Cardiovascular disease and lipids

The commonest manifestations of cardiovascular disease, namely coronary heart disease (CHD) and stroke, represent the two most common causes of death in the world today. Furthermore, cardiovascular diseases have the highest healthcare utilisation costs in most countries. Both primary and secondary prevention management strategies are essential. Although more than 200 risk factors for CHD have now been identified, the single most powerful predictor of CHD risk is abnormal lipid levels. The relative risk influences of the various lipid sub-fractions are described, with particular emphasis on LDL cholesterol, which represents the principal target for treatment in most management guidelines. Unfortunately, there remains considerable evidence of continued under-management of patients with elevated cholesterol and cardiovascular risk who are eligible for secondary prevention. The barriers contributing to such physician under-performance are numerous. The more recent recognition of the importance of identifying patients at enhanced risk, but without established disease (primary prevention), will require greatly familiarity with the clinical use of CHD risk scoring systems, most of which are based upon the Framingham equation. Special reference is made to groups at particular risk of CHD. In summary, the application of the enormous evidence-base for interventions in cardiovascular disease, especially over the treatment of elevated cholesterol, pose a huge challenge to primary and secondary care in most healthcare systems.

Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening

OBJECTIVES

To examine the effectiveness and cost-effectiveness of two interventions based in primary care aimed at increasing uptake of breast screening.

SETTING

24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round.

METHODS

Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-effectiveness of the interventions.

RESULTS

6,133 Women were included: 1,721 control; 1,818 letter; 1,232 flag; 1,362 both interventions. Attendance data were obtained for 5,732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more effective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were 26 pounds (letter) and 41 pounds (flag).

CONCLUSIONS

Although both interventions increased attendance for breast screening, the letter was the more cost-effective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (41 pounds) costs are judged worthwhile in terms of the gains in breast screening uptake.

Doctor-patient discussions of alternative medicine for back pain

OBJECTIVE

To document the frequency of conversations about alternative medicine during primary care consultations for back pain in diverse settings.

DESIGN

"Exit interview" type patient survey.

SETTINGS

General practices in Seattle, Washington; rural Israel; and Birmingham, England.

PATIENTS

A convenience sample of 218 adults completing a doctor visit for back pain.

MAIN OUTCOME MEASURES

Frequencies of doctor-patient discussions of alternative medicine.

RESULTS

Alternative medicine was discussed in a minority of visits (US site 40%, Israel site 37%, UK site 14%, p < 0.05). At each site, patients initiated at least half of the discussions. Users were five to six times more likely to discuss alternative medicine with their doctor than non-users (p < 0.05 for comparison at each site). The percentage of patients who used alternative medicine but left the consultation without discussing it was similar at all sites (US site 17%, Israel site 23%, UK site 15%).

CONCLUSIONS

Discussions of alternative medicine occurred in a minority of consultations for back pain although the rate varied considerably by site. Discussions were initiated primarily by patients who use it.

Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

OBJECTIVE

To determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia.

DESIGN

Randomised controlled trial.

SETTING

31 UK primary care centres.

PARTICIPANTS

478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration.

INTERVENTIONS

Near patient testing for H pylori and open access endoscopy for patients with positive results. Control patients received acid suppressing drugs or specialist referral at general practitioner's discretion.

MAIN OUTCOME MEASURES

Cost effectiveness based on improvement in symptoms and use of resources at 12 months; quality of life.

RESULTS

40% of the study group tested positive for H pylori. 45% of study patients had endoscopy compared with 25% of controls. More peptic ulcers were diagnosed in the study group (7.4% v 2.1%, P=0.011). Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups. No significant differences were observed in rates of prescribing, consultation, or referral. Costs were higher in the study group ( 367.85 pound sterling v 253.16 pound sterling per patient).

CONCLUSIONS

The test and endoscopy strategy increases endoscopy rates over usual practice in primary care. The additional cost is not offset by benefits in symptom relief or quality of life.

Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care

OBJECTIVES

To examine the effectiveness and cost-effectiveness of two primary care based interventions aimed at increasing breast screening uptake for women who had recently failed to attend.

SETTING

13 General practices with low uptake in the second round of breast screening (below 60%) in north west London and the West Midlands, United Kingdom. Participants were women in these practices who were recent non-attenders for breast screening in the third round.

METHODS

Pragmatic factorial randomised controlled trial, with people randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after randomisation and cost-effectiveness of the interventions.

RESULTS

1,158 Women were individually randomised as follows: 289 control; 291 letter; 290 flag; 288 both interventions. Attendance was ascertained for 1,148 (99%) of the 1,158 women. Logistic regression adjusting for the other intervention and practice produced an odds ratio (OR) for attendance of 1.51 (95% confidence interval (95% CI 1.02 to 2.26; p=0.04) for the letter, and 1.39 (95% CI 0.93 to 2.07; p=0.10) for the flag. Health service costs/ additional attendance were 35 pounds (letter) and 65 pounds (flag).

CONCLUSIONS

Among recent non-attenders, the letter was effective in increasing breast screening attendance. The flag was of equivocal effectiveness and was considerably less cost-effective than the letter.

Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care

BACKGROUND

Dyspepsia can be managed by initial endoscopy and treatment based on endoscopic findings, or by empirical prescribing. We aimed to determine the cost effectiveness of initial endoscopy compared with usual management in patients with dyspepsia over age 50 years presenting to their primary care physician.

METHODS

422 patients were recruited and randomly assigned to initial endoscopy or usual management. Primary outcomes were effect of treatment on dyspepsia symptoms and cost effectiveness. Secondary outcomes were quality of life and patient satisfaction. Total costs were calculated from individual patient's use of resources with unit costs applied from national data. Statistical analysis of uncertainty on incremental cost-effectiveness ratio (ICER) was done along with a sensitivity analysis on unit costs with cost-effectiveness acceptability curves.

FINDINGS

In the 12 months following recruitment, 213 (84%) patients had an endoscopy compared with 75 (41%) controls. Initial endoscopy resulted in a significant improvement in symptom score (p=0.03), and quality of life pain dimension (p=0.03), and a 48% reduction in the use of proton pump inhibitors (p=0.005). The ICER was Pound Sterling1728 (UK Pound Sterling) per patient symptom-free at 12 months. The ICER was very sensitive to the cost of endoscopy, and could be reduced to Pound Sterling165 if the unit cost of this procedure fell from Pound Sterling246 to Pound Sterling100.

INTERPRETATION

Initial endoscopy in dyspeptic patients over age 50 might be a cost-effective intervention.

European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF)

AIMS

To survey a random sample of primary care physicians across six European countries regarding their perceptions of diagnostic and prescribing issues in heart failure, and to consider factors that might be associated with physician under-performance.

METHODS AND RESULTS

Qualitative, postal questionnaire-based, validated survey in the native tongue of a random sample of 200 primary care physicians in each of five European countries (France, Germany, Italy, The Netherlands and Spain) and of 250 U.K. primary care physicians. Respondents provided: details of practice characteristics; the usual way a diagnosis of heart failure was established; access to investigations; names of drugs prescribed in heart failure, with estimates of the proportion of patients supplied with particular classes; and physician attitudes regarding the evidence base (in terms of benefits and risks) for treatments used. Outcomes were physician perceptions and attitudes about heart failure diagnosis and treatment. Adjusted response rates varied from 17% (France) to 56% (Britain). Primary care physicians underestimate the prevalence of heart failure. Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Although most primary care physicians stated they prescribe ACE inhibitors in heart failure, this was for only 47-62% of patients, and at doses below those identified as effective in trials. Most prescribing doctors (91%) believe there is strong evidence of reduced mortality in heart failure patients using ACE inhibitors, but 51% also consider ACE inhibitors have substantial risks with their use.

CONCLUSION

Limitations of the data include the general problem of questionnaires, whether responses accord with actual clinical practice, and, specific to these data, the low response rate in some countries (although the study does provide information from nearly 300 randomly selected primary care physicians across Europe). New preliminary insights include exposition of the 'low tech' approach to heart failure diagnosis across Europe: doctors report the use of symptoms and signs alone; the lack of direct (open) access to objective investigations, such as echocardiography, which almost guarantees that misdiagnoses will occur; and the under-utilization and under-dosing with ACE inhibitors. The main factor influencing under-use would appear to be the exaggerated perceptions of treatment risk amongst primary care physicians that dominate the widespread and accurate knowledge of treatment benefits.

Management of heart failure: evidence versus practice. Does current prescribing provide optimal treatment for heart failure patients?

Heart failure is an increasingly common and costly chronic disorder, with a rising prevalence of at least 2% in populations over the age of 45 years, mortality rates that are as poor as common solid cancers, and very high health care utilisation costs. Despite increased evidence supporting a range of effective interventions, predominantly therapeutic, there remain significant degrees of physician underperformance in terms of heart failure diagnosis and management. Until the early 1990s, the management of heart failure was largely confined to the symptomatic relief of patients with well established heart failure in fluid overload. The introduction of angiotensin-converting enzyme (ACE) inhibitors provided the first treatments that beneficially altered the prognosis of patients with the most common expression of heart failure, namely established systolic dysfunction, whether symptomatic or asymptomatic. Evidence has now extended these benefits to delaying progression of heart failure and reducing hospitalisation. Much of our understanding of the pathophysiology of heart failure stems from these studies. More recent data has clarified the limited role of digoxin, the important benefits of beta-blockade and aldosterone blockers as adjuvants to ACE inhibition, and the emerging evidence on angiotensin II antagonists. There are, in contrast to these positive findings, reliable data from Europe and North America revealing significant underperformance of primary care and hospital physicians in heart failure diagnosis and management, with evidence of underuse and underdosing of evidence-based therapies. Limited qualitative data suggest the reasons for this underperformance are complex and relate to lack of access to objective testing of ventricular function and exaggerated concerns over treatment risks and side-effects. Heart failure represents a complex cluster of aetiologies and risks that are not easy to correctly identify, even in specialist settings. Since there is now powerful evidence on how heart failure can be modified and improved, explicit guidance is needed for which suspected patients should be referred, for confirmation of diagnosis and advice on appropriate treatment regimes, and for which patients can be handled mainly within primary care but with enhanced access to objective non-invasive tests to improve diagnostic reliability and to stratify patients to evidence-based therapies. Current evidence suggests that in North America and Europe today primary care physicians do underperform in their management of patients with heart failure, often owing to factors outside of their immediate control.

Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial

BACKGROUND

There is increased pressure on primary care physicians to monitor oral anticoagulation.

OBJECTIVE

To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic, involving near-patient testing and computerized decision support software, compared with routine hospital management based on a variety of clinical outcome measures.

METHODS

A randomized, controlled trial in 12 primary care practices in Birmingham, England (9 intervention and 3 control). Two control populations were used: patients individually randomly allocated as controls in the intervention practices (intrapractice controls) and all patients in control practices (interpractice controls). Intervention practices' patients were randomized to the intervention (practice-based anticoagulation clinic) or control (hospital clinic) group. The main outcome measure was therapeutic control of the international normalized ratio.

RESULTS

Three hundred sixty-seven patients were recruited (122 intervention patients, 102 intrapractice control patients, and 143 interpractice control patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the intervention and control groups. Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in the intervention group (paired t test, P =.008).

CONCLUSIONS

Nurse-led anticoagulation clinics can be implemented in novice primary care settings by means of computerized decision support software and near-patient testing. Care given by this model is at least as good as routine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.

Research in primary care: extent of involvement and perceived determinants among practitioners from one English region

The lack of research evidence relevant to and generated by general practitioners (GPs) has been a concern in the context of a putative primary care-led National Health Service (NHS). However, very little has been published on the current extent or determinants of research activity among United Kingdom primary care doctors. We surveyed all (n = 2770) service GPs in the West Midlands Region in order to quantify their research involvement and to explore determinants of this. The response rate was 49% (n = 1351). A total of 84% of responders reported participating in research or audit, with 16% having initiated their own research; 9% of GPs had been published in a peer-reviewed journal; 6% had generated research funding; and 3% had held a research training fellowship. The characteristics positively associated with initiating research included an involvement in teaching, having research-active partners, the availability of protected time, and working in a larger practice. The most commonly perceived barriers to undertaking research were lack of time (92%), lack of staff to collect data (73%), and a lack of funding (71%). In all, 41% of responders reported no interest in research. Overall, the extent of research activity among responding GPs appears to be greater than is often assumed. Recent NHS research and development proposals to strengthen and develop research in primary care are, therefore, relevant in highlighting changes to address these issues.

Imprecision in medical communication: study of a doctor talking to patients with serious illness

Uncertainty is believed to be a central feature in illness experiences. Conversations between a consultant hematologist and 61 seriously ill patients were transcribed, entered on a database and scrutinized for patterns of language uncertainty by linguistic concordancing analysis. Transcripts were then discussed in detail with the hematologist, and techniques of protocol analysis were used to gain insight into his thought processes during consultations. The main findings were that the doctor used many more expressions of uncertainty than did patients: that evaluative terms were widely used to reassure rather than to worry patients; and that patients and doctor together used certain key terms ambiguously, in a manner which allowed the doctor to feel that facts were not misrepresented while perhaps permitting the patient to feel reassured.

A primary care evaluation of three near patient coagulometers

AIM

To compare the reliability and relative costs of three international normalised ratio (INR) near patient tests.

MATERIALS

Protime (ITC Technidyne), Coaguchek (Boehringer Mannheim), and TAS (Diagnostic Testing).

METHODS

All patients attending one inner city general practice anticoagulation clinic were asked to participate, with two samples provided by patients not taking warfarin. A 5 ml sample of venous whole blood was taken from each patient and a drop immediately added to the prepared Coaguchek test strip followed by the Protime cuvette. The remainder was added to a citrated bottle. A drop of citrated blood was then placed on the TAS test card and the remainder sent to the reference laboratory for analysis. Parallel INR estimation was performed on the different near patient tests at each weekly anticoagulation clinic from July to December 1997.

RESULTS

19 patients receiving long term warfarin treatment provided 62 INR results. INR results ranged from 0.8-8.2 overall and 1.0-5.7 based on the laboratory method. Taking the laboratory method as the gold standard, 12/62 results were < 2.0 and 2/62 were > 4.5. There were no statistical or clinically significant differences between results from the three systems, although all near patient tests showed slightly higher mean readings than the laboratory, and 19-24% of tests would have resulted in different management decisions based on the machine used in comparison with the laboratory INR value. The cost of the near patient test systems varied substantially.

CONCLUSIONS

All three near patient test systems are safe and efficient for producing acceptable and reproducible INR results within the therapeutic range in a primary care setting. All the systems were, however, subject to operator dependent variables at the time of blood letting. Adequate training in capillary blood sampling, specific use of the machines, and quality assurance procedures is therefore essential.

Systematic review of near patient test evaluations in primary care

OBJECTIVE

To identify and qualitatively synthesise the findings from all studies that have examined the performance and effect of near patient tests in the primary care setting.

DESIGN

Systematic review of published and unpublished research 1986-99.

MAIN OUTCOME MEASURES

Test performance characteristics, measures of effect on clinical practice or patient outcome.

RESULTS

101 relevant publications were identified. The general quality of these papers was low, and consequently only 32 papers were assessed in detail. Although these papers gave some indication of the value of near patient testing in areas such as anticoagulation monitoring and group A beta haemolytic streptococcus testing, the research raised many more questions than it answered. Almost no reports were found of unbiased assessment of the effect of near patient tests in primary care on patient outcomes, organisational outcomes, or cost.

CONCLUSIONS

Available research provides little evidence to guide the expansion of use of near patient testing in primary care. Further research is needed in areas of clinical practice where near patient tests might be most beneficial.

Is the international normalised ratio (INR) reliable? A trial of comparative measurements in hospital laboratory and primary care settings

AIM

To determine the reliability of international normalised ratio (INR) measurement in primary care by practice nurses using near patient testing (NPT), in comparison with results obtained within hospital laboratories by varied methods.

METHODS

As part of an MRC funded study into primary care oral anticoagulation management, INR measurements obtained in general practice were validated against values on the same samples obtained in hospital laboratories. A prospective comparative trial was undertaken between three hospital laboratories and nine general practices. All patients attending general practice based anticoagulant clinics had parallel INR estimations performed in general practice and in a hospital laboratory.

RESULTS

405 tests were performed. Comparison between results obtained in the practices and those in the reference hospital laboratory (gold standard), which used the same method of testing for INR, showed a correlation coefficient of 0.96. Correlation coefficients comparing the results with the various standard laboratory techniques ranged from 0.86 to 0.92. It was estimated that up to 53% of tests would have resulted in clinically significant differences (change in warfarin dose) depending upon the site and method of testing. The practice derived results showed a positive bias ranging from 0.28 to 1.55, depending upon the site and method of testing.

CONCLUSIONS

No technical problems associated with INR testing within primary care were uncovered. Discrepant INR results are as problematic in hospital settings as they are in primary care. These data highlight the failings of the INR to standardise when different techniques and reagents are used, an issue which needs to be resolved. For primary care to become more involved in therapeutic oral anticoagulation monitoring, close links are needed between hospital laboratories and practices, particularly with regard to training and quality assurance.

Descriptive study of cooperative language in primary care consultations by male and female doctors

OBJECTIVE

To compare the use of some of the characteristics of male and female language by male and female primary care practitioners during consultations.

DESIGN

Doctors' use of the language of dominance and support was explored by using concordancing software. Three areas were examined: mean number of words per consultation; relative frequency of question tags; and use of mitigated directives. The analysis of language associated with cooperative talk examines relevant words or phrases and their immediate context.

SUBJECTS

26 male and 14 female doctors in general practice, in a total of 373 consecutive consultations.

SETTING

West Midlands.

RESULTS

Doctors spoke significantly more words than patients, but the number of words spoken by male and female doctors did not differ significantly. Question tags were used far more frequently by doctors (P<0.001) than by patients or companions. Frequency of use was similar in male and female doctors, and the speech styles in consultation were similar.

CONCLUSIONS

These data show that male and female doctors use a speech style which is not gender specific, contrary to findings elsewhere; doctors consulted in an overtly non-directive, negotiated style, which is realised through suggestions and affective comments. This mode of communication is the core teaching of communication skills courses. These results suggest that men have more to learn to achieve competence as professional communicators.

Concordancing: use of language-based research in medical communication

BACKGROUND

The available literature on medical communication reports almost exclusively on observational, qualitative studies. We aimed to apply a novel approach to the analysis of doctor-patient consultation by means of computer concordancing. This methodology, established in linguistic research but rarely applied to professional language, allows both the quantitative and qualitative study of language.

METHODS

We analysed the language of 40 doctors and their patients during 373 complete primary-care consultations. We examined the use of jargon by doctors, the language of power and absence of power, and ways in which language was used to diminish the potential threat of the presenting disorder.

FINDINGS

There was no evidence that the doctors used medical jargon. Some doctors used language associated with social power, and some patients used language associated with absence of power. There was substantial evidence that the doctors used language to express emotions (eg, anxiety), to diminish threats (eg, words such as "little"), and to reassure patients.

INTERPRETATION

Concordancing is a valuable resource to study the consultation. The finding that doctors do not use jargon suggests that they are aware of the need to avoid it, but it does not follow that they are easily understood by patients. The use of some elements of the language of power may imply that consultations may be less democratic than is appropriate. The language of emotion and diminution is a major part of the primary-care doctor's repertoire and denotes a therapeutic use of language.

Review of computerized decision support systems for oral anticoagulation management

Computerized decision support systems (CDSS) are available to assist clinicians in the therapeutic management of oral anticoagulation. We report the findings relating to CDSS for oral anticoagulation management of a primary-care-based systematic review which largely focused on near-patient testing. Seven papers were reviewed which covered four different systems. The methodology of these papers was generally poor, although one randomized controlled trial showed improved therapeutic control associated with computerized management compared with human performance.

Survey of research activity, training needs, departmental support, and career intentions of junior academic general practitioners

BACKGROUND

Recent changes in the organization of the National Health Service have created new roles and responsibilities for academic general practice. Previous work on the constraints and opportunities of a career in academic general practice is largely anecdotal and is often based on the views of more senior members of the profession.

AIM

To survey the research activity, perceived level of training, support needs, and career intentions of junior academic general practitioners (GPs).

METHOD

A postal, validated, semistructured questionnaire was sent to the 121 eligible junior academic GPs in the academic departments of general practice in the United Kingdom and Dublin. Main outcome measures were 'research activity score', as measured by publications in peer-reviewed journals and involvement in research projects, 'training score' devised from 13 skills required for both research and teaching, and perceived level of departmental support assessed by six different support mechanisms.

RESULTS

Response rate was 89% (n = 108). Forty-six responders (43%) had no publications. Twenty-five responders (23%) had no principal project. Thirty-nine responders (37%) had a mentor. Research activity appeared to be dependent on sex, having a predominantly research role rather than a full-time teaching role, and a positive perception of academic training (P < 0.05). Increasing departmental 'support scores' and length of time in the department were both significantly associated with more positive perceptions of academic training (P < 0.05). Only 29 (27%) responders wanted to progress to senior positions within academic general practice.

CONCLUSION

Training and departmental support and guidance available to junior academics in primary care are perceived as variable and often inadequate. If academic general practice is to thrive, improved academic training is required, such as taught Master's degrees, supervised personal projects or 'apprenticeship' as a co-investigator, and improved methods of departmental support.

Primary care anticoagulant clinic management using computerized decision support and near patient International Normalized Ratio (INR) testing: routine data from a practice nurse-led clinic

BACKGROUND

Increasing indications for warfarin therapy has led to increased pressure on primary care to undertake therapeutic monitoring.

OBJECTIVE

This study evaluates a primary care model of oral anticoagulation monitoring which utilises computerized decision support (CDSS) and near patient testing (NPT) within a practice nurse-led clinic. Whilst this has been shown to be a successful model under trial conditions, this paper reports the first data from a long-standing clinic, outside a formal study.

METHOD

A prospective evaluation of therapeutic and clinical control of all patients taking warfarin within one inner city general practice. Data were collected via CDSS.

RESULTS

29 patients were seen in 208 appointments. The mean percentage of patients within therapeutic range was 72%. The costs to the practice were pound sterling 1751. The costs the practice would have incurred had these patients been seen at the hospital with the same frequency would have been pound sterling 2290.

CONCLUSIONS

The use of CDSS and NPT for nurse-delivered oral anticoagulation monitoring could enable the safe transfer of the majority of patients from secondary to primary care. Funding mechanisms to support the transfer of costs will be essential for most practices, as will be the maintenance of adequate staff training and quality assurance.

A review of near patient testing in primary care

AIMS AND OBJECTIVES

The aim was to identify publications relating to near patient testing (NPT), the use of alternative delivery systems between laboratory and general practice, including electronic data interchange (EDI), and computerised diagnostic decision support (CDDS), in the primary care setting to answer the following questions. What is the availability of NPT for primary care? What evidence is available to support the clinical effectiveness of NPT? What evidence is available on the accuracy and reliability of NPT within primary care? What evidence is available on the cost-effectiveness of different NPTs? How may CDDS improve the effectiveness of NPT? What evidence is available that compares NPT and existing laboratory services? What evidence is available on the cost-effectiveness of EDI or alternative delivery systems?

HOW THE RESEARCH WAS CONDUCTED

Eight databases were searched, and the bibliographies from relevant publications checked for completeness. Unpublished work and publications not included in the databases were obtained by personal contact with collaborators, and from a postal survey sent to heads of academic departments of general practice and clinical chemistry and to researchers active or interested in the field worldwide. Questionnaires were also sent to 150 commercial organisations. Publications that met agreed definitions and reported original data were included in the systematic review. Of the 1057 publications identified, 102 (92 related to NPT, eight to CDDS, and two to EDI) were passed to the reviewers for appraisal of validity. The limited amount of published research relating to any particular NPT prohibited meta-analysis. Scoring systems to assess the validity of evaluations were also difficult to apply.

RESEARCH FINDINGS

A wide variety of NPT systems have been developed. In general, the quality of the methods reported in the literature was poor. The issue of patient convenience and acceptability has not been adequately addressed. No evaluations of alternative delivery systems met the review criteria. No studies have evaluated the telephone or fax machine as a means of reporting results. For EDI, the majority of papers were descriptive. EDI and alternative delivery systems are not a replacement for NPT when the provision of an immediate result might have an impact on the quality of care. EDI may have clinical and cost advantages over traditional means of communication, but this has not been evaluated. The advisory role of the laboratory can be supported by CDDS. The use of CDDS and NPT has not, however, been fully evaluated. Few economic analyses have been conducted, and most were simple cost analyses. There are insufficient data for conclusions to be drawn on the cost-effectiveness of NPT in primary care.

RECOMMENDATIONS

FURTHER SYSTEMATIC REVIEWS: Subject-specific systematic reviews are required that include laboratory and secondary care studies, and consider the potential for altering current management and patient acceptability. Priority topics include: biochemistry profiles on desktop analysers; cholesterol testing; urinalysis for the diagnosis of urinary tract infection; anticoagulation control; NPTs for the identification of acute infection. (ABSTRACT TRUNCATED)

General practitioner perceptions of treatment benefits and costs in patients with hyperlipidaemia

This study explored general practitioner (GP) perceptions of use of treatments to manage hyperlipidaemia and their cost implications. GPs recognized different levels of coronary heart disease (CHD) risk, but were not always aware of which were major factors. Most were unfamiliar with published guidelines on managing hyperlipidaemia, and were likely to initiate drug therapies even in low-risk patients with mild hyperlipidaemia. Clearer advice is needed on whom to treat and on dietary intervention with high-fibre as well as low-fat diets.

Accuracy of routinely collected clinical data on acute medical admissions to one hospital

Despite the rapid growth in routine computerized data collection within the National Health Service (NHS), and the increased use of such data for generating hospital statistics and doctor activity rates, few validation studies exist. During a study of 158 acute medical admissions, and examination of hospital data revealed numerous and systematic inaccuracies. If general practitioner (GP) performance statistics are to be reliably based on such sources, data validation, staff training, and protocols for data entry should form a routine part of NHS practice.

Is the calcium antagonist debate having an effect on clinical practice?

The controversies over the long-term safety of calcium antagonists have produced considerable debate in both the medical and lay press. However, there are no data on whether this debate has influenced routine clinical practice. As most drugs in the Western healthcare systems are prescribed by primary care physicians, the aim of this study was to explore the perceptions of primary care clinicians with regard to their prescribing of calcium antagonists. Semistructured interviews of primary care physicians were performed in four countries, the Netherlands, Germany, Spain, and the United States. These interviews investigated the levels of awareness of primary care physicians about the recent calcium antagonist debate, and whether the debate had influenced their personal prescribing practice. Physicians were also asked if they considered the duration of calcium antagonist action to be clinically important. The results indicated that, despite the recent controversy over the safety of calcium antagonists, primary care physicians were largely unaware of the debate and had made no significant alterations to their routine practice. Although 15% cited potential nonspecified side effects, only 14% recalled a specific connection between the use of calcium antagonists and adverse cardiac events or higher mortality. Knowledge of adverse risks was significantly greater among physicians in the United States than among physicians in the other 3 countries. Finally, 90% of respondents were aware of the differences in duration of action of various calcium antagonists; of these, 90% felt that this had clinical significance.

Analysis of primary care staff language about aggression at work using concordancing techniques to identify themes

OBJECTIVE

We aimed to describe features of language used during interviews about the extent of aggression and violence at work and their effect on primary care staff.

METHOD

Forty-four primary health care team members in the West Midlands were interviewed, and interviews were recorded on videotape. The language content of these interviews was analysed using Cobuild concordancing software. Outcome measures used were word frequency, collocation and mutual information (MI) scores for language use.

RESULTS

A total of 17517 words spoken by interviewees were analysed. Violence in this sample was perceived as occurring principally in connection with unmet demands for such things as prescriptions and referrals. Only patients were perceived as violent; health care workers used other terms to describe their own feelings and responses. Sixty-eight specific incidents of violence were recounted, features perceived as salient being drink, youth and to a lesser extent mental illness.

CONCLUSIONS

Concordancing software can be successfully used in the qualitative examination of videotaped interviews. In this study, the technique rapidly identified a number of perceived training needs among a variety of primary care staff.

Acquisition of basic clinical skills in the general practice setting

Undergraduate medical education in the UK is changing due to both education pressure (from the General Medical Council) and changes in the hospital service. As a result the role of general practice in providing core clinical experience is under debate. The purpose of this study was to determine the clinical contact available for junior clinical medical clerks (third year) attached to five general practices. We report here on the clinical experience recorded by students during 106 sessions (74% of possible sessions). One hundred and one patients were seen, 54% females; ages ranging from 14 to 92. Four hundred and twenty-six symptoms were recorded; the largest category (36%) was CVS/respiratory followed by neurological (20%). Shortness of breath was the commonest single symptom (46% in the CVS/respiratory category). Three hundred and seventy-one signs were recorded; 48% were in the CVS/respiratory category, 33% in the neurological category. Cardiac murmurs were the commonest single sign (34% of the CVS/respiratory category). Sixty-nine separate comments were made by students about the range of clinical experience available; all were favourable. Forty-eight per cent of comments highlighted the availability of patients with appropriate symptoms and signs. This study has demonstrated that general practices can provide appropriate clinical exposure which complements hospital teaching for junior students.

Evaluation of computerized decision support for oral anticoagulation management based in primary care

BACKGROUND

Increasing indications for oral anticoagulation has led to pressure on general practices to undertake therapeutic monitoring. Computerized decision support (DSS) has been shown to be effective in hospitals for improving clinical management. Its usefulness in primary care has previously not been investigated.

AIM

To test the effectiveness of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled, defined as within the appropriate therapeutic range of International Normalised Ratio (INR).

METHOD

All patients receiving warfarin from two Birmingham inner city general practices were invited to attend a practice-based anticoagulation clinic. In practice A all patients were managed using DSS. In practice B patients were randomized to receive dosing advice either through DSS or through the local hospital laboratory. Clinical outcomes, adverse events and patient acceptability were recorded.

RESULTS

Forty-nine patients were seen in total. There were significant improvements in INR control from 23% to 86% (P > 0.001) in the practice where all patients received dosing through DSS. In the practice where patients were randomized to either DSS or hospital dosing, logistic regression showed a significant trend for improvement in intervention patients which was not apparent in the hospital-dosed patients (P < 0.001). Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 12 months (24 days to 36 days) (P = 0.033). Adverse events were comparable between hospital and practice-dosed patients, although a number of esoteric events occurred. Patient satisfaction with the practice clinics was high.

CONCLUSION

Computerized DSS enables the safe and effective transfer of anticoagulation management from hospital to primary care and may result in improved patient outcome in terms of the level of control, frequency of review and general acceptability.