Developing a measure of patient access to primary care: the access response index (AROS)

Access to appointments in primary care is not routinely measured, and there is no one standardized method for doing so. Any measurement tool has to take account of the dynamic status of appointment availability and the definitional problems of appointment types. The aim of this study was to develop and trial a method for measuring access that is valid, reliable, quick and provides a daily longitudinal record of access on an organizational basis (not for individual clinicians). Using the results of a literature review and following discussions with clinicians and managers a tool was designed following agreed specifications. After initial adjustments of the tool a feasibility study tested the acceptability of a data collection exercise on 11 practices of varying types, over a 4- to 8-week period. The development phase led to the design of a tool named the access response index (AROS). The method was well received in the practices, with a low incidence of missed days and only one practice failing to return data. The index measures the number of days' wait to the next available appointment with any general practitioner. The inclusion in the score of urgent appointments was abandoned due to definitional problems. A 5-day moving average was chosen to represent the data in graph form to demonstrate overall trends. AROS is a useful tool usable in any practice, and our feasibility study points to it being widely acceptable in the field. Data are represented in clear graphical daily format, either just for one practice or as an anonymous composite graph with other practices in the locality.     

Dyadic OPTION: Measuring perceptions of shared decision-making in practice

Background

Current models of the medical consultation emphasize shared decision-making (SDM), whereby the expertise of both the doctor and the patient are recognised and seen to equally contribute to the consultation. The evidence regarding the desirability and effectiveness of the SDM approach is often conflicting. It is proposed that the conflicts are due to the nature of assessment, with current assessments from the perspective of an outside observer.

Aims

To empirically assess perceived involvement in the medical consultation using the dyadic OPTION instrument.

Method

36 simulated medical consultations were organised between general practitioners and standardized- patients, using the observer OPTION and the newly developed dyadic OPTION instruments.

Results

SDM behaviours observed in the consultations were seen to depend on both members of the doctor and patient dyad, rather than each in isolation. Thus a dyadic approach to measurement is supported.

Conclusions

This current study highlights the necessity for a dyadic approach to assessment and introduces a novel research instrument: the dyadic OPTION instrument.     

Changes in collagen fibril network organization and proteoglycan distribution in equine articular cartilage during maturation and growth

The aim of this study was to record growth‐related changes in collagen network organization and proteoglycan distribution in intermittently peak‐loaded and continuously lower‐level‐loaded articular cartilage. Cartilage from the proximal phalangeal bone of the equine metacarpophalangeal joint at birth, at 5, 11 and 18 months, and at 6–10 years of age was collected from two sites. Site 1, at the joint margin, is unloaded at slow gaits but is subjected to high‐intensity loading during athletic activity; site 2 is a continuously but less intensively loaded site in the centre of the joint. The degree of collagen parallelism was determined with quantitative polarized light microscopy and the parallelism index for collagen fibrils was computed from the cartilage surface to the osteochondral junction. Concurrent changes in the proteoglycan distribution were quantified with digital densitometry. We found that the parallelism index increased significantly with age (up to 90%). At birth, site 2 exhibited a more organized collagen network than site 1. In adult horses this situation was reversed. The superficial and intermediate zones exhibited the greatest reorganization of collagen. Site 1 had a higher proteoglycan content than site 2 at birth but here too the situation was reversed in adult horses. We conclude that large changes in joint loading during growth and maturation in the period from birth to adulthood profoundly affect the architecture of the collagen network in equine cartilage. In addition, the distribution and content of proteoglycans are modified significantly by altered joint use. Intermittent peak‐loading with shear seems to induce higher collagen parallelism and a lower proteoglycan content in cartilage than more constant weight‐bearing. Therefore, we hypothesize that the formation of mature articular cartilage with a highly parallel collagen network and relatively low proteoglycan content in the peak‐loaded area of a joint is needed to withstand intermittent stress and shear, whereas a constantly weight‐bearing joint area benefits from lower collagen parallelism and a higher proteoglycan content.     

The effects of the Two-Week Rule on NHS colorectal cancer diagnostic services: A systematic literature review

Background  

The Two-Week Rule (TWR) was introduced to ensure that all patients with a suspected colorectal cancer (CRC) saw a hospital specialist within 14 days of an urgent GP referral. Guidelines were available to GPs to facilitate the appropriate TWR referral of patients exhibiting high-risk CRC symptoms.     

Using simulated consultations to develop communications skills for neurology trainees.

Communication skills are essential for clinical medicine yet, unlike in general practice, trainees in specialist and general medicine are not formally trained in them. We have used videotaped recording of simulated consultations to evaluate their acceptability and usefulness for training neurology specialist registrars. Twelve specialist registrars in neurology participated; their perceptions of the method were assessed using quantified scales and focus groups. All but one of the 12 trainees found the exercise useful both for improving clinical skills and for the imparting of information. The median visual analogue scores (0=useless, 100=very useful) for history taking and for imparting information were 91 and 90%, respectively. The median scores [and interquartile range (IQR)] of perceived usefulness for communication skills increased before to after (for use of video) from 68 (58-78) to 88 (80-92)% (P < 0.02), and (for use of simulated patients) from 51 (40-71) to 86 (79-89)% (P < 0.02). The focus groups provided additional qualitative data supporting the technique. We conclude that videotaped consultations with simulated patients are valued by most neurology trainees, both for improving their history-taking skills and for imparting information. The technique could be used more widely in neurology training, and may have a role in assessment.     

Protein metabolism and requirements in the critically ill patient

The metabolic alterations of the critically ill patient greatly affect the processes of both protein synthesis and degradation as well as the nitrogen balance. It is important to understand these affects so that protein and nitrogen balance may be accounted for in parenteral nutritional support.