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1.
Amy L Ahern Paul Aveyard Emma J Boyland Jason CG Halford Susan A Jebb 《The British journal of general practice》2016,66(645):e258-e263
Background
Primary care referral to a commercial open-group behavioural weight-loss programme is a cost-effective intervention, but only 10% of patients receiving this intervention are male.Aim
To explore whether observed biases in participation in these interventions reflect biases in the uptake of the invitation to participate.Design and setting
Comparison of invited population and recruited participants in a multicentre randomised controlled trial of primary care referral to a commercial open-group behavioural weight-loss programme in England (WRAP [Weight loss Referrals for Adults in Primary care]).Method
Between October 2012 and February 2014, participants were recruited through 23 primary care practices in England; 17 practices provided data on the characteristics of invited participants.Results
Females were twice as likely as males to enrol in the trial (odds ratio [OR] 2.01, 95% confidence interval [CI] = 1.75 to 2.32). However, the proportion of males was threefold higher than seen in routine primary care referrals or similar trials that invited patients opportunistically. People from less deprived areas were more likely to enrol than those in more deprived areas (OR 1.77, 95% CI = 1.55 to 2.03). Older patients (≥40 years) were more likely to enrol than younger patients (OR 1.60, 95% CI = 1.34 to 1.91).Conclusion
Males, younger people, and those from more deprived areas were less likely to take up the invitation to participate in this trial. The gender bias was smaller than observed in routine practice, suggesting that a substantial proportion of the inequity observed previously is a consequence of bias with regard to the offer of intervention. This study suggests that a simple way to overcome much of the gender bias is to write to patients who are overweight and offer referral. Uptake of the invitation to participate was lower in groups of lower socioeconomic status suggesting the need to preferentially offer referrals to this group to reduce health inequalities and for research to explore barriers to uptake. 相似文献2.
Background
The Care Of Childhood Obesity (COCO) clinic at the Bristol Royal Hospital for Children (BRHC) uses a multidisciplinary approach comprising a consultant, dietitian, and exercise specialist. The clinic has demonstrated efficacy in managing children''s weight but similar clinics are scarce in the UK.Aim
This pilot randomised controlled trial (RCT) aimed to examine the feasibility of undertaking a fully powered RCT and to gauge whether the COCO model could be effective as a nurse-led clinic in primary care settings.Design and setting
Patients were randomised to a hospital-based childhood obesity clinic or a nurse-led clinic in a primary care setting in south-west England.Method
Children aged 5–16 years with a body mass index (BMI) ≥98th centile were referred by GPs to the consultant in charge of the COCO clinic at BRHC. Referred children were clinically screened for suitability and invited into the study. Consenting families were randomised to BRHC or a primary care clinic (PCC) and offered five appointments over 12 months. Clinical effectiveness was measured by change in body mass index standard deviation score (BMI SDS) at 12 months. Other measures included: treatment adherence, quality of life (QOL), and satisfaction. Feasibility was examined by assessing referral, screening, and recruitment data.Results
A total 152 patients were referred by GPs: 31 (20%) were screened out; 45 (30%) declined to participate. Seventy-six (50%) patients were randomised and 68 provided baseline data (PCC = 42; BRHC = 26); 52 provided outcome data (PCC = 29; BRHC = 23). Mean change in BMI SDS was PCC –0.17 (95% confidence interval [CI] = –0.27 to –0.07); BRHC –0.15 (95% CI = –0.26 to –0.05). QOL, adherence, and satisfaction data indicated similar positive patterns in both trial arms.Conclusion
Screening and recruitment data indicate that primary care is a clinically appropriate setting and acceptable to families. The primary clinical outcome measure (reduction in BMI SDS), along with secondary outcome measures, indicate that primary care has the potential to be effective in providing weight management for children, using the COCO model. 相似文献3.
M. Jutel N. G. Papadopoulos H. Gronlund H.‐J. Hoffman B. Bohle P. Hellings G.‐J. Braunsthal A. Muraro P. Schmid‐Grendelmeier T. Zuberbier I. Agache 《Allergy》2014,69(6):708-718
The majority of patients seeking medical advice for allergic diseases are first seen in a primary care setting. Correct diagnosis with identification of all offending allergens is an absolute prerequisite for appropriate management of allergic disease by the general practitioner. Allergy diagnostic tests recommended for use in primary care are critically reviewed in accordance with the significant workload in a primary care setting. Simplified pathways for recognition and diagnosis of allergic diseases are proposed, that should be further adapted to local (national) conditions. 相似文献
4.
Kiran Nanchahal Joy Townsend Louise Letley David Haslam Kaye Wellings Andy Haines 《The British journal of general practice》2009,59(562):e157-e166
Background
There is a paucity of randomised controlled trials of weight management in primary care.Aim
To ascertain the feasibility of a full trial of a nurse-led weight-management programme in general practice.Design of study
Factorial randomised control trial.Setting
Primary care, UK.Method
A total of 123 adults (80.3% women, mean age 47.2 years) with body mass index ≥27 kg/m2, recruited from eight practices, were randomised to receive structured lifestyle support (n = 30), structured lifestyle support plus pedometer (n = 31), usual care (n = 31), or usual care plus pedometer (n = 31) for a 12-week period.Results
A total of 103 participants were successfully followed up. The adjusted mean difference in weight in structured support compared to usual care groups was −2.63 kg (95% confidence interval [CI] = −4.06 to −1.20 kg), and for pedometer compared to no pedometer groups it was −0.11 kg (95% CI = −1.52 to 1.30 kg). One in three participants in the structured-support groups (17/50, 34.0%) lost 5% or more of their initial weight, compared to less than one in five (10/53, 18.9%) in usual-care groups; provision of a pedometer made little difference (14/48, 29.2% pedometer; 13/55, 23.6% no pedometer). Difference in waist circumference change between structured-support and usual-care groups was −1.80 cm (95% CI = −3.39 to −0.20 cm), and between the pedometer and no pedometer groups it was −0.84 cm (95% CI = −2.42 to 0.73 cm). When asked about their experience of study participation, most participants found structured support helpful.Conclusion
The structured lifestyle support package could make substantial contributions to improving weight-management services. A trial of the intervention in general practice is feasible and practicable. 相似文献5.
6.
Jodie T Allen Simon R Cohn Amy L Ahern 《The British journal of general practice》2015,65(633):e248-e255
BackgroundReferral to a commercial weight-loss programme is a cost-effective intervention that is already used within the NHS. Qualitative research suggests this community-based, non-medical intervention accords with participants’ view of weight management as a lifestyle issue.AimTo examine the ways in which participants’ attitudes and beliefs about accessing a commercial weight management programme via their doctor relate to their weight-loss experience, and to understand how these contextual factors influence motivation and adherence to the intervention.MethodTwenty-nine participants (body mass index [BMI] ≥28 kg/m2; age ≥18 years), who took part in the WRAP (Weight Loss Referrals for Adults in Primary Care) trial, were recruited at their 3-month assessment appointment to participate in a semi-structured interview about their experience of the intervention and weight management more generally. Interviews were audiorecorded, transcribed verbatim, and analysed inductively using a narrative approach.ResultsAlthough participants view the lifestyle-based, non-medical commercial programme as an appropriate intervention for weight management, the referral from the GP and subsequent clinical assessments frame their experience of the intervention as medically pertinent with clear health benefits.ConclusionReferral by the GP and follow-up assessment appointments were integral to participant experiences of the intervention, and could be adapted for use in general practice potentially to augment treatment effects. 相似文献
7.
8.
Katrina M Turner Julian PH Shield Chris Salisbury 《The British journal of general practice》2009,59(568):856-862
Background
In 2006 the Department of Health and the National Institute for Health and Clinical Excellence (NICE) published guidance on the management of childhood obesity, for use by primary care practitioners. Little is known, however, about practitioners'' views and experiences of managing childhood obesity in primary care.Aim
To explore practitioners'' views of primary care as a setting in which to treat childhood obesity.Design of study
Qualitative interview study.Setting
Primary care and other community settings based in Bristol, England.Method
Interviews explored practitioners'' views and experiences of managing childhood obesity and their knowledge of the recent guidance provided by the Department of Health and NICE. Interviews were audiotaped and transcribed verbatim. Analysis was thematic and comparisons made both within and across the interviews.Results
Thirty practitioners were interviewed: 12 GPs, 10 practice nurses, four school nurses, and four health visitors. Participants varied in their views about whether primary care is an appropriate treatment setting for childhood obesity. However, all described factors that limited the extent to which they could intervene effectively: a lack of expertise, resources, and contact with primary school children; the causes of childhood obesity; and the need to work with parents. It was also apparent that very few participants had knowledge of the recent guidance.Conclusion
Practitioners do not currently view primary care as an effective treatment setting for childhood obesity and it is unlikely that the guidance from the Department of Health and NICE will have a meaningful impact on their management of this condition. 相似文献9.
Anne McAteer Deokhee Yi Verity Watson Patricia Norwood Mandy Ryan Philip C Hannaford Alison M Elliott 《The British journal of general practice》2015,65(636):e478-e488
BackgroundSymptoms are important drivers for the use of primary care services. Strategies aimed at shifting the focus away from the GP have broadened the range of primary healthcare available.AimTo explore preferences for managing symptoms and investigate trade-offs that the public are willing to make when deciding between different primary care services.MethodA discrete choice experiment examined management preferences for three symptoms of differing seriousness (diarrhoea, dizziness, and chest pain). Willingness-to-pay estimates compared preferences between symptoms, and by sex, age, and income.ResultsPreferences differed significantly between symptoms. ‘Self-care’ was the preferred action for diarrhoea and ‘consulting a GP’ for dizziness and chest pain. ‘Waiting time’ and ‘chance of a satisfactory outcome’ were important factors for all three symptoms, although their relative importance differed. Broadly, people were more prepared to wait longer and less prepared to trade a good chance of a satisfactory outcome for symptoms rated as more serious. Generally, preferences within subgroups followed similar patterns as for the whole sample, although there were differences in the relative strength of preferences.ConclusionDespite increased choices in primary care, ‘traditional’ actions of ‘self-care’ for minor symptoms and ‘GP consultation’ for more serious symptoms were preferred. The present findings suggest, however, that people may be willing to trade between different health services, particularly for less serious symptoms. Understanding the relative importance of different factors may help inform interventions aimed at changing management behaviour or improving services. 相似文献
10.
Kirsty Boyd Bruce Mason Marilyn Kendall Stephen Barclay David Chinn Keri Thomas Aziz Sheikh Scott A Murray 《The British journal of general practice》2010,60(581):e449-e458
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. 相似文献11.
Mansell G Shapley M Jordan JL Jordan K 《The British journal of general practice》2011,61(593):e821-e835
Background
Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.Aim
To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.Design and setting
Systematic review in primary care.Method
Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.Results
Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.Conclusion
There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so. 相似文献12.
Catherine Walshe Chris Todd Ann-Louise Caress Carolyn Chew-Graham 《The British journal of general practice》2008,58(549):264-272
BACKGROUND: Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. AIM: To explore the influences on referrals within general and specialist community palliative care services. DESIGN OF STUDY: Qualitative, multiple-case study. SETTING: Three primary care trusts in the north-west of England. METHOD: Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. RESULTS: Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes. CONCLUSION: Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care. 相似文献
13.
Eric Robinson Helen Parretti Paul Aveyard 《The British journal of general practice》2014,64(628):e703-e708
Background
Guidelines suggest that GPs should intervene on patients’ weight, but to do so GPs must first recognise that a patient may have a weight problem and weigh them.Aim
To examine whether GPs and trainee GPs can identify overweight and obese body weights by sight, and if this influences whether they would discuss weight with a potential patient.Design and setting
Study of GPs and trainee GPs on the lists of the UK NHS Workforce West Midlands Deanery and NHS Sandwell and West Birmingham Clinical Commissioning Group.Method
Participants viewed 15 standardised photographs of healthy-weight, overweight, and obese young males, and estimated their BMI, classified their weight status, and reported whether they would be likely to make a brief intervention for weight loss with that person.Results
The sample of GPs and trainee GPs correctly classified a mean of 4.0/5.0 of the healthy weight males, a mean of 2.4/5.0 of the overweight, and a mean of 1.7/5.0 of the obese males. For each 1 kg/m2 increase in actual BMI, participants underestimated BMI by −0.21 (95% CI = −0.22 to −0.18), meaning that participants would underestimate the BMI of a man of 30 kg/m2 by approximately 2.5 kg/m2, but were more accurate for lower body weights. Participants were more likely to intervene with those with a higher estimated BMI (OR 1.53, 95% CI = 1.49 to 1.58).Conclusion
This sample of predominantly trainee GPs perceived overweight and obese weights as being of lower BMI and weight status than they actually are, and this was associated with a lower intention of discussing weight management with a potential patient. This was found to be true for trainee and fully qualified GPs who participated in the study. Healthcare professionals should not rely on visual judgements when identifying patients who may benefit from weight management treatment. 相似文献14.
Colin J. Greaves Leon Poltawski Samantha B. van Beurden Lisa Price Rodney S. Taylor Richard Merrifield Lucy O'Loughlin 《British journal of health psychology》2023,28(4):1261-1282
Objectives
Building on prior theory, we aimed to evaluate the feasibility and acceptability of integrating novel, weight loss maintenance strategies into existing weight management programmes. We also piloted recruitment and data collection procedures for future research.Design
Two phases of action research nested within a single-arm feasibility study. The intervention was refined between phases using feedback from intervention fidelity analysis and qualitative exploration of patient and provider experiences. Changes in outcomes were assessed up to 18 months post-baseline.Methods
One hundred adults with a mean body mass index of 37 kg/m2 were offered the Skills for weight loss and Maintenance (SkiM) intervention. This included existing weight management programme content and additional weight loss maintenance techniques delivered fortnightly for 6 months in local community centres to groups of 11–15 people.Results
Of the 100 participants, 65%, 58% and 56% provided data at 7, 12 and 18 months. Across both phases, the mean initial weight loss was 4.2 kg (95% CI: 2.4–5.9) and 3.1 kg at 18 months (95% CI: .8–5.5). In Phase 2, we observed better weight loss maintenance (.5 kg [13.2%] regain from 7 to 18 months, vs. 1.7 kg [36.2%] in Phase 1). Variation in outcomes, high early dropout rates and qualitative feedback indicated that, although delivery of the intervention and trial procedures was feasible and acceptable, there was scope to refine the intervention to engage a wider range of participants. Intervention fidelity was acceptable, particularly in Phase 2.Conclusions
The SkiM intervention seems promising, but more research is needed to improve recruitment and retention prior to further evaluation. 相似文献15.
Lindsay McMahon Karin M Foran Stephen D Forrest Michelle L Taylor Graham Ingram Madhuri Rajwal Peter L Cornwall R Hamish McAllister-Williams 《The British journal of general practice》2007,57(544):880-885
BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial. 相似文献
16.
M. Jutel L. Angier S. Palkonen D. Ryan A. Sheikh H. Smith E. Valovirta O. Yusuf R. G. van Wijk I. Agache 《Allergy》2013,68(11):1362-1369
The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist‐based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre‐ and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health‐care related costs in the context of the patient‐centered decision making process. 相似文献
17.
Bruno Rushforth Carolyn McCrorie Liz Glidewell Eleanor Midgley Robbie Foy 《The British journal of general practice》2016,66(643):e114-e127
Background
Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.Aim
To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care.Design and setting
Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework.Method
Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians’ or nurses’ perceived influences on treatment goals for type 2 diabetes.Results
A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.Conclusion
Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change. 相似文献18.
19.
Colin R Simpson Philip C Hannaford Lewis D Ritchie Aziz Sheikh David Williams 《The British journal of general practice》2011,61(588):e443-e451