Early diagnostic suggestions improve accuracy of GPs: a randomised controlled trial using computer-simulated patients

BackgroundDesigners of computerised diagnostic support systems (CDSSs) expect physicians to notice when they need advice and enter into the CDSS all information that they have gathered about the patient. The poor use of CDSSs and the tendency not to follow advice once a leading diagnosis emerges would question this expectation.AimTo determine whether providing GPs with diagnoses to consider before they start testing hypotheses improves accuracy.MethodData were collected over the internet. After reading some initial information about the patient and the reason for encounter, GPs requested further information for diagnosis and management. Those receiving early support were shown a list of possible diagnoses before gathering further information. In late support, GPs first gave a diagnosis and were then shown which other diagnoses they could still not discount.ResultsEarly support significantly improved diagnostic accuracy over control (odds ratio [OR] 1.31; 95% confidence interval [95%CI] = 1.03 to 1.66, P = 0.027), while late support did not (OR 1.10; 95% CI = 0.88 to 1.37). An absolute improvement of 6% with early support was obtained. There was no significant interaction with case difficulty and no effect of GP experience on accuracy. No differences in information search were detected between experimental conditions.ConclusionReminding GPs of diagnoses to consider before they start testing hypotheses can improve diagnostic accuracy irrespective of case difficulty, without lengthening information search.     

Development and validation of the Molluscum Contagiosum Diagnostic Tool for Parents: diagnostic accuracy study in primary care

Background

Molluscum contagiosum (MC) is diagnosed by its distinct appearance. Parental diagnosis of MC may reduce anxiety and lead to reductions in healthcare consultations, and may be particularly useful in large-scale epidemiological studies. However, there are currently no published, validated tools allowing parental diagnosis of MC.

Aim

To develop and validate a tool for parental diagnosis of MC.

Design and setting

The Molluscum Contagiosum Diagnostic Tool for Parents (MCDTP) was developed and its diagnostic accuracy was compared with GP diagnosis in 12 GP surgeries in South Wales.

Method

Following development, which involved three phases with dermatologists, nurses, GPs, and parents, parents completed the MCDTP (index test) in the practice waiting room, and rated their confidence in their diagnosis. A GP then examined their child for MC (reference test). Test characteristics were calculated for all responders and for those who expressed being confident or very confident in their diagnosis.

Results

A total of 203 parents completed the MCDTP. The MCDTP showed a sensitivity of 91.5% (95% confidence intervals (CI) = 81.3 to 97.2) and a specificity of 88.2% (95% CI = 81.8 to 93.0) in all parents and a sensitivity of 95.8% (95% CI = 85.7 to 99.5) and a specificity of 90.9% (95% CI = 83.9 to 95.6) in parents who were confident or very confident in their diagnosis. The positive predictive value was 76.1% (95% CI = 64.5 to 85.4) and negative predictive value was 96.2% (95% CI = 91.4 to 98.8) for all parents.

Conclusion

The MCDTP performed well compared with GP diagnosis and is suitable for clinical use by parents and in population-based studies.     

Primary care: the cornerstone of diagnosis of allergic rhinitis

Allergic rhinitis (AR) is a very common disease with over 600 million people (200 million of them with concomitant asthma) worldwide suffering from it. The majority of patients who seek medical advice are seen in primary care. Although there is a selection of guidelines focused on the management of AR, there is a paucity of guidance on how best to identify patients who would most benefit from treatment. The aim of this paper was to review the best practice for primary care with respect to the diagnosis of AR within that clinical environment.     

Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries

The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. The purpose of this review was to identify the current state of knowledge about health information systems adoption in primary care. The goal was to understand factors and influencers affecting implementation outcomes from previous health information systems implementations experiences. A comprehensive systematic literature review of peer reviewed and grey literature was undertaken to identify the current state of knowledge regarding the implementation of health information systems. A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commission websites were searched. The searches returned almost 3700 article titles. Eighty-six articles met our inclusion and exclusion criteria.Articles show that systems’ graphical user interface design quality, feature functionality, project management, procurement and users’ previous experience affect implementation outcomes. Implementers had concerns about factors such as privacy, patient safety, provider/patient relations, staff anxiety, time factors, quality of care, finances, efficiency, and liability. The review showed that implementers can insulate the project from such concerns by establishing strong leadership, using project management techniques, establishing standards and training their staff to ensure such risks do not compromise implementation success. The review revealed the concept of socio-technical factors, or “fit” factors, that complicate health information systems deployment. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a health care work environment.The review showed that quality of care, patient safety and provider/patient relations were not, positively or negatively, affected by systems implementation. The fact that no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions. No studies were found that compared how provider-patient interactions in interviews are effected when providers used electronic health information systems as opposed to the paper equivalent. Very little information was available about privacy and liability.     

The compatibility of prescribing guidelines and the doctor-patient partnership: a primary care mixed-methods study

Background

UK policy expects health professionals to involve patients in decisions about their care (including medicines use) and, at the same time, to follow prescribing guidelines. The compatibility of these approaches is unclear.

Aim

To explore the relationship between prescribing guidelines and patient-partnership by exploring the attitudes of patients, GPs and primary care trust (PCT) prescribing advisors.

Design and setting

A mixed-methods study using qualitative, semi-structured interviews followed by a quantitative, questionnaire survey in primary care in Northern England.

Method

Interviews were conducted with 14 patients taking a statin or a proton pump inhibitor, eight GPs and two prescribing advisors. A multi-variate sampling strategy was used. Qualitative findings were analysed using framework analysis. Questionnaires based on themes derived from the interviews were distributed to 533 patients and 305 GPs of whom 286 (54%) and 142 (43%) responded.

Results

Areas of tension between guidelines and patient partnership were identified, including potential damage to trust in the doctor and reduced patient choice, through the introduction of the policy maker as a third stakeholder in prescribing decisions. Other areas of tension related to applying single condition guidelines to patients with multiple illnesses, competition for doctors'' time and the perception of cost containment. Many GPs coped with these tensions by adopting a flexible approach or prioritising the doctor–patient relationship over guidelines.

Conclusion

Rigidly applied guidelines can limit patient choice and may damage the doctor–patient relationship. GPs need flexibility in order to optimise the implementation of prescribing guidelines, while responding to individuals'' needs and preferences.     

Strategies for distributing cancer screening decision aids in primary care

Objective

Decision aids (DAs) have been shown to facilitate shared decision making about cancer screening. However, little data exist on optimal strategies for dissemination. Our objective was to compare different decision aid distribution models.

Methods

Eligible patients received video decision aids for prostate cancer (PSA) or colon cancer screening (CRC) through 4 distribution methods. Outcome measures included DA loans (N), % of eligible patients receiving DA, and patient and provider satisfaction.

Results

Automatically mailing DAs to all age/gender appropriate patients led to near universal receipt by screening-eligible patients, but also led to ineligible patients receiving DAs. Three different elective (non-automatic) strategies led to low rates of receipt. Clinician satisfaction was higher when patients viewed the DA before the visit, and this model facilitated implementation of the screening choice. Regardless of timing or distribution method, patient satisfaction was high.

Conclusions

An automatic DA distribution method is more effective than relying on individual initiative. Enabling patients to view the DA before the visit is preferred.

Practice implications

Systematically offering DAs to all eligible patients before their appointments is the ideal strategy, but may be challenging to implement.     

Manual-Based Treatment: An Essential Ingredient of Clinical Practice in the 21st Century

Wilson (this issue) raises several thought-provoking issues pertaining to the use of manual-based treatments (MBTs) in clinical practice. Based on my experiences as a researcher of manual-based treatments for social phobia and as a clinical psychologist in independent practice, I share my perspective on several of Wilson's points. Comorbid conditions do not appear to hinder the outcomes of MBTs for social phobia, and participants in controlled clinical trials do not appear very different from persons who refuse or are excluded from participation. Manuals can be written in a manner that retains a great deal of flexibility for the clinician, and these manuals may be productively employed in clinical settings. Proper implementation of MBTs requires experience with the disorder of interest and a strong background in theories of psychopathology and therapy technique.     

Hospital admissions from nursing homes: a qualitative study of GP decision making

Background

Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As ‘gatekeepers’ to NHS, GPs are expected to make best use of resources and may be criticised for ‘inappropriate’ admissions. Little is understood about the influences on GPs as they make such decisions

Aim

To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital.

Design and setting

A purposive sample of 21 GPs from two counties in the South of England.

Method

Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.

Results

This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients’ and relatives’ preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable.

Conclusion

Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.     

Clinical history for diagnosis of dementia in men: Caerphilly Prospective Study

Background

Diagnosis of dementia often requires specialist referral and detailed, time-consuming assessments.

Aim

To investigate the utility of simple clinical items that non-specialist clinicians could use, in addition to routine practice, to diagnose all-cause dementia syndrome.

Design and setting

Cross-sectional diagnostic test accuracy study. Participants were identified from the electoral roll and general practice lists in Caerphilly and adjoining villages in South Wales, UK.

Method

Participants (1225 men aged 45–59 years) were screened for cognitive impairment using the Cambridge Cognitive Examination, CAMCOG, at phase 5 of the Caerphilly Prospective Study (CaPS). Index tests were a standardised clinical evaluation, neurological examination, and individual items on the Informant Questionnaire for Cognitive Disorders in the Elderly (IQCODE).

Results

Two-hundred and five men who screened positive (68%) and 45 (4.8%) who screened negative were seen, with 59 diagnosed with dementia. The model comprising problems with personal finance and planning had an area under the curve (AUC) of 0.92 (95% confidence interval [CI] = 0.86 to 0.97), positive likelihood ratio (LR+) of 23.7 (95% CI = 5.88 to 95.6), negative likelihood ratio (LR−) of 0.41 (95% CI = 0.27 to 0.62). The best single item for ruling out was no problems learning to use new gadgets (LR− of 0.22, 95% CI = 0.11 to 0.43).

Conclusion

This study found that three simple questions have high utility for diagnosing dementia in men who are cognitively screened. If confirmed, this could lead to less burdensome assessment where clinical assessment suggests possible dementia.     

Public attitudes towards opt-out testing for HIV in primary care: a qualitative study

Background

The rate of new HIV infections in the UK continues to rise, with one-quarter of cases undiagnosed. Opt-out HIV testing — in which tests are routinely offered to all patients, with the offer to decline — have proved effective in antenatal care. Pilot studies of HIV opt-out testing at GP registration and acute medical admission to hospital have described service-level issues and the clinician’s perspective, but not the views of the general public.

Aim

To further understand the public’s perspective on opt-out testing for HIV in England.

Design and setting

Focus groups (n = 9) with a total of 54 participants in Brighton, England, where HIV prevalence is high.

Method

Quota sampling on sexual orientation, age, sex, and testing experience was applied to groups with high and low HIV prevalences, and analysed using framework analysis.

Results

Opt-out testing for HIV was acceptable. Testing on GP registration was regarded as a more appropriate setting than acute medical admission. Participants from groups in which HIV has a higher prevalence felt HIV testing required consideration that may not be possible during acute hospital admission. However, there was concern that screening would still be targeted at groups in which HIV prevalence is higher, based on clinicians’ judgement of patients’ behaviours, sexuality, or ethnicity.

Conclusion

The opt-out method of testing for HIV must be routinely offered to all who are eligible, to increase test uptake and to prevent communities feeling targeted. Any pressure to test is likely to be poorly received. Inaccurate concerns about medical records being shared with financial services are a disincentive to test. Primary care should be an active setting for opt-out HIV testing.     

Introducing case management for people with dementia in primary care: a mixed-methods study

Background

Case management may be a feasible solution to the problem of service fragmentation for people with dementia.

Aim

To adapt a US model of primary care-based case management for people with dementia and test it in general practice.

Design and setting

Mixed-methodology case studies of case management implementation in four general practices: one rural, one inner-city, and two urban practices. Practice nurses undertook the case manager role in the rural and inner-city practices, and were allocated one session per week for case management by their practices. A seconded social worker worked full time for the two urban practices.

Method

Participants were community-dwelling patients with dementia who were living at home with a family carer, and who were not receiving specialist care coordination. Case study methods included analysis of case loads and interviews with patients, carers, local NHS and other stakeholders, and case managers. Measures included numbers of patients with dementia and their carers, number of unmet needs identified, and actions taken to meet needs. Case manager records were compared with findings from interviews with patients and carers, and with other stakeholders.

Results

The number of eligible patients was smaller than expected. No practice achieved its recruitment target. Researchers identified more unmet needs than case managers. The practice nurse case managers reported lack of time and found research documentation burdensome. Patients and carers were positive about case management as a first point of contact with the practice, as a ‘safety net’, and for creating a one-to-one therapeutic relationship.

Conclusion

Further investigation is required before case management for people with dementia and their carers can be implemented in primary care.     

Developing performance indicators for primary care: Walsall's experience

Background

There has been increasing interest in the development of performance indicators in primary care, especially since the introduction of the Quality and Outcomes Framework (QOF). Public health and primary care trusts collect a range of data from routine or non-routine sources that may be useful for this purpose.

Aim

To assess whether performance against the QOF is a robust measure of practice performance when compared with health-inequality indicators and to contribute to the development of a tool to monitor and improve primary care services.

Design of study

A retrospective cross-sectional study.

Setting

Sixty-three GP practices contracted with Walsall Teaching Primary Care Trust.

Method

Correlation analysis and scatter plots were used to identify possible significant relationships between QOF scores and health-inequality data. The study also utilised confidence limit theory and control chart methodology as tools to identify possible performance outliers.

Results

Little correlation was found between overall QOF score and deprivation score. Uptake of flu immunisation (r² = 0.22) and cervical screening (r² = 0.11) both showed a slight increase with increased QOF score. Benzodiazepine (r² = 0.06) and antibiotic prescribing levels (r² = 0.02) decreased slightly with increased QOF scores, although not significantly. An increase in practice-population deprivation score was correlated with a reduction in cervical screening uptake (r² = 0.27) and an increase in benzodiazepine prescribing (r² = 0.25). Statistically significant relationships were found between the patient: GP ratio and flu immunisation uptake (r² = 0.1) and antibiotic prescribing (r² = 0.1). The majority of GPs found it acceptable to use performance indicator data as part of their annual appraisal.

Conclusion

QOF and health-inequality data can be used together to measure practice performance and to develop tools to help identify areas for performance development and the sharing of best practice.     

Bereavement care in primary care: a systematic literature review and narrative synthesis

Background

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

Aim

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them.

Design

Systematic literature review.

Method

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

Results

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to ‘medicalise’ normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

Conclusion

A small number of studies were identified, most of which were >10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.