Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial

OBJECTIVES

To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed.

RESULTS

No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions.

CONCLUSIONS

Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.

Provision of emergency contraception in general practice and confidentiality for the under 16's: results of a postal survey by general practitioners in Avon

OBJECTIVE

To describe the provision of emergency contraception and confidentiality for the under 16's by general practitioners (GPs) in Avon, in order to inform the development of a health promotion intervention in schools in Avon.

DESIGN

Confidential postal questionnaire survey.

SETTING

All principals in general practice in Avon Health Authority, South West England.

SUBJECTS

Five hundred and eighty general practice principals were sent the questionnaire.

RESULTS

Four hundred and eighty-six (84%) principals in general practice responded to the questionnaire. Only three (0.6%) GPs did not provide hormonal emergency contraception. Nearly half (232, 47.7%) would fit the intrauterine device (IUD) as emergency contraception. Fitting an IUD was associated with female gender of the GP (OR = 2.34, 95% CI 1.53-3.71), and whether the GP had a family planning qualification (OR = 4.55, 95% CI 2.41-8.60). Three hundred and fifty-two (72%) respondents would provide emergency contraception on a Sunday if requested to do so by a 14-year-old who reported having had unprotected sex the night before. Practice nurses in 26 (5%) of the respondent's practices were available to provide advice and tablets for patients requesting hormonal emergency contraception. However, 74 (21%) respondents employed a family planning trained practice nurse who was not involved in any way in the provision of emergency contraception. Practice nurses remain an under used resource in this area.

CONCLUSION

Our findings suggest that most GPs provide hormonal emergency contraception. Only eight (1.6%) of respondents would need to ask for parental consent prior to providing hormonal emergency contraception to a 14-year old-girl. Young people need to be informed of GPs widespread adherence to current confidentiality guidelines.

Intellectual problems shown by 11-year-old children whose mothers had postnatal depression

The aim of the study was to examine long-term sequelae in the children of mothers who were depressed at 3 months postpartum. In a community sample from two general practices in South London. 149 women were given psychiatric interviews at 3 months postpartum and 132 of their children (89 %) were tested at 11 years of age. The children of women who were depressed at 3 months postpartum had significantly lower IQ scores. They also had attentional problems and difficulties in mathematical reasoning. and were more likely than other children to have special educational needs. Boys were more severely affected than girls, with the sex difference most pronounced on Performance IQ. The links between postnatal depression and the children's intellectual problems were not mediated by parental IQ and were not accounted for by measures of social disadvantage nor by the mother's later mental health problems. Breastfeeding did not remove the effect of the mother's illness on Full Scale IQ, but exerted its own influence on Verbal IQ and appeared to mediate the link with mathematical ability. The findings show that adverse experiences in infancy predict cognitive ability and academic performance a decade later.

Urinary incontinence in older people in the community: a neglected problem?

BACKGROUND

The prevalence and impact of urinary incontinence has been investigated much less in older men than in older women. It is suggested that those who perceive that their daily lives are affected should have priority for services. However, many people do not seek medical help, even though they may be severely affected.

AIM

To investigate unmet need in relation to the prevalence and impact on everyday life of urinary incontinence in men and women over the age of 65 years.

DESIGN OF STUDY

Cross-sectional survey to measure prevalence of urinary incontinence, the impact on people's lives, use of protection, and health services.

SETTING

Stratified random sample of 2000 community-living elderly (equal numbers of men and women, aged 65 to 74 years and over 75 years) in 11 general practices in a British city.

RESULTS

The response rate was 79%. The overall prevalence of incontinence in the previous month was 31% for women and 23% for men. Women generally had more severe frequency of incontinence and a greater degree of wetness than men. Protection use was greater in women than in men. Only 40% of men and 45% of women with incontinence had accessed health services. Significant predictors of the use of health services were: incontinence reported as a problem, increased frequency of incontinence, and greater degree of wetness. About one-third of people who leaked with severe frequency or who reported that it was a problem had not accessed NHS services for incontinence.

CONCLUSIONS

Urinary incontinence is a common problem for older men and women living in the community and can have a deleterious effect on their lives. There is the opportunity to improve the lives of many older people with urinary incontinence, probably by a combination of increased public, patient, and professional awareness that should lead to earlier presentation and initiation of effective care.

A randomised controlled trial of flexibility in routine antenatal care

OBJECTIVE

To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk.

DESIGN

Randomised controlled trial.

SETTING

Eleven primary care centres providing midwifery care in Avon.

PARTICIPANTS

Six hundred and nine women at low risk of obstetric complications presenting for antenatal care.

METHODS

A standard antenatal care schedule ('traditional care') was compared with a schedule based on a minimum number of visits and additional visits with timing agreed between women and midwives ('flexible care').

MAIN OUTCOME MEASURES

Women's attitudes to pregnancy and motherhood using a subscale of the Maternal Adjustment and Maternal Attitudes scale, satisfaction with antenatal care, and perception of the speed of recognition of antenatal complications.

RESULTS

There was no difference between the two groups in terms of attitudes to pregnancy and motherhood (mean difference on Maternal Adjustment and Maternal Attitudes scale -0.64, 95% CI -1.39 to 0.11, P = 0.068) and no difference in the proportions of women reporting antenatal problems as soon as possible (traditional group 74.5%, flexible group 76.4%, difference -2%, 95% CI -12.1 to 8.2, P = 0.70). Women receiving traditional care reported higher levels of satisfaction for the care provided by community midwives (P < 0.01). Women receiving flexible care were more likely to report having a choice over the number and timing of their antenatal visits (P < 0.001), but were also more likely to report that they would like to have been seen more often (P < 0.01). There was no difference between the groups in rates of obstetric complications.

CONCLUSIONS

An imposed reduction in antenatal visits has been reported to increase dissatisfaction in other studies. In this study, encouraging women to adopt a flexible approach to antenatal care resulted in a similar finding. Successful implementation of such approaches may depend on more careful selection of women who welcome such an approach, more encouragement to pregnant women to express their own needs and greater feelings of commitment on the part of the care providers.

An intelligent rapid odour recognition model in discrimination of Helicobacter pylori and other gastroesophageal isolates in vitro

Two series of experiments are reported which result in the discrimination between Helicobacter pylori and other bacterial gastroesophageal isolates using a newly developed odour generating system, an electronic nose and a hybrid intelligent odour recognition system. In the first series of experiments, after 5 h of growth (37 degrees C), 53 volatile 'sniffs' were collected over the headspace of complex broth cultures of the following clinical isolates: Staphylococcus aureus, Klebsiella sp., H. pylori, Enterococcus faecalis (10(7) ml(-1)), Mixed infection (Proteus mirabilis, Escherichia coli, and E. faecalis 3 x 10(6) ml each) and sterile cultures. Fifty-six normalised variables were extracted from 14 conductive polymer sensor responses and analysed by a 3-layer back propagation neural network (NN). The NN prediction rate achieved was 98% and the test data (37.7% of all data) was recognised correctly. Successful clustering of bacterial classes was also achieved by discriminant analysis (DA) of a normalised subset of sensor data. Cross-validation identified correctly seven 'unknown' samples. In the second series of experiments after 150 min of microaerobic growth at 37 degrees C, 24 volatile samples were collected over the headspace of H. pylori cultures in enriched (HPP) and normal (HP) media and 11 samples over sterile (N) cultures. Forty-eight sensor parameters were extracted from 12 sensor responses and analysed by a 3-layer NN previously optimised by a genetic algorithm (GA). GA-NN analysis achieved a 94% prediction rate of 'unknown' data. Additionally the 'genetically' selected 16 input neurones were used to perform DA-cross validation that showed a clear clustering of three groups and reclassified correctly nine 'sniffs'. It is concluded that the most important factors that govern the performance of an intelligent bacterial odour detection system are: (a) an odour generation mechanism, (b) a rapid odour delivery system similar to the mammalian olfactory system, (c) a gas sensor array of high reproducibility and (d) a hybrid intelligent model (expert system) which will enable the parallel use of GA-NNs and multivariate techniques.

The views and anticipated needs of women in early pregnancy

OBJECTIVE

To assess the expectations of antenatal care of pregnant women at the outset of pregnancy.

DESIGN

Questionnaire study within a randomised controlled trial, comparing traditional antenatal care with a more flexible schedule.

SETTING

Eleven primary care centres providing midwifery care in Avon.

POPULATION

Five hundred and ninety-three pregnant women at low risk of obstetric complications presenting for antenatal care.

METHODS

A questionnaire was completed by women who agreed to participate in the trial shortly after antenatal booking. The questionnaire explored women's views on their attitudes to pregnancy and antenatal care, the locus of control related to pregnancy, the planning of the pregnancy and expectations of care.

MAIN OUTCOME MEASURES

Comparisons between nulliparous and multiparous women in terms of their views of antenatal care, and their stated preference for a particular package of care.

RESULTS

There was no difference in their views of pregnancy as an event entailing risk. On a locus of control scale that measured women's perceptions of factors which might affect their babies' health, nulliparous women rated antenatal care higher than multiparous women (P = 0.0001). However, this was not associated with any difference between the two groups in their stated preference for traditional or flexible care. Approximately half of the women expressed no preference, and of those who did 61% would opt for traditional care. Almost one-fifth of the whole sample welcomed the idea of flexible care.

DISCUSSION

These data support the evidence of previous studies that there remains a strong desire among pregnant women to receive a 'traditional' pattern of care, even among those who have previously experienced normal pregnancy. However, a minority can be identified at the outset of pregnancy who may welcome a change to a more flexible pattern of care.

Sequence variation within the RPGR gene: evidence for a founder complex allele

In our study of sequence variation within the RPGR gene associated with X-linked retinitis pigmentosa, we and others have observed a high rate of new mutation within this gene, as all reported mutations are unique or uncommon. In this article we report the identification in a single family of a complex allele of 7 sequence variants in linkage disequilibrium, of which four result in amino-acid alterations (Arg425Lys, DGlu, Thr533Met and Gly566Glu). This complex allele was initially found in a family with XLRP. However, further study revealed an estimated prevalence of 4.3% (15/344 chromosomes) with this complex allele in the European population indicating the non-pathogenic nature of this allele and, along with previously reported polymorphisms, further supporting a high level of human protein diversity for RPGR. This common complex allele may have been established in the population as a founder effect. Complete gene sequencing identified a potential pathogenic sequence variant in the family described (IVS6+5G>A). This study emphasises the need to create a more complete picture of the allelic variation within a gene, suggests cautious interpretation of a phenotypic association with variant sequences, and highlights the potential problems associated with interpreting genetic studies for diagnostic purposes.

Identifying and screening patients at high risk of colorectal cancer in general practice

OBJECTIVES

To determine the feasibility and acceptability of selecting patients at risk of colorectal cancer by taking family histories by means of a postal questionnaire. To determine if this information could be translated into simple risk categories to guide subsequent management.

SETTING

Patients aged between 30 and 69 years inclusive, registered with a mixed suburban and rural training general practice in south west England.

METHOD

A postal questionnaire survey seeking demographic information and family history of colorectal cancer was sent to all eligible patients. Personal risk of colorectal cancer was stratified according to predetermined criteria. Risk assessment was modified if necessary after the general practitioner conferred with a geneticist. Patients were subsequently offered colonoscopy (high risk) or faecal occult blood testing (intermediate risk).

RESULTS

Response to the questionnaire was 84.7%. 250 patients had a family history of colorectal cancer, of whom 52 were assigned to the high risk group, 104 to the intermediate group, and 94 to the low risk group. The geneticist reassigned five intermediate risk patients to the high risk group. Of 27 patients who had a colonoscopy, two were found to have an adenocarcinoma and a further two adenomatous polyps. In the group given faecal occult blood testing, two patients presented with colorectal cancer before being screened.

CONCLUSIONS

A postal questionnaire is feasible and acceptable for the collection of information about a family history of colorectal cancer from patients in general practice. The personal risk of developing the disease according to standard criteria can be estimated and then managed by a simple protocol.

To see or not to see? Midwives' perceptions of reduced antenatal attendances for 'low-risk' women

OBJECTIVE

To explore the views of midwives towards traditional and flexible schedules of antenatal attendance for women at low risk.

DESIGN

A qualitative approach using focus groups.

SETTING

Three NHS Trusts providing maternity care in and around Bristol.

SAMPLE

14 midwives who had provided antenatal care to women participating in the Bristol Antenatal Care Study.

FINDINGS

Midwives generally expressed support for a move away from the traditional schedule of antenatal attendances, suggesting that this represented a move towards the acceptance of pregnancy as a normal life event. They recognised that some women would prefer flexible care and the possibility of a reduction in the number of antenatal attendances. However, they suggested that some women would require additional information in order to feel confident in these circumstances. The midwives also recognised that both they and pregnant women have reservations about reducing contact during the antenatal period. Central to these reservations is a concern that women's psychosocial as well as physical needs may go unmet if antenatal contact is reduced.

IMPLICATIONS FOR PRACTICE

Although in principle supporting a move away from the traditional schedule of antenatal attendances, the reservations felt by midwives towards a reduction in antenatal attendances are reflected in their practice. These concerns currently impede any radical move away from the traditional schedule of antenatal check-ups and will need to be addressed by midwifery managers prior to the implementation of a more flexible schedule of antenatal attendances, if any such change is to be sustainable.