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Knowledge, Attitudes, and Management of General Practitioners of the Hospital Districts of Ouagadougou about Migraine (Burkina Faso). Pain Res Manag 2021; 2021:9327363. [PMID: 34840637 PMCID: PMC8616706 DOI: 10.1155/2021/9327363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/14/2021] [Accepted: 11/02/2021] [Indexed: 11/26/2022]
Abstract
Background Migraine is a common neurological disorder characterized by severe headache attacks that may be debilitating. The objective of this study is to determine the knowledge and attitudes of general practitioners in the hospital districts of the city of Ouagadougou on migraine. Methods This cross-sectional study was carried out in hospital districts of Ouagadougou. The data were collected during three months from February 1 to April 30, 2020. Results The study included 116 general practitioners. Thirteen percent of them were suffering from migraine. All participants had previous experience with migraine diagnosis before the survey. Eighty percent of general practitioners had a good level of knowledge of ICDH-3 criteria (knowing 6-7 criteria). The most widely recognized IHS criteria were pulsatility quality (93.1%), photophobia or sonophobia (80.2%), and mild-to-moderate intensity (80%). Ninety-five (81.9%) general practitioners rarely ordered brain imaging. The most common acute treatments were nonsteroidal inflammatory drug (39.47%), paracetamol (44.74%), and derivate of ergot (3.95%). The most common preventive treatments were amitriptyline (27.8%), derivate of ergot (18.9%), and NSAID (16.7%). The majority of general practitioners (56.9%) have referred headache patients to a colleague or specialist. Conclusions Our study found that diagnostic criteria and acute treatment of migraine were well known by the majority of general practitioners, in contrast of preventive treatment.
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Rua T, Mazumder A, Akande Y, Margariti C, Ochulor J, Turville J, Razavi R, Peacock JL, McCrone P, Goh V, Shearer J, Afridi S. Management of chronic headache with referral from primary care to direct access to MRI compared with Neurology services: an observational prospective study in London. BMJ Open 2020; 10:e036097. [PMID: 33067273 PMCID: PMC7569948 DOI: 10.1136/bmjopen-2019-036097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache. INTERVENTION Management of chronic headache following referral from Primary Care that differed in the first appointment, either a Neurology appointment or an MRI brain scan. DESIGN AND SETTING A pragmatic, non-randomised, prospective, single-centre study at a Central Hospital in London. PARTICIPANTS Adult patients with chronic headache referred from primary to secondary care. PRIMARY AND SECONDARY OUTCOME MEASURES Participants' use of healthcare services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months postrecruitment. Cost analyses were compared using generalised linear models. Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (Migraine Disability Assessment Scale and Headache Impact Test) and a generic questionnaire (5-level EQ-5D). RESULTS Mean (SD) cost up to 6 months postrecruitment per participant was £578 (£420) for the Neurology group (n=128) and £245 (£172) for the MRI group (n=95), leading to an estimated mean cost difference of £333 (95% CI £253 to £413, p<0.001). The mean cost difference at 12 months increased to £518 (95% CI £401 to £637, p<0.001). When adjusted for baseline and follow-up imbalances between groups, this remained statistically significant. The utilisation of brain MRI improved access to care compared with the Neurology group (p<0.001). Participants in the Neurology group reported higher levels of satisfaction associated with the pathway and led to greater change in care management. CONCLUSION Direct referral to brain MRI from Primary Care led to cost-savings and quicker access to care but lower satisfaction levels when compared with referral to Neurology services. Further research into the use of brain MRI for a subset of patient population more likely to be reassured by a negative brain scan should be considered. TRIAL REGISTRATION NUMBER NCT02753933.
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Affiliation(s)
- Tiago Rua
- King's Health Economics, King's College London, London, UK
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Asif Mazumder
- Neuroradiology Group, Department of Radiology, Lambeth Wing, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Yvonne Akande
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Charikleia Margariti
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Juliana Ochulor
- Neurology Department, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Joanna Turville
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Reza Razavi
- Imaging Science Division, King's College London, London, UK
| | - Janet L Peacock
- Division of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Paul McCrone
- King's Health Economics, King's College London, London, UK
| | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - James Shearer
- Division of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Shazia Afridi
- Neurology Department, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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Kamtchum-Tatuene J, Kenteu B, Fogang YF, Zafack JG, Nyaga UF, Noubiap JJ. Neuroimaging findings in headache with normal neurologic examination: Systematic review and meta-analysis. J Neurol Sci 2020; 416:116997. [DOI: 10.1016/j.jns.2020.116997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 01/16/2023]
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Adekanmi A, Balogun J, Adenigba P. Cranial tomographic angiographic evaluation of suspected intracranial vascular abnormalities among a Nigerian cohort. WEST AFRICAN JOURNAL OF RADIOLOGY 2020. [DOI: 10.4103/wajr.wajr_10_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McKinlay A, Underwood R, Wojewodka G, Mazumder A, Kilner R, Ridsdale L. Should GPs have direct access to imaging for headache? A qualitative study of patients' views in the UK. BMJ Open 2019; 9:e029376. [PMID: 31427332 PMCID: PMC6701632 DOI: 10.1136/bmjopen-2019-029376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We aimed to describe patients' views of a new referral pathway of general practitioner (GP) direct access to MRI, versus imaging after referral to a specialist. DESIGN This qualitative study involved 20 semistructured interviews. Twenty patients (10 from each pathway) were purposively recruited and interviewed to describe their attitudes. SETTING A neurology headache clinic and neuroradiology services from the boroughs of Southwark and Lambeth in South London, UK. PARTICIPANTS Twenty patients were involved in this study. RESULTS Over half of the participants felt relieved once they received their scan results, while some remained uncertain about the underlying cause of their symptoms. Some participants described a long wait to see a specialist. Others described a long wait time to receive scan results, especially from their GP. Spontaneous reduction in headache symptoms occurred for some participants and for others, normal imaging results allowed them to focus more on symptom management. CONCLUSION Relief was reported especially when scan results had been explained clearly and without too much delay. Those with continuing pain focused on how to get relief from symptoms. Patient experience might be improved with clearer information from GPs about how patients can access results, standard reporting procedures and closer liaison between neuroradiology and GPs.
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Affiliation(s)
- Alison McKinlay
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Raphael Underwood
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Gabriella Wojewodka
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Asif Mazumder
- Neuroradiology Group, Department of Radiology, Lambeth Wing, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Rachael Kilner
- Department of Neurology, King’s College Hospital, London, UK
| | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res 2018; 18:986. [PMID: 30572898 PMCID: PMC6302393 DOI: 10.1186/s12913-018-3745-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated. METHODS We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes. RESULTS We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies. CONCLUSION The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.
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Affiliation(s)
- James Greenwood-Lee
- Centre for Science, Athabasca University, 6th Floor, 345 6 Avenue SE, Calgary, Alberta, T2G 4V1, Canada
| | - Lauren Jewett
- Geography & Planning, University of Toronto, Sidney Smith Hall, Rm 594, 100 St George St., Toronto, Ontario, M5S 3G3, Canada
| | - Linda Woodhouse
- Faculty of Rehabilitation Medicine, University of Alberta, 3-10 Corbett Hall, 8205 114 Street, Edmonton, Alberta, T6G 2G4, Canada
| | - Deborah A Marshall
- Canada Research Chair, Health Services and Systems Research, Arthur J.E. Child Chair in Rheumatology Outcomes Research, Department of Community Health Sciences, University of Calgary, Calgary, Canada.
- 3C56 Health Research Innovation Centre (HRIC), 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.
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Smith CF, Tompson AC, Jones N, Brewin J, Spencer EA, Bankhead CR, Hobbs FR, Nicholson BD. Direct access cancer testing in primary care: a systematic review of use and clinical outcomes. Br J Gen Pract 2018; 68:e594-e603. [PMID: 30104328 PMCID: PMC6104856 DOI: 10.3399/bjgp18x698561] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/04/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING Systematic review assessing the effectiveness of GP DA testing in adults. METHOD MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction.
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Affiliation(s)
| | - Alice C Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Nicholas Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Josh Brewin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Elizabeth A Spencer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Underwood R, Kilner R, Ridsdale L. Primary care management of headaches and how direct-access MRI fits: a qualitative study of UK general practitioners' views. BMJ Open 2017; 7:e018169. [PMID: 29127230 PMCID: PMC5695367 DOI: 10.1136/bmjopen-2017-018169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/01/2017] [Accepted: 09/18/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To develop a better understanding of general practitioners' (GPs) views and experiences of the management of patients with headaches and use of direct-access MRI scans, and observe outcomes of an educational session offered by a GP with a special interest (GPwSI) to GPs. DESIGN A qualitative study using semistructured interviews, analysed using thematic analysis. A GPwSI in headaches visited practices delivering a talk on headache medication, diagnosis and management. SETTING Sixteen (16) primary care family practices in South London, UK. PARTICIPANTS Twenty (20) GPs. RESULTS Not all GPs were aware of the availability of direct-access MRI, but all acknowledged having used referral or direct scans to manage patients' concern about their headaches. A normal scan result helped resolve uncertainty for patient and GP and helped management towards discussion of preventative treatment. However, patients with psychological and/or severe headache symptoms could not necessarily be reassured. GPs reported difficulty interpreting radiology reports, particularly incidental abnormalities. Those who received the educational talk gained knowledge in diagnosis and medication, improving their confidence in management. CONCLUSIONS Increased access to imaging, training in headache management, addressing physical and psychological symptoms and standardised reporting of scans may improve GPs' use of direct-access MRI in the future.
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Affiliation(s)
- Raphael Underwood
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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Achieving a balance between the physical and the psychological in headache. Br J Gen Pract 2017; 67:374-375. [PMID: 28751350 DOI: 10.3399/bjgp17x692093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M. Outpatient services and primary care: scoping review, substudies and international comparisons. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | - Ellen Nolte
- RAND Europe, Cambridge, UK
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Greenhalgh
- Faculty of Education, Social Sciences and Law, University of Leeds, Leeds, UK
| | - Martin Roland
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Pawson R, Greenhalgh J, Brennan C. Demand management for planned care: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BackgroundThe task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution.MethodsThis report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become ‘whole-system’ models; over time policy-makers have advocated the need for concerted action on all of these fronts.FindingsThe remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes ‘work’ only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high ‘rule-out’ rates; and referral guidelines are more likely to work when implemented by staff with responsibility for their creation.ConclusionsThe report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Ray Pawson
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Cathy Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Gupta V, Khandelwal N, Prabhakar A, Satish Kumar A, Ahuja CK, Singh P. Prevalence of normal head CT and positive CT findings in a large cohort of patients with chronic headaches. Neuroradiol J 2015; 28:421-5. [PMID: 26342061 DOI: 10.1177/1971400915602801] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study was carried out to ascertain the frequency of normal head computed tomography (CT) scans and positive CT scan findings in patients having chronic headache as chief complaint. Head CT scans done over a period of two years were retrospectively evaluated. On the basis of CT reports, the patients were divided into two groups: Group A, having headache as the only complaint, and Group B, having headache and additional neurological signs or symptoms. A total of 2498 patient reports were evaluated. There were 1772 patients in Group A and 726 patients in Group B. In Group A, 82% (n=1453) patients had normal head CT, whereas in Group B 74.5% (n=541) patients had a normal CT scan. There were 13.22% head CT scans showing significant findings in Group B, as compared to 6.2% in Group A. Both these differences were found to be statistically significant. CT findings such as infections, neoplasm, hydrocephalus, and extra-axial collections were higher in Group B when compared to Group A. CT examination in patients with isolated chronic headache is normal in high percentage of patients. The frequency and distribution of various CT findings over different age groups in a large cohort of patients presenting with chronic headache are discussed.
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Affiliation(s)
- Vivek Gupta
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
| | - N Khandelwal
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
| | - Anuj Prabhakar
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
| | - A Satish Kumar
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
| | - Chirag K Ahuja
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
| | - Paramjeet Singh
- Department of Radio-diagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Elliot S, Kernick D. Why do GPs with a special interest in headache investigate headache presentations with neuroradiology and what do they find? J Headache Pain 2011; 12:625-8. [PMID: 21956455 PMCID: PMC3208048 DOI: 10.1007/s10194-011-0375-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 07/22/2011] [Indexed: 11/27/2022] Open
Abstract
The general practitioner with a special interest in headache offers an important contribution to the management of headache in primary care where the majority of presentations take place. A number of guidelines have been developed for neuroradiological investigation of headache, but their clinical utility and relevance is not known. Fourteen general practitioners with a special interest in headache recorded consecutive headache consultations over a 3-month period, whether patients were investigated with neuroradiology and if so the reason for investigation and outcome. Reason for investigation was compared to the guidelines published for the use in primary care. 895 patients were seen, of whom 270 (30.1%) were investigated. 47% of indications were outside the guidance framework used, the most common reason for investigation being reassurance. Of those investigated, 5.6% showed positive findings but only 1.9% of findings were felt to be of clinical significance. General practitioners with a special interest investigated with neuroradiology a greater level than general practitioners, but less than neurologists. However, yields of significant findings are broadly comparative across all groups. This report confirms other studies that suggest that even when there is a high level of clinical suspicion, yields of significant findings are very low.
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Affiliation(s)
- Steven Elliot
- Horizon Centre, 94 Littleton Road, Salford, M7 3SE UK
| | - David Kernick
- St Thomas Health Centre, Cowick Street, Exeter, EX4 1HJ UK
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Should GPs have direct access to neuroradiological investigation when adults present with headache? Br J Gen Pract 2011; 61:409-11. [PMID: 21801533 DOI: 10.3399/bjgp11x578124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Access to computed tomography. Br J Gen Pract 2010; 60:617. [DOI: 10.3399/bjgp10x515160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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18
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Authors' response. Br J Gen Pract 2010. [DOI: 10.3399/bjgp10x515151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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