A cardiovascular educational intervention for primary care professionals in Spain: positive impact in a quasi-experimental study

BackgroundRoutine general practice data collection can help identify patients at risk of cardiovascular disease.AimTo determine whether a training programme for primary care professionals improves the recording of cardiovascular disease risk factors in electronic health records.MethodThe prevalence rates of recording of cardiovascular factors (recorded every 6 months over a 4-year period) were compared between intervention and control group. Clinical relevance was calculated by absolute risk reduction (ARR), relative risk reduction (RRR), and number of patients needed-to-attend (NNA), to avoid under-recording, with their 95% confidence intervals (CIs). Linear regression models were used for each of the variables.ResultsOf the 941 professionals initially registered, 78.1% completed the programme. The ARR ranged from 1.87% (95% CI = 1.79 to 1.94) in the diagnosis of diabetes to 15.27% (95% CI = 15.14 to 15.40) in the recording of basal blood glucose. The NNA ranged from 7 in blood pressure, cholesterol, and blood glucose recording to 54 in the diagnosis of diabetes. The RRR ranged from 26.7% in the diagnosis of diabetes to 177.1% in the recording of the Systematic Coronary Risk Evaluation (SCORE). The rates of change were greater in the intervention group and the differences were significant for recording of cholesterol (P<0.001), basal blood glucose (P<0.001), smoking (P<0.001), alcohol (P<0.001), microalbuminuria (P = 0.001), abdominal circumference (P<0.001), and SCORE (P<0.001).ConclusionThe education programme had a beneficial effect at the end of the follow-up that was significant and clinically relevant.     

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study

ObjectiveDuring critical care, physicians are frequently confronted with bad-news communication because of patients’ frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context.MethodsEthnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients’ medical records. Data were thematically analysed.ResultsBad-news communication was primarily dominated by physicians. Patients’ and relatives’ input and other professionals’ involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out.ConclusionDelivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved.Practice implicationsThe challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.     

Results of an allergy educational needs questionnaire for primary care

It is well recognized that knowledge of allergic conditions is suboptimal in primary care. The Primary Care Interest Group of the European Academy of Allergy and Clinical Immunology undertook an educational needs survey to better understand what they were and how best to meet them, in the primary care environment. An electronic questionnaire was devised and distributed as widely as possible. A total of 2226 people from 63 countries opened the e‐questionnaire of which 692 provided evaluable responses. In total, 81% were medical doctors with 299 possessing additional qualifications. Self‐declared gaps in knowledge were expressed for most manifestations of allergy with a correspondingly high self‐expressed educational need. The preferred learning modalities were online guidelines (69.6%) and courses (68.8%) followed closely by workshops (68%), structured online modules (63.9%) and small local working groups (59.75%). Podcasts and webinars scored poorly with only 25% expressing these as preferred learning modes although there was an age gradient. The preferred electronic platform was the personal computer (82.6%). A better understanding of the needs of primary care should help guide the design of educational initiatives to meet those needs.     

Towards the reality of the primary health care team: an educational approach

We report our assessment of a study day on the primary health care team for trainee general practitioners, student health visitors and student district nurses. We found that insufficient attention has been given to helping learners co-operate with other disciplines in delivering primary health care and consider that team members need to acquire skills which will help them to communicate with their colleagues. We suggest that the training practice with its defined population should be the training base for district nurses and health visitors.     

Labelling chronic illness in primary care: a good or a bad thing?

Traditionally the management of any chronic condition starts with its diagnosis. The labelling of disease can be beneficial in terms of defining appropriate treatment such as in coronary artery disease. However, sometimes it may be detrimental such as when x-rays are used to diagnose lumbar spondylosis leading to patients inappropriately limiting their activity. Chronic knee pain in the elderly is another example where applying labels is problematical. A common diagnosis in this situation is osteoarthritis, but this label can be applied in two ways: as a radiological diagnosis, or as a clinical one. The x-ray diagnosis, however, does not equate with the clinical syndrome, and vice versa. In addition, diagnosing knee pain as osteoarthritis does not necessarily help in management, since a patient's debility is more dependent upon their clinical signs and symptoms than the presence of radiographic osteoarthritis, and by the same token its clinical counterpart. GPs are consistent in their management of knee pain, but in attempting to diagnose the pain as osteoarthritis, these plans can alter and become more dependent on the actual diagnosis than the clinical picture. As a result management may well diverge from what the current best evidence supports. Diagnosis for diagnosis sake, should therefore be discouraged, and chronic knee pain gives us one example of why this is the case. GPs would be better placed to manage this condition if it was considered more as a regional pain syndrome, perhaps defining it simply as 'chronic knee pain in older people'. This example suggests that there is a pressing need in primary care to carefully consider in chronic disease when it is appropriate to be definitive in diagnosis such that when using disease specific labels, there is definite benefit for the patient and doctor.     

Cost-effectiveness of a primary care intervention for depressed females

BACKGROUND: To date, there is little information about the differential impact of primary care interventions by gender. We conducted an exploratory cost-effectiveness analysis by gender of an intervention to improve recognition and guideline-concordant treatment of depression in primary care. METHODS: Primary care practices that did not employ an onsite mental healthcare specialist were randomized to enhanced (intervention) versus usual care. All subjects met study criteria for current major depression. Medical Outcomes Study SF-36 scores were converted into quality-adjusted life years (QALYs) to compare the 1-year effectiveness of enhanced versus usual care by gender. Based on results of previous studies, antidepressant acceptors beginning a new depression treatment episode were the focus of the analysis. Statistical analyses included multivariate regression models controlling for sociodemographic and clinical covariates. RESULTS: In the main analysis, enhanced care for females was more expensive and more effective than usual care, at an additional cost of $5244 per QALY. For males, enhanced care was essentially cost and outcome neutral compared to usual care. The cost-effectiveness ratio estimates were robust to sensitivity analyses. Psychological side effects to the intervention may partially explain the limited effect of the intervention on outcomes for males. LIMITATIONS: We consider these results exploratory because the SF-36 to quality-adjusted life year conversion formula is preliminary and because of the relatively small sample size. CONCLUSIONS: The estimated cost-effectiveness ratio of this depression intervention is within the acceptable range for females, but not males. If replicated, these exploratory findings suggest that interventions to improve primary care depression treatment may need to be modified to improve their effectiveness in males while maintaining their effectiveness in females.     

Managing the delivery of bad news: an in-depth analysis of doctors' delivery style

Objective

The purpose of this study was to identify and describe the delivery styles doctors typically use when breaking bad news (BBN).

Methods

Thirty one doctors were recruited to participate in two standardised BBN consultations involving a sudden death. Delivery styles were determined using time to deliver the bad news as a standardised differentiation as well as qualitative analysis of interaction content and language style. Communication performance was also assessed.

Results

Analysis of BBN interactions revealed three typical delivery styles. A blunt style characterised by doctors delivering news within the first 30 s of the interaction; Forecasting, a staged delivery of the news within the first 2 min and a stalling approach, delaying news delivery for more than 2 min. This latter avoidant style relies on the news recipient reaching a conclusion about event outcome without the doctor explicitly conveying the news.

Conclusion

Three typical bad news delivery styles used by doctors when BBN were confirmed both semantically and operationally in the study. The relationship between delivery style and the overall quality of BBN interactions was also investigated.

Practice implications

This research provides a new template for approaching BBN training and provides evidence for a need for greater flexibility when communicating bad news.     

Qualitative study of an educational intervention for GPs in the assessment and management of depression

BACKGROUND: Previous research has not shown any significant health gain for patients as a result of providing education about depression for GPs. Reasons for this, however, are unclear. AIMS: To explore relationships between process and outcome in the setting of a randomised controlled trial of a complex educational intervention designed to provide GPs with training in the assessment and management of depression. DESIGN OF STUDY: Qualitative study utilising semi-structured interviews. SETTING: General practice in the northwest of England. METHOD: Semi-structured interviews with 30 GPs in Liverpool and Manchester who participated in a randomised controlled trial. RESULTS: Three major barriers to the effectiveness of the intervention were identified: the lack of the GP's belief that he/she could have an impact on the outcome of depression, the appropriateness of the training, and the organisational context in which doctors had to implement what they had learned. CONCLUSION: Attitudes toward treating depression may need addressing at a much earlier point in medical education. If students are introduced to a biosocial model of depression at an early stage, they may feel more hopeful about their ability to intervene when faced with patients who exhibit significant degrees of functional disability in the context of apparently socially determined disorders. Postgraduate interventions should be tailored to the treatment of depression as a common chronic condition and be focused at the level of the organisation, not the individual practitioner.     

Barriers to early diagnosis of cancer in primary care: a needs assessment of GPs

This is the first needs assessment of general practitioners (GPs) in relation to early detection of cancer in the Republic of Ireland. Data was collected using focus groups with 47 GPs and a national survey of 929 GPs. Overall,74.6% of survey respondents had >10 years experience in general practice and 22.7% were single handed. Distance from the practice to the nearest hospital to which they could refer patients for assessment of suspected cancer was <5 miles for 53.3% of GPs. The principle barriers identified were not confined to early diagnosis but apply to the diagnosis of cancer at any stage. These included delayed patient presentation, lack of direct GP access to investigations, difficulty with hospital referral, lack of clear recommendations for screening, poor communication with hospital services, inequitable access to hospital services and a need for further education and clinical practice guidelines. The barriers identified have serious implications for early detection of cancer in primary care and are remedial.     

Diagnosis of heart failure in primary care: an assessment of international guidelines.

An appraisal of published, peer-reviewed guidelines, in terms of their development methodologies and clinical effectiveness, was undertaken using a published and validated appraisal tool. Electronic databases revealed 13 guidelines on heart failure but only seven of these referred to diagnosis. The quality of the published guidelines was variable but there was consensus over the main symptoms and diagnostic tests, although only two symptoms were mentioned in all guidelines. Only two guidelines scored greater than 50% for rigour of development.     

Effectiveness of a brief advance directive intervention in primary care: a randomized clinical trial

ObjectiveTo measure the effectiveness of a brief intervention aimed at increasing interest in and use of advanced directives (AD) among primary care patients.MethodsRandomized controlled trial. In the intervention arm, patients were given brief oral information and a leaflet on AD by General Practitioners (GPs), in the control group were briefly informed about the study’s purpose. Outcome variables were the proportion of patients who expressed interest in AD and those who completed one. Covariates were sex, age, education, race, Charlson comorbidity index (CCI), religion, and possession of financial will.ResultsOverall, 332 patients were recruited; 58 in the intervention and 36 in the control group expressed interest in AD (p = 0.033) and 18 (5.4 %) made an AD (nine in each group). Variables associated with interest were Caucasian race (odds ratio [OR], 1.88), the intervention (OR, 1.86), and CCI extreme scores (OR, 0.36). Variables associated with AD completion were primary education/no schooling (OR, 5.69) and fewer children (OR, 0.57).ConclusionsA brief oral and written intervention delivered by GP significantly increased interest in AD and achieved a completion rate of 5.4 %, without differences with the control group.Practice ImplicationsAD interventions should focus on individuals already likely to be motivated.     

Recommendations for future studies: a systematic review of educational interventions in primary care settings.

Systematic reviews are an important part of the current move towards evidence-based practice. Independent reviewers use a variety of search strategies to identify and assess relevant articles in the field of concern. Criteria for quality must be agreed and articles evaluated accordingly. This study systematically reviewed educational interventions targeting physicians in primary care (excluding hospital clinic and academic settings) to determine their effectiveness in changing behaviour and to investigate whether studies gave information about the resource implications of the interventions described and their rationale for choosing a particular target group. Studies in English, French, or German language journals were included. The review applied the criteria of the Cochrane Collaboration for methodological quality of studies (but was not conducted under the auspices of the Cochrane Collaboration). The results showed that relatively few studies had occurred in primary care compared with academic and hospital clinic settings. Many articles did not fit the criteria for rigour of method, and those that did were very heterogeneous in method and target group. Only two studies assessed resource implications, and one study also calculated economic benefits. The review suggests that future studies should either target geographical areas or doctors with an identifiable learning need associated with patient outcome, and that studies should be evaluated on their 'intention to educate'. Evaluations of educational initiatives need to describe the resource implications versus measurable benefits of the intervention to make their studies useful to policymakers and planners of educational provision.     

Anxiety among women with mild dyskaryosis: a randomized trial of an educational intervention.

BACKGROUND: Women with mild dyskaryosis are currently managed by six-month cytological surveillance. While there is good evidence that women suffer psychological distress on receipt of an abnormal test, and that this is amenable to educational intervention, it remains uncertain whether this distress is prolonged and, if so, how it should best be managed. AIM: To investigate whether a structured educational intervention containing a risk communication package impacts upon psychological sequelae associated with this surveillance. METHOD: A pragmatic cluster-randomized controlled trial during 14 months in 1995 and 1996, based in general practices in Avon and South Glamorgan, that compared the intervention with standard care. Follow-up was by postal questionnaire at six weeks and four months after the screening laboratory had reported the test result. The intervention was an invitation to attend the general practice to consult with a practice nurse trained to deliver the package. The main outcome measures were Spielberger state-anxiety, SF-36 Mental Health dimension, four condition-specific questions regarding concerns about gynaecological health and timing of the repeat smear test, and attendance for the repeat test. RESULTS: Of 514 eligible women, 270 were recruited, of whom 240 returned the six-week questionnaire and 181 returned the four-month questionnaire. On all but one outcome measure, the differences between the groups were not statistically significant. At six-week follow-up, the proportion who preferred the repeat test to be sooner than six months was statistically significantly higher among controls (74% versus 53%; 95% CI = 9% to 33%). At the four-month follow-up, the difference was 7% (95% CI = -7% to 21%). CONCLUSION: There appear to be high levels of anxiety during surveillance for mild dyskaryosis that were not reduced by the intervention. Given that a personally delivered educational intervention designed to reduce anxiety could be viewed as the best available practice, it is of concern that women in the intervention group demonstrated sustained anxiety over a four-month period. The research agenda therefore seems to return to the fundamental question of whether surveillance should be the management of choice.