disease with high morbidity and mortality.

Objective

The aim of this study was to assess the prevalence and associated factors of tuberculosis treatment failure, death and default among hazardous or harmful alcohol users.

Method

We conducted a prospective study with TB patients in 40 public health clinics in three districts in South Africa. All consecutively new tuberculosis and retreatment patients presenting at the 40 primary health care facilities with hazardous or harmful alcohol use were included in this study. Logistic regression was used to assess determinants of TB treatment failure, death and default.

Results

The findings of our study showed that 70% of TB patients were either cured or had completed their TB treatment by the end of 6 months. In multivariate analysis participants living in a shack or traditional housing (Odds Ratio=OR: 0.63, Confidence Interval=CI: 0.45–0.89), being a TB retreatment patient (OR: 1.61, CI: 1.15–2.26) and residing in the eThekwini district (OR: 1.82, CI: 1.27–2.58) were significant predictors of treatment failure, death and default.

Conclusion

A high rate of treatment failure, death and default were found in the TB patients. Several factors were identified that can guide interventions for the prevention of treatment failure, death and default.     

Seeking ethical approval for an international study in primary care patient safety

Seeking ethics committee approval for research can be challenging even for relatively simple studies occurring in single settings. Complicating factors such as multicentre studies and/or contentious research issues can challenge review processes, and conducting such studies internationally adds a further layer of complexity. This paper draws on the experiences of the LINNAEUS Collaboration, an international group of primary care researchers, in obtaining ethics approval to conduct an international study investigating medical error in general practice in six countries. It describes the ethics review processes applied to exactly the same research protocol for a study run in Australia, Canada, England, the Netherlands, New Zealand, and the US. Wide variation in ethics review responses to the research proposal occurred, from no approval being deemed necessary to the study plan narrowly avoiding rejection. The authors'' experiences demonstrated that ethics committees operate in their own historical and cultural context, which can lead to radically different subjective interpretations of commonly-held ethical principles, and raised further issues such as ‘what is research?’. This first LINNAEUS study started when patient safety was a particularly sensitive subject. Although it is now a respectable area of inquiry, patient safety is still a topic that can excite emotions and prejudices. The LINNAEUS Collaboration now extends to more countries and continues to pursue an international research agenda, so reflection on the influences of history, social context, and structure of each country''s ethical review processes is timely.     

Views of cancer care reviews in primary care: a qualitative study

Background

The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.

Aim

To describe: (1) implementation of the QOF cancer care review; (2) patients'' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients'' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.

Design of study

Qualitative study using thematic analysis and a framework approach.

Setting

Six general practices in the Thames Valley area.

Method

Semi-structured interviews with cancer patients and focus groups with primary care teams.

Results

Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients'' needs and closer links with secondary care to facilitate a more involved role.

Conclusion

Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care.     

Association of GPs’ risk attitudes,level of empathy,and burnout status with PSA testing in primary care

BackgroundRates of prostate specific antigen (PSA) test ordering vary among GPs.AimTo examine whether GPs’ risk attitude, level of empathy, and burnout status are associated with PSA testing.MethodPSA tests from 2012 were retrieved from a register and classified as incident (that is, the first PSA test within 24 months), repeated normal, or repeated raised tests. This was merged with information on GPs’ risk attitudes, empathy, and burnout status from a 2012 survey.ResultsPatients registered with a GP with a high score on anxiety caused by uncertainty (odds ratio [OR] 1.03, 95% confidence interval [CI] = 1.00 to 1.06, P = 0.025) or concern about bad outcomes (OR 1.04; 95% CI = 1.00 to 1.08, P = 0.034) were more likely to have an incident PSA test, whereas those registered with a GP with increased tolerance for ambiguity were less likely (OR 0.98, 95% CI = 0.96 to 1.00, P = 0.025). Patients registered with a GP reporting high tolerance for ambiguity (OR 0.96, 95% CI = 0.94 to 0.99, P = 0.009) or high propensity to risk-taking (OR 0.97, 95% CI = 0.93 to 1.00, P = 0.047) were less likely to have a repeated normal PSA test.ConclusionVarious aspects of GPs’ risk-taking attitudes were associated with patients’ probability of having an incident and a repeated normal PSA test. The probability of having a repeated raised PSA test was not influenced by any of the psychological factors. Burnout and empathy were not associated with PSA testing.     

The strength of primary care in Europe: an international comparative study

Background

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking.

Aim

Evaluation of strength of primary care in Europe.

Design and setting

International comparative cross-sectional study performed in 2009–2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey.

Method

Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts’ consultations.

Results

Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries.

Conclusion

Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.     

Histological demonstration and frequency of intrahepatocytic copper in patients suffering from alcoholic liver disease

This study was carried out to determine whether stainable copper accumulates in the hepatocytes of patients with alcoholic liver disease. Liver sections from 44 cases of alcoholic cirrhosis and 32 cases of non-cirrhotic alcoholic liver disease were stained by the rubeanic acid, rhodanine and orcein methods. Intrahepatocytic copper granules were found in 13 cases of cirrhosis (30%), but in none of the non-cirrhotic livers. The abundance of granules did not appear to be related either to the activity of the cirrhotic process or to the presence of cholestasis. It may well be that alcoholic cirrhosis is the most common disease associated with excess of intrahepatocytic copper.