Evidence-Based Treatment in Practice: PCIT Research on Addressing Individual Differences and Diversity Through the Lens of 20 Years of Service

Parent-Child Interaction Therapy (PCIT) is an intensive parent support program for caregivers and their children who exhibit difficult-to-manage disruptive behaviors. After more than four decades of research supporting its efficacy for reducing children's disruptive behaviors and improving parent-child relationships, PCIT has become one of the most popular and widely disseminated parenting support programs in the world. The evidence for the efficacy of PCIT can be found in many reviews of randomized clinical trials and other rigorous studies. To add to those reviews, our aim was to provide practical guidance on how PCIT can be part of an evidence-based program for families that depends on practitioner expertise, as well as attention to families' diverse needs. To do this, we describe the evolution of PCIT as practiced in a university-community partnership that has continued for over 20 years, alongside a narrative description of selected and recent findings on PCIT and its use in specific client presentations across four themes. These themes include studies of 1) whether the standard manualized form of PCIT is efficacious across a selection of diverse family situations and child diagnoses, 2) the mechanisms of change that explain why some parents and some children might benefit more or less from PCIT, 3) whether treatment content modifications make PCIT more feasible to implement or acceptable to some families, at the same time as achieving the same or better outcomes, and 4) whether PCIT with structural modifications to the delivery, such as online or intensive delivery, yields similar outcomes as standard PCIT. Finally, we discuss how these directions in research have influenced research and practice, and end with a summary of how the growing attention on parent and child emotion regulation and parents' responses to (and coaching of) their children's emotions has become important to PCIT theory and our practice.

The Circle of Security Parenting Program (COS-P): A Randomized Controlled Trial of a Low Intensity, Individualized Attachment-Based Program With at-Risk Caregivers

The Circle of Security-Parenting Intervention (COS-P; Cooper et al., 2009) is a psychoeducational program for caregivers of young children that has been widely disseminated. The program is founded in attachment theory and relies on computer-delivered content and parent reflection and discussion to teach concepts of safety and security to promote better caregiver-child relationships and child wellbeing. The present study is a randomized controlled trial of COS-P, individually delivered to 85 Australian caregivers (51 COS-P, 34 waitlist control) who reported parenting distress and child disruptive behaviors. Caregivers completed a baseline assessment and repeated the assessment after completion of COS-P or 8 weeks on the waitlist. Caregivers completed surveys to report child symptoms, and parenting stress, anxious and avoidant attachment, reflective functioning, parenting practices, and depressive symptoms. No differences in COS-P vs. waitlist participants were found at baseline. Analyses of complete data (35 COS-P, 25-26 waitlist) revealed a greater decline in caregivers' attachment anxiety and negative parenting relative to waitlist, but only attachment anxiety in intent-to-treat analyses. Other improvements were found, but these extended to both the COS-P and waitlist conditions and did not differ between conditions. Overall, effects of COS-P were small and rarely significant, suggesting the need to consider alternative programs that have evidence of effectiveness when providing services to at-risk families.

Peer relationships and stress: Indirect associations of dispositional mindfulness with depression, anxiety and loneliness via ways of coping

INTRODUCTION

Adolescents higher in the trait of dispositional mindfulness report fewer socioemotional problems. Focusing on the domain of peer stressors, we tested a model of adolescents' mindfulness as a resource that undergirds more constructive stress coping responses, in turn resulting in fewer socioemotional problems.

METHOD

The participants were 361 Australian secondary school students (40% boys; ages 11 to 18; M = 14.9 years; SD = 1.4). Each completed a questionnaire to report four facets of dispositional mindfulness; engagement and disengagement coping and involuntary stress responses to recent peer interpersonal stressful events; and socioemotional problems of loneliness, social anxiety, and depression.

RESULTS

Adolescents who reported more dispositional mindfulness, including facets of awareness, describing, non-judgement and non-reactivity, were lower in involuntary peer stress responses, disengagement coping, loneliness, social anxiety, and depression; associations of mindfulness facets with engagement coping were mixed. Mediational path models showed that almost all the significant negative associations of dispositional mindfulness with loneliness, social anxiety and depression were fully indirect via peer stress coping responses. Further, an alternative model, which tested whether loneliness, social anxiety and depression were the instigators of stress coping responses via mindfulness, had an adequate but poorer fit.

CONCLUSION

As hypothesized, the benefit of adolescents' dispositional mindfulness for reducing loneliness, social anxiety and depression seems to be indirect, with positive peer stress coping responses key mediators in these indirect pathways. It is less likely that the alternative occurs, whereby adolescents' socioemotional problems are the foundation for mindfulness and peer stress coping responses.

Attachment and emotion regulation: A person-centred examination and relations with coping with rejection, friendship closeness, and emotional adjustment

Guided by attachment theory of emotion regulation (ER), the current study utilized a person-centred approach to identify clusters of individuals that differed in their attachment representations and ER, and further examined individual differences in socio-emotional functioning based on these profiles. Participants included 658 emerging adults (M = 19.9, SD = 2.7, 65.5% female) who completed surveys measuring responses to rejection, friendship closeness, and emotional maladjustment. Five clusters were identified: secure regulated (19%), disorganized unregulated (21%), anxious unregulated (16%), emotive (21%), and avoidant suppressor (22%). Each group displayed unique patterns, with the secure regulated group reporting significantly less withdrawal, retribution, rumination, and emotional maladjustment, and the disorganized unregulated group reporting the poorest functioning across all indicators. Significant cluster × sex effects were also found for friendship closeness. These findings suggest the importance of considering attachment and ER, and implications for attachment theory and development are discussed. Statement of contribution What is already known on this subject? Insecure attachment representations are a significant risk factor for poorer outcomes across development. Hyperactivating and deactivating strategies are maladaptive responses to coping with emotional threat. These strategies are an extension of the internal working model and positive correlates of poorer functioning. What does this study add? Previous studies have over-relied on variable-centred approaches to replicate findings of attachment theory. A person-centred approach allowing for the joint consideration of patterns of both attachment and ER strategies. The identification of five novel profiles revealing unique differences in three important domains of functioning.

The impact of intrinsic and extrinsic factors on the job satisfaction of dentists

The Two-Factor Theory of job satisfaction distinguishes between intrinsic-motivation (i.e. recognition, responsibility) and extrinsic-hygiene (i.e. job security, salary, working conditions) factors. The presence of intrinsic-motivation facilitates higher satisfaction and performance, whereas the absences of extrinsic factors help mitigate against dissatisfaction. The consideration of these factors and their impact on dentists' job satisfaction is essential for the recruitment and retention of dentists.

OBJECTIVES

The objective of the study is to assess the level of job satisfaction of German dentists and the factors that are associated with it.

METHODS

This cross-sectional study was based on a job satisfaction survey. Data were collected from 147 dentists working in 106 dental practices. Job satisfaction was measured with the 10-item Warr-Cook-Wall job satisfaction scale. Organizational characteristics were measured with two items. Linear regression analyses were performed in which each of the nine items of the job satisfaction scale (excluding overall satisfaction) were handled as dependent variables. A stepwise linear regression analysis was performed with overall job satisfaction as the dependent outcome variable, the nine items of job satisfaction and the two items of organizational characteristics controlled for age and gender as predictors.

RESULTS

The response rate was 95.0%. Dentists were satisfied with 'freedom of working method' and mostly dissatisfied with their 'income'. Both variables are extrinsic factors. The regression analyses identified five items that were significantly associated with each item of the job satisfaction scale: 'age', 'mean weekly working time', 'period in the practice', 'number of dentist's assistant' and 'working atmosphere'. Within the stepwise linear regression analysis the intrinsic factor 'opportunity to use abilities' (β = 0.687) showed the highest score of explained variance (R(2) = 0.468) regarding overall job satisfaction.

CONCLUSIONS

With respect to the Two-Factor Theory of job satisfaction both components, intrinsic and extrinsic, are essential for dentists but the presence of intrinsic motivating factors like the opportunity to use abilities has most positive impact on job satisfaction. The findings of this study will be helpful for further activities to improve the working conditions of dentists and to ensure quality of care.

Multiple strategies for quality improvement and patient safety--money alone is not the answer, nor is trust. Conclusions of the 6th EQuiP Invitational Conference April 2011

On 7-9 April 2011 the 6th EQuiP Invitational Conference took place in Copenhagen. Key note lectures were delivered by Professor Frede Olesen (Denmark), Professor Andreas Christian Soennichsen (Austria), Professor Martin Roland (UK) and Professor Richard Roberts (US), and a key note panel discussion was held on the pros and cons of pay-for-performance led by Doctors Iona Heath (UK) and José Braspenning (The Netherlands). In addition, there were 9 workshops and 23 oral presentations. Videos of many presentations as well as PowerPoint and other materials can be found at EQuiP's website: http://www.equip.ch .

Comparison of protoporphyrin IX accumulation and destruction during methylaminolevulinate photodynamic therapy of skin tumours located at acral and nonacral sites

BACKGROUND

Topical photodynamic therapy (PDT) is successful in the treatment of nonmelanoma skin cancers and associated precancers, but efficacy is significantly reduced in actinic keratosis lesions not located on the face or scalp.

OBJECTIVES

To compare the changes in protoporphyrin IX (PpIX) fluorescence in lesions undergoing routine methylaminolevulinate (MAL) PDT and the clinical outcome observed 3 months after treatment in lesions located at acral and nonacral sites.

METHODS

This study was a noninterventional, nonrandomized, observational study, which monitored changes in PpIX fluorescence in 200 lesions during standard dermatological MAL-PDT. These data were subsequently analysed in terms of lesions located at acral and nonacral sites.

RESULTS

Clinical clearance was significantly reduced (P < 0·01) in acral skin lesions when compared with lesions located at nonacral sites. The accumulation and destruction of PpIX fluorescence was significantly reduced in these acral lesions (P < 0·05 and P < 0·001, respectively). Specifically, lesion location at acral sites significantly reduced changes in PpIX fluorescence in actinic keratosis lesions during MAL-PDT (P < 0·01 and P < 0·05).

CONCLUSIONS

These data suggest that reduced PpIX accumulation and the subsequent reduction in PpIX photobleaching within acral lesions result in the reduced responsiveness of these lesions to MAL-PDT. Future work should therefore aim to improve photosensitizer accumulation/photobleaching within lesions located at acral sites.

Clinical investigation of the novel iron-chelating agent, CP94, to enhance topical photodynamic therapy of nodular basal cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) involves the activation of a photosensitizer by visible light to produce activated oxygen species within target cells, resulting in their destruction. Evidence-based guidelines support the efficacy of PDT using topical 5-aminolaevulinic acid (ALA-PDT) in actinic keratoses, Bowen disease and basal cell carcinoma (BCC). Efficacy for nodular BCC appears inferior to that for superficial BCC unless prior debulking or repeat treatments are performed. Objectives The aim of this study was to assess the safety and efficacy of adding a novel iron-chelating agent, CP94 (1,2-diethyl-3-hydroxypyridin-4-one hydrochloride), to topical ALA, to temporarily increase the accumulation of the photosensitizer in the tumour.

METHODS

A mixed topical formulation of ALA + increasing concentrations of CP94 was used to carry out PDT on previously biopsied nodular BCC with no prior lesion preparation using standard light delivery. The area was assessed clinically and surgically excised 6 weeks later for histological examination.

RESULTS

Enhanced PDT using 40% CP94 resulted in significantly greater clearance rates in nodular BCC than with ALA-PDT alone, in our protocol of single-treatment PDT with no lesion preparation.

CONCLUSIONS

The results of this study demonstrate the safe and effective use of an enhanced ALA-PDT protocol for nodular BCC using CP94, with no adverse reactions to this modification. This is the first time this formulation has been used in patients. This formulation is now the focus of further study.

Cost of gastro-oesophageal reflux disease to the employer: a perspective from the United States

BACKGROUND

Employers pay more than just salary for their employees. Previous studies have largely focused on direct medical and prescription drug costs of gastro-oesophageal reflux disease (GERD), and few have reported on total absenteeism costs.

AIMS

To examine the annual cost of illness of GERD in an employed US population by benefit category and by place of service for direct medical costs.

METHODS

Retrospective data analysis from 2001 to 2004. International Classification of Diseases (ICD)-9 codes (530.1, 530.10, 530.11, 530.12, 530.19, 530.81, 787.1x, 787.2x or 251.5x) were used to identify employees with and without GERD (the control group). Measures included medical and prescription drug claims, plus indirect costs for sick leave, short- and long-term disability, and workers' compensation. For a subset of the population, the direct medical claims were analysed by place of service.

RESULTS

Data were available for 267,269 eligible employees of which 11,653 had gastro-oesophageal reflux disease. GERD was associated with a mean incremental cost of US $3,355 per employee of which direct medical costs accounted for 65%, prescription drug costs 17%, and indirect costs 19%. The place of service 'out-patient hospital or clinic' accounted for the largest part (47%) of the difference in medical costs.

CONCLUSIONS

GERD is associated with substantial direct and indirect costs, which highlight the importance of managing the disease effectively.

Defining and investigating occupational asthma: a consensus approach

BACKGROUND

At present there is no internationally agreed definition of occupational asthma and there is a lack of guidance regarding the resources that should be readily available to physicians running specialist occupational asthma services.

AIMS

To agree a working definition of occupational asthma and to develop a framework of resources necessary to run a specialist occupational asthma clinic.

METHOD

A modified RAND appropriateness method was used to gain a consensus of opinion from an expert panel of clinicians running specialist occupational asthma clinics in the UK.

RESULTS

Consensus was reached over 10 terms defining occupational asthma including: occupational asthma is defined as asthma induced by exposure in the working environment to airborne dusts vapours or fumes, with or without pre-existing asthma; occupational asthma encompasses the terms "sensitiser-induced asthma" and "acute irritant-induced asthma" (reactive airways dysfunction syndrome (RADS)); acute irritant-induced asthma is a type of occupational asthma where there is no latency and no immunological sensitisation and should only be used when a single high exposure has occurred; and the term "work-related asthma" can be used to include occupational asthma, acute irritant-induced asthma (RADS) and aggravation of pre-existing asthma. Disagreement arose on whether low dose irritant-induced asthma existed, but the panel agreed that if it did exist they would include it in the definition of "work-related asthma". The panel agreed on a set of 18 resources which should be available to a specialist occupational asthma service. These included pre-bronchodilator FEV1 and FVC (% predicted); peak flow monitoring (and plotting of results, OASYS II analysis); non-specific provocation challenge in the laboratory and specific IgE to a wide variety of occupational agents.

CONCLUSION

It is hoped that the outcome of this process will improve uniformity of definition and investigation of occupational asthma across the UK.

Defining and investigating difficult asthma: developing quality indicators

BACKGROUND

There is no agreed definition of 'difficult asthma' or what investigations should be available to investigate these patients. Patients with difficult asthma remain symptomatic on high levels of treatment and are high users of medical resources.

AIM

To develop a set of quality indicators for the definition and investigation of difficult asthma.

METHOD

Modified RAND Appropriateness Method was used. An expert panel composed of nine hospital asthma specialists who run 'difficult' asthma clinics and were identified from a short list of key workers in the field. Indicators were rated as necessary to define and investigate difficult asthma.

RESULTS

Difficult asthma was defined as 'symptoms persisting beyond therapy consistent with step 4 of the British Thoracic Society (BTS) guidelines' (high dose inhaled corticosteroids and long acting beta(2)-agonists). Eighty-three indicators were identified (40 relating to definition and 43 relating to investigations). Of these 32 (39%) were rated as necessary: 7 out of 40 (18%) for defining difficult asthma and 23 out of 43 (53%) for investigations. Indicators of high medical resource usage were characteristic of the 'difficult' nature of the management of patient with difficult asthma. A framework for the investigation of these patients was created.

CONCLUSION

The listed performance indicators identify a range of requirements that are necessary to define difficult asthma. Targeting of real needs in this group of patients will lead to better patient care and reduction of 'waste' in provision of healthcare.

Photodynamic therapy using meta-tetrahydroxyphenylchlorin (Foscan) for the treatment of vulval intraepithelial neoplasia

BACKGROUND

Photodynamic therapy (PDT) has unique properties which make it suitable for the local treatment of superficial epithelial disorders; it has been suggested as a useful treatment for carcinoma in situ of the vulva.

OBJECTIVES

To evaluate the effect of the systemic photosensitizing agent meta-tetrahydroxyphenylchlorin (mTHPC or temoporfin; Foscan, Biolitec, Edinburgh, U.K.) in vulval intraepithelial neoplasia type III (VIN III).

METHODS

PDT using mTHPC was performed in six patients with VIN III. A dose of 0.1 mg kg(-1) body weight mTHPC was injected intravenously and the area of VIN irradiated 96 h later with 652-nm light from a diode laser. Patients were reviewed 1 week, 6 months and 2 years following treatment.

RESULTS

Patients experienced only minimal pain from the initial treatment but two patients subsequently developed severe pain at the treated site for up to 2 weeks following PDT. All patients developed oedema and slough formation at the treated site and one patient developed cellulitis. At 6 months two patients had developed small recurrences of VIN at the original site and one patient had an area of VIN at a new site. These were treated either with further PDT or with a small excision. At 2 years there was no recurrence of VIN at the original site in all patients reviewed.

CONCLUSIONS

This small case series demonstrates that mTHPC-PDT is a useful initial treatment for VIN III. It is relatively selective, shows good cosmesis and conserves form and function. This is a major advantage over surgery. Repeat treatments are also possible, which is important in a condition such as VIN, which tends to be multifocal. Systemic mTHPC-PDT appears to have an advantage over topical 5-aminolaevulinic acid-PDT as the photosensitizer is distributed widely in areas of disease and consequently identifies foci which may not be apparent clinically but become evident when illuminated.

How do stakeholder groups vary in a Delphi technique about primary mental health care and what factors influence their ratings?

BACKGROUND

While mental health is a core part of primary care, there are few validated quality measures and little relevant internationally published research. Consensus panel methods are a useful means of developing quality measures where evidence is sparse and/or opinions are diverse. However, little is known about the dynamics of consensus techniques and the factors that influence the judgements and ratings of panels and individual panelists.

OBJECTIVES

(1) To describe differences in panel ratings on the quality of primary mental health care services by patient, carer, professional and managerial panels within a Delphi procedure; and (2) to explore why different panels and panelists rate quality indicators of primary mental health care differently.

DESIGN

Two round postal Delphi technique and exploratory semi-structured interviews.

PARTICIPANTS

115 panelists across 11 panels. Eleven panelists were subsequently interviewed.

RESULTS

87 of 334 indicators (26%) were rated face valid by all 11 panels. There was little disagreement within panel ratings but significant differences between panels. The GP panel rated the least number of indicators valid (n = 138, 41%) and carers the most (n = 304, 91%). The way in which panelists interpreted and conceptualised the indicators and their definition of quality of mental health care affected the way in which participants made their ratings.

CONCLUSIONS

Stakeholders in primary mental health care have diverse views of quality of care and these differences translate into how they rate quality indicators. Exploratory interviews suggest that ratings are influenced by past experience, expectations, definitions of quality of care, and perceived power relationships between stakeholders.

How do stakeholder groups vary in a Delphi technique about primary mental health care and what factors influence their ratings?

BACKGROUND

While mental health is a core part of primary care, there are few validated quality measures and little relevant internationally published research. Consensus panel methods are a useful means of developing quality measures where evidence is sparse and/or opinions are diverse. However, little is known about the dynamics of consensus techniques and the factors that influence the judgements and ratings of panels and individual panelists.

OBJECTIVES

(1) To describe differences in panel ratings on the quality of primary mental health care services by patient, carer, professional and managerial panels within a Delphi procedure; and (2) to explore why different panels and panelists rate quality indicators of primary mental health care differently.

DESIGN

Two round postal Delphi technique and exploratory semi-structured interviews.

PARTICIPANTS

115 panelists across 11 panels. Eleven panelists were subsequently interviewed.

RESULTS

87 of 334 indicators (26%) were rated face valid by all 11 panels. There was little disagreement within panel ratings but significant differences between panels. The GP panel rated the least number of indicators valid (n = 138, 41%) and carers the most (n = 304, 91%). The way in which panelists interpreted and conceptualised the indicators and their definition of quality of mental health care affected the way in which participants made their ratings.

CONCLUSIONS

Stakeholders in primary mental health care have diverse views of quality of care and these differences translate into how they rate quality indicators. Exploratory interviews suggest that ratings are influenced by past experience, expectations, definitions of quality of care, and perceived power relationships between stakeholders.

Improving the quality of mental health services in Personal Medical Services pilots: a longitudinal qualitative study

BACKGROUND

A series of government initiatives in the UK have included strategies to improve the quality of services received by patients, including fundholding, the development of National Service Frameworks, clinical governance, and Personal Medical Services (PMS). PMS represents a new contractual arrangement between government and general practitioners (GPs) which provides new investment in return for more detailed specification of processes and outcomes of care.

OBJECTIVES

To evaluate the effects of PMS on the quality of primary mental health care between 1998 and 2001.

DESIGN

Multiple longitudinal case studies. Semi-structured interviews with key staff within practices (GPs, nurses, practice managers) and outside (health authority and primary care group/trust managers).

SAMPLE

Six first wave PMS sites which had specifically planned to improve their mental health care.

RESULTS

Improvements in mental health care were found in some PMS practices and not in others. Five mechanisms associated with successful quality improvement in mental health were identified: clear goals, effective teamwork within the practice, routine use of protocols and audits, additional resources, and effective collaboration with community and secondary care. Sites where these factors were not present struggled to meet their objectives.

CONCLUSION

The five mechanisms which resulted in improved mental health care were facilitated by the new contractual arrangements in PMS. The new contracts were not a necessary part of these changes, but they enabled sites with an identified interest and motivation to make the changes. The contractual changes were not in themselves sufficient to improve care.

Assessing the quality of care of multiple conditions in general practice: practical and methodological problems

OBJECTIVE

To investigate practical and methodological problems in assessing the quality of care of multiple conditions in general practice.

SETTING

Sixteen general practices from two socioeconomically diverse regions in the UK.

METHOD

Quality of care was assessed in 100 randomly selected patient records in each practice using an established set of quality indicators covering 23 conditions commonly seen in primary care. Inter-rater reliability assessment was carried out for five of the conditions.

RESULTS

Conducting simultaneous quality assessment across multiple conditions is highly resource intensive. Poor data quality and the low prevalence of some items of care defined by the indicators are significant problems. Scores for individual indicators require very large samples for reliable assessment. Quality scores are more reliable when reported at a higher unit of analysis. This is particularly true for indicators and conditions with low prevalence where data may need to be aggregated to the level of groups of conditions or organisational providers. There is no single ideal way of aggregating quality scores.

CONCLUSION

The study identified some of the practical and methodological difficulties in assessing quality of care across multiple conditions. For improved quality assessment, advances in information technology and improvements in data quality are required for more efficient and reliable data extraction from medical records, together with the development of methods for combining scores across indicators, conditions, and practices. However, electronic data extraction methods will still be based on the assumption that the care recorded reflects the care provided.

The dimer initiation sequence stem-loop of human immunodeficiency virus type 1 is dispensable for viral replication in peripheral blood mononuclear cells

Human immunodeficiency virus type 1 (HIV-1) contains two copies of genomic RNA that are noncovalently linked via a palindrome sequence within the dimer initiation site (DIS) stem-loop. In contrast to the current paradigm that the DIS stem or stem-loop is critical for HIV-1 infectivity, which arose from studies using T-cell lines, we demonstrate here that HIV-1 mutants with deletions in the DIS stem-loop are replication competent in peripheral blood mononuclear cells (PBMCs). The DIS mutants contained either the wild-type (5'GCGCGC3') or an arbitrary (5'ACGCGT3') palindrome sequence in place of the 39-nucleotide DIS stem-loop (NL(CGCGCG) and NL(ACGCGT)). These DIS mutants were replication defective in SupT1 cells, concurring with the current model in which DIS mutants are replication defective in T-cell lines. All of the HIV-1 DIS mutants were replication competent in PBMCs over a 40-day infection period and had retained their respective DIS mutations at 40 days postinfection. Although the stability of the virion RNA dimer was not affected by our DIS mutations, the RNA dimers exhibited a diffuse migration profile when compared to the wild type. No defect in protein processing of the Gag and GagProPol precursor proteins was found in the DIS mutants. Our data provide direct evidence that the DIS stem-loop is dispensable for viral replication in PBMCs and that the requirement of the DIS stem-loop in HIV-1 replication is cell type dependent.

Research methods used in developing and applying quality indicators in primary care

Quality indicators have been developed throughout Europe primarily for use in hospitals, but also increasingly for primary care. Both development and application are important but there has been less research on the application of indicators. Three issues are important when developing or applying indicators: (1). which stakeholder perspective(s) are the indicators intended to reflect; (2). what aspects of health care are being measured; and (3). what evidence is available? The information required to develop quality indicators can be derived using systematic or non-systematic methods. Non-systematic methods such as case studies play an important role but they do not tap in to available evidence. Systematic methods can be based directly on scientific evidence by combining available evidence with expert opinion, or they can be based on clinical guidelines. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximise the effectiveness of quality indicators in quality improvement strategies. It is also necessary to consider what the results of applying indicators tell us about quality of care.

Quality assessment for three common conditions in primary care: validity and reliability of review criteria developed by expert panels for angina, asthma and type 2 diabetes

OBJECTIVES

To field test the reliability, validity, and acceptability of review criteria for angina, asthma, and type 2 diabetes which had been developed by expert panels using a systematic process to combine evidence with expert opinion.

DESIGN

Statistical analysis of data derived from a clinical audit, and postal questionnaire and semi-structured interviews with general practitioners and practice nurses in a representative sample of general practices in England.

SETTING

60 general practices in England.

MAIN OUTCOME MEASURES

Clinical audit results for angina, asthma, and type 2 diabetes. General practitioner and practice nurse validity ratings from the postal questionnaire.

RESULTS

54%, 59%, and 70% of relevant criteria rated valid by the expert panels for angina, asthma, and type 2 diabetes, respectively, were found to be usable, valid, reliable, and acceptable for assessing quality of care. General practitioners and practice nurses agreed with panellists that these criteria were valid but not that they should always be recorded in the medical record.

CONCLUSION

Quality measures derived using expert panels need field testing before they can be considered valid, reliable, and acceptable for use in quality assessment. These findings provide additional evidence that the RAND panel method develops valid and reliable review criteria for assessing clinical quality of care.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance

OBJECTIVES

To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care.

DESIGN

Qualitative case studies using semi-structured interviews and documentation review.

SETTING

Twelve purposively sampled PCG/Ts in England.

PARTICIPANTS

Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members.

MAIN OUTCOME MEASURES

Participants' perceptions of the role of clinical governance in PCG/Ts.

RESULTS

PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment).

CONCLUSION

PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand

OBJECTIVES

Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

DESIGN

A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995-9.

SETTING

General practice based care in the UK, Australia, and New Zealand. Main outcome measures-Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study.

RESULTS

Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction.

CONCLUSIONS

This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Identifying predictors of high quality care in English general practice: observational study

OBJECTIVES

To assess variation in the quality of care in general practice and identify factors associated with high quality care.

DESIGN

Observational study.

SETTING

Stratified random sample of 60 general practices in six areas of England.

OUTCOME MEASURES

Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate.

RESULTS

Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.

CONCLUSIONS

Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Lipid rafts and HIV-1: from viral entry to assembly of progeny virions

BACKGROUND

Lipid rafts are currently an intensely investigated topic of cell biology. In addition to a demonstrated role in signal transduction of the host cell, lipid rafts serve as entry and exit sites for microbial pathogens and toxins, such as FimH-expressing enterobacteria, influenza virus, measles virus and cholera toxin. Furthermore, caveolae, a specialised form of lipid raft, are required for the conversion of the non-pathogenic prion protein to the pathogenic scrapie isoform.

OBJECTIVES

A number of reports have shown, directly or indirectly, that lipid rafts are important at various stages of the human immunodeficiency virus type-1 (HIV-1) replication cycle. The purpose of this paper is to provide a brief overview of the role of membrane-associated lipid rafts in cell biology, and to evaluate how HIV-1 has hijacked this cellular component to support HIV-1 replication. Special sections are devoted to discussing the role of lipid rafts in (1) the entry of HIV-1, (2) signal transduction regulation in HIV-1-infected cells, (3) the trafficking of HIV-1 proteins via lipid rafts during HIV-1 assembly; and a further section discusses the role of cholesterol in mature HIV-1.

SUMMARY

Like a number of other pathogens, HIV-1 has evolved to rely on the host cell lipid rafts to support its propagation during multiple stages of the HIV-1 replication cycle. This review has highlighted the importance of lipid rafts in HIV-1 replication.

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand

OBJECTIVES

Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

DESIGN

A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995-9.

SETTING

General practice based care in the UK, Australia, and New Zealand. Main outcome measures-Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study.

RESULTS

Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction.

CONCLUSIONS

This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Defining quality of care

This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components--effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.

Prescribing indicators for UK general practice: Delphi consultation study

OBJECTIVES

To identify prescribing indicators based on prescribing analysis and cost (PACT) data that have face validity for measuring quality or cost minimisation.

DESIGN

Modified two round Delphi questionnaire requiring quantitative and qualitative answers.

SETTING

Health authorities in England.

PARTICIPANTS

All health authority medical and pharmaceutical advisers in the first round and lead prescribing advisers for each health authority in the second round.

MAIN OUTCOME MEASURES

Face validity (median rating of 7-9 on a nine point scale without disagreement) and reliability (rating 8 or 9) of indicators for assessing quality and cost minimisation.

RESULTS

Completed second round questionnaires were received from 79 respondents out of 99. The median rating was 7 for cost minimisation and 6 for quality, and in all except four cases individual respondents rated indicators significantly higher for cost than for quality. Of the 41 indicators tested, only seven were rated valid and reliable for cost minimisation and five for quality.

CONCLUSION

The 12 indicators rated as valid by leading prescribing advisers had a narrow focus and would allow only a limited examination of prescribing at a general practice, primary care group, or health authority level.

Activation of cutaneous sarcoidosis following Mycobacterium marinum infection of skin

Sarcoidosis has long been associated with mycobacterial infection, especially with Mycobacterium tuberculosis, although a causal association has not been proven. Atypical mycobacteria have also been implicated in causing sarcoidosis, but there is as yet no conclusive evidence. We report the activation of cutaneous sarcoidosis following infection with M. marinum, raising further questions about the role of these bacteria in causing this chronic granulomatous disorder.

Research capacity in UK primary care

BACKGROUND

Moves towards a 'primary care-led' National Health Service (NHS) and towards evidence-based care have focused attention upon the need for evaluative research relating to the structure, delivery, and outcome of primary health care in the United Kingdom (UK). This paper describes work carried out to inform the Department of Health Committee on Research and Development (R&D) in Primary Care (Mant Committee).

AIM

To describe the extent and nature of current research capacity in primary care in the UK and to identify future needs and priorities.

METHOD

Funding data were requested from NHS National Programmes, NHS Executive Regional Offices, the Department of Health (DoH), Scottish Office, Medical Research Council, and some charities. A postal survey was sent to relevant academic departments, and appropriate academic journals were reviewed from 1992 to 1996. In addition, interviews were conducted with academic and professional leaders in primary care.

RESULTS

Overall, total annual primary care R&D spend by the NHS and the DoH was found to be 7% of the total spend, although annual primary care R&D spend differs according to funding source. Journals relating to primary care do not, with some notable exceptions (e.g. British Journal of General Practice, Family Practice), have high academic status, and research into primary care by academic departments is, with perhaps the exception of general practice, on a small scale. The research base of most primary care professions is minimal, and significant barriers were identified that will need addressing if research capacity is to be expanded.

CONCLUSION

There are strong arguments for the development of primary care research in a 'primary care-led' NHS in the UK. However, dashes for growth or attempts to expand capacity from the present infrastructure must be avoided in favour of endeavours to foster a sustainable, long-term research infrastructure capable of responding meaningfully to identified needs.

The effect of panel membership and feedback on ratings in a two-round Delphi survey: results of a randomized controlled trial

BACKGROUND

Past observational studies of the RAND/UCLA Appropriateness Method have shown that the composition of panels affects the ratings that are obtained. Panels of mixed physicians make different judgments from panels of single specialty physicians, and physicians who use a procedure are more likely to rate it more highly than those who do not.

OBJECTIVES

To determine the effect of using physicians and health care managers within a panel designed to assess quality indicators for primary care and to test the effect of different types of feedback within the panel process.

METHOD

A two-round postal Delphi survey of health care managers and family physicians rated 240 potential indicators of quality of primary care in the United Kingdom to determine their face validity. Following round one, equal numbers of managers and physicians were randomly allocated to receive either collective (whole sample) or group-only (own professional group only) feedback, thus, creating four subgroups of two single-specialty panels and two mixed panels.

RESULTS

Overall, managers rated the indicators significantly higher than physicians. Second-round scores were moderated by the type of feedback received with those receiving collective feedback influenced by the other professional group.

CONCLUSIONS

This paper provides further experimental evidence that consensus panel judgments are influenced both by panel composition and by the type of feedback which is given to participants during the panel process. Careful attention must be given to the methods used to conduct consensus panel studies, and methods need to be described in detail when such studies are reported.

Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice

OBJECTIVE

To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus.

SUBJECTS AND METHODS

Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses.

RESULTS

The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence.

CONCLUSION

The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.

Quality indicators for general practice: which ones can general practitioners and health authority managers agree are important and how useful are they?

BACKGROUND

The aim of the study was to assess the face validity of quality indicators being proposed for use in general practice by health authorities.

METHOD

A national survey of health authorities was carried out to identify quality indicators being proposed for use in general practice. A two-stage Delphi process was used to establish general practitioners' (GPs') and health authority managers' views on the face validity of identified indicators. A total of 240 separate indicators identified by health authorities and the NHS Executive as potential markers of the quality of general practice care were assessed. Indicators related to access, organizational performance, preventive care, care for a small number of chronic diseases, prescribing and gatekeeping. The subjects were a purposive sample of 47 health authority managers and 57 general practice course organizers.

RESULTS

Thirty-six indicators received median validity scores of 8 or 9 out of a maximum possible score of 9. Of this set, 83 per cent was rated identically by both groups of respondents. Prescribing and gatekeeping indicators generally received low validity scores.

CONCLUSION

Acceptable face valid indicators were identified for all domains except gatekeeping. However, the indicators rated by the sample do not cover all aspects of care. No indicators were proposed for use by health authorities relating to effective communication, care of acute illness, health outcomes or patient evaluation. Although it is possible to develop indicators of general practice care which have face validity in the view of both GPs and managers, these will be very partial measures of quality. In the indicators used in this study, no explicit distinction was made between indicators designed to assess minimum standards with which all practices should comply, and indicators which could be used to reward higher levels of performance. Failure to separate these will result in antagonism from practitioners to quality improvement initiatives in the NHS, and a failure to engage the profession in improving quality of care.

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Hypothalamic-pituitary-insulin-like growth factor-I axis dysfunction in patients with fibromyalgia

OBJECTIVE

To investigate the serum levels of insulin-like growth factor-I (IGF-I) in patients with fibromyalgia (FM) compared to healthy controls and patients with other rheumatic diseases, and to explore possible etiologic mechanisms of low IGF-I levels in patients with FM.

METHODS

Five hundred patients with FM and 152 controls (74 healthy blood donors, 26 myofascial pain patients and 52 patients with other rheumatic diseases) were studied. All had measurements of acid extracted serum IGF-I. A subset of 90 patients with FM were evaluated for clinical features that might explain low IGF-I levels. Twenty-five patients with FM underwent growth hormone (GH) provocation testing with l-dopa and clonidine.

RESULTS

The mean serum IGF-I level in patients with FM was 138 +/- 56 ng/ml and in controls 215 +/- 86 ng/ml (p = 0.00000000001). Low levels of IGF-I were not due to depression, tricyclic medications, nonsteroidal antiinflammatory drugs, poor aerobic conditioning, obesity, or pain level. Patients with focal myofascial pain syndromes had normal IGF-I levels (236 +/- 68), as did most patients with other rheumatic disorders, unless they had concomitant FM. Patients with FM with initially normal levels often had a rapid decline of IGF-I over 1 to 2 years. Most patients with FM with low IGF-I levels failed to secrete GH after stimulation with clonidine and l-dopa.

CONCLUSION

Many, but not all, patients with FM have low levels of IGF-I that cannot be explained by clinical associations. These results suggest that low IGF-I levels in patients with FM are a secondary phenomenon due to hypothalamic-pituitary-GH axis dysfunction.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care

OBJECTIVE

To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services.

DESIGN

Randomised controlled trial.

SETTING

Four urban areas in Manchester, Salford, Stockport, and Leicester.

SUBJECTS

2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests.

MAIN OUTCOME MEASURES

Health status outcome, patient satisfaction, and subsequent health service use.

RESULTS

Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups.

CONCLUSIONS

Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care

OBJECTIVE

To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services.

DESIGN

Randomised controlled trial.

SETTING

Four urban areas in Manchester, Salford, Stockport, and Leicester.

SUBJECTS

2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests.

MAIN OUTCOME MEASURES

Response to call, time to visit, prescribing, and hospital admissions.

RESULTS

1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions.

CONCLUSIONS

By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Evaluation of a computerized appointment system in general practice

Computers have gained rapid acceptance in general practice. A recent development has been the use of computers to run practice appointment systems. This study demonstrates the benefits of installing a computerized appointment system, with improved service for patients, and more efficient use of time by both doctors and receptionists.

Group treatment of fibromyalgia: a 6 month outpatient program

OBJECTIVE

To evaluate the impact of a 6 month group therapy program on the treatment of patients with fibromyalgia (FM). Since FM is a common problem in rheumatology practice, a program was designed to treat patients in a group setting using allied health professionals.

METHODS

The FM group (15 to 25 patients) met once a week for 6 months. The average session lasted 90 min and consisted of formal lectures, group sessions emphasizing behavior modification, stress reduction techniques, strategies to improve fitness and flexibility and support sessions for spouses/significant others. The 2 major outcome measures were the fibromyalgia impact questionnaire (FIQ) and the total tender point score. Secondary outcome measures were the quality of life scale, questionnaires to assess coping strategies and attitudes to illness, an index of aerobic conditioning, flexibility, distance walked in 6 min., Beck depression and Beck anxiety questionnaires. Patients were followed 2 years and compared to a group of patients outside the program.

RESULTS

Between 1989 and 1993 170 patients were evaluated and 104 patients completed the program. At the end of the 6 months 73 (70%) of patients had <11 tender points and FIQ improved 25%. Having a pain profile on MMPI or having major depression, did not predict poorer outcome. Thirty-three patients followed for 2 years after the program continue to show improvement. A control group of 29 patients who never entered the program showed no significant improvement.

CONCLUSION

The group treatment of patients with FM in an outpatient setting shows promise; a more formal controlled study is needed to confirm this impression.

Why do people consult the doctor?

BACKGROUND

Symptoms are an everyday part of most peoples' lives and many people with illness do not consult their doctor. The decision to consult is not based simply on the presence or absence of medical problems. Rather it is based on a complex mix of social and psychological factors.

OBJECTIVES

This literature review seeks to explore some of the pathways to care and those factors associated with low and high rates of consultation.

METHODS

The paper examines the impact of socioeconomic and demographic factors on consultation rates and, using a revised version of the Health Belief Model, it highlights the psychological factors which influence decisions to seek medical care. Barriers which can inhibit consultation are discussed, as the decision to seek care will only result in a consultation if there is adequate access to care.

RESULTS AND CONCLUSIONS

Whilst poor health status and social disadvantage increase both "objective" medical need and in turn, consultation rates, a range of other social and psychological factors have been shown to influence consulting behaviour.

The influence of smoking cessation on the prevalence of overweight in the United States

BACKGROUND

The proportion of U.S. adults 35 to 74 years of age who were overweight increased by 9.6 percent for men and 8.0 percent for women between 1978 and 1990. Since the prevalence of smoking declined over the same period, smoking cessation has been suggested as a factor contributing to the increasing prevalence of overweight.

METHODS

To estimate the influence of smoking cessation on the increase in the prevalence of overweight, we analyzed data on current and past weight and smoking status for a national sample of 5247 adults 35 years of age or older who participated in the third National Health and Nutrition Examination Survey, conducted from 1988 through 1991. The results were adjusted for age, sociodemographic characteristics, level of physical activity, alcohol consumption, and (for women) parity.

RESULTS

The weight gain over a 10-year period that was associated with the cessation of smoking (i.e., the gain among smokers who quit that was in excess of the gain among continuing smokers) was 4.4 kg for men and 5.0 kg for women. Smokers who had quit within the past 10 years were significantly more likely than respondents who had never smoked to become overweight (odds ratios, 2.4 for men and 2.0 for women). For men, about a quarter (2.3 of 9.6 percentage points) and for women, about a sixth (1.3 of 8.0 percentage points) of the increase in the prevalence of overweight could be attributed to smoking cessation within the past 10 years.

CONCLUSIONS

Although its health benefits are undeniable, smoking cessation may nevertheless be associated with a small increase in the prevalence of overweight.

Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991

OBJECTIVE

To examine prevalence of overweight and trends in overweight for children and adolescents in the US population.

DESIGN

Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight.

PARTICIPANTS

Between 3000 and 14,000 youths aged 6 through 17 years examined in each of five separate national surveys during 1963 to 1965, 1966 to 1970, 1971 to 1974, 1976 to 1980, and 1988 to 1991 (Cycles II and III of the National Health Examination Survey, and the first, second, and third National Health and Nutrition Examination Surveys, respectively).

MAIN OUTCOME MEASURES

Prevalence of overweight based on body mass index and 85th or 95th percentile cutoff points from Cycles II and III of the National Health Examination Survey.

RESULTS

From 1988 to 1991, the prevalence of overweight was 10.9% based on the 95th percentile and 22% based on the 85th percentile. Overweight prevalence increased during the period examined among all sex and age groups. The increase was greatest since 1976 to 1980, similar to findings previously reported for adults in the United States.

CONCLUSIONS

Increasing overweight among youths implies a need to focus on primary prevention. Attempts to increase physical activity may provide a means to address this important public health problem.

Longitudinal and behavioral analysis of masculinity and femininity in marriage

Spouses' masculinity and femininity were examined in relation to longitudinal change in marital satisfaction and behavior displayed in a problem-solving discussion. Results indicated, first, that wives' satisfaction declined to the extent that their husband endorsed fewer desirable masculine traits (Study 1) and more undesirable masculine traits (Study 2). Second, masculinity and femininity covaried with problem-solving behavior, particularly for behavioral sequences involving husbands' responses to wives' negative behavior. Finally, the relation between husbands' masculinity and change in wives' satisfaction was not mediated by husbands' behavior; instead, sex role and behavioral variables made independent contributions to change in wives' satisfaction. These results are important because they highlight the value of examining intraindividual and interpersonal variables when determining how marriages improve and deteriorate.

Longitudinal and behavioral analysis of masculinity and femininity in marriage

Spouses' masculinity and femininity were examined in relation to longitudinal change in marital satisfaction and behavior displayed in a problem-solving discussion. Results indicated, first, that wives' satisfaction declined to the extent that their husband endorsed fewer desirable masculine traits (Study 1) and more undesirable masculine traits (Study 2). Second, masculinity and femininity covaried with problem-solving behavior, particularly for behavioral sequences involving husbands' responses to wives' negative behavior. Finally, the relation between husbands' masculinity and change in wives' satisfaction was not mediated by husbands' behavior; instead, sex role and behavioral variables made independent contributions to change in wives' satisfaction. These results are important because they highlight the value of examining intraindividual and interpersonal variables when determining how marriages improve and deteriorate.

Out of hours primary care centres: characteristics of those attending and declining to attend

OBJECTIVES

To study the number, demography, and clinical details of patients who agreed or refused to attend centralised primary care centres for out of hours medical care and to study the satisfaction with the service of those who attended.

DESIGN

Data collected by telephonists and doctors. Satisfaction questionnaires given to patients who attended.

SETTING

Five out of hours primary care centres in the United Kingdom.

SUBJECTS

All patients contacting the deputising service to request medical help out of hours who were asked to attend a primary care centre. The study terminated when 1000 patients had agreed to attend (200 from each centre). 1000 patients not agreeing to attend were also sampled.

RESULTS

The attendance rate varied from 8.9% to 52.3% in the five centres. The overall standardised attendance rate was 22.4%. The attendance rate was highest in children under 5 (465/2380, 19.5%) and fell with increasing age. Of the 1000 sampled non-attenders, 403 said that they had no transport and 345 said that they were too ill to attend. Those who attended were seen by the doctor more quickly. There was no significant difference between the groups in the number who received a prescription (810 attenders v 820 non-attenders, P = 0.57) or who were admitted to hospital (59 v 52, P = 0.5). Satisfaction with the service among those who attended was very high; 95% (694/731) said that they would be prepared to attend under similar circumstances in the future.

CONCLUSION

Most patients are not able or prepared to attend a central facility for primary care out of hours. Substantial cultural change will be necessary and careful consideration given to planning if such centres are to provide a major part of out of hours care.