Treatment burden and associated factors: a population-based survey in Central Denmark Region 2017

Background

Exploring treatment burden at a population level can provide evidence of the types of patients who need special attention and support. We aimed to determine factors associated with high perceived treatment burden in a population-based survey of adults living in the Central Denmark Region (23% of the Danish population).

Methods

The Danish Multimorbidity Treatment Burden Questionnaire (MTBQ) was included in the 2017 Danish population health survey. 28,627 individuals aged 25 years or over participated (64% response rate). Individuals who reported having one or more medical conditions or attending regular health check-ups were asked to complete the MTBQ. A global MTBQ score was calculated (range 0-100) and both the continuous scores and a four-category grouping of the scores into no, low, medium and high burden were used to statistically assess the association between treatment burden and sociodemographic and health-related factors.

Results

13,407 individuals completed the Danish MTBQ (mean age 59 years). Treatment burden was negatively associated with self-related health (rs = -0.45, P < 0.0001), health-related quality of life (rs = -0.46/-0.51, P < 0.0001) and positively associated with the number of long-term conditions (rs = 0.26, P < 0.0001) and perceived stress (rs = 0.44, P < 0.0001). Higher treatment burden was associated with young age, male sex, high educational level, unemployment, not living with a spouse/cohabitant, living with child(ren) and specific long-term conditions, including heart disease, stroke, diabetes and mental illness.

Conclusions

This is the first known population-based study of treatment burden. The findings provide important evidence to policy makers and clinicians about sociodemographic groups at risk of higher treatment burden. We recommend that patient-perceived treatment burden is included when evaluating interventions targeting patients with long-term conditions and multimorbidity and health-care system reorganisations.

Key messages

• Treatment burden is associated with poor health and health-related quality of life and, among others, young age, male sex, unemployment, not living with a spouse, and specific long-term conditions.

• We recommend that patient-perceived treatment burden is included when evaluating interventions targeting patients with long-term conditions and multimorbidity and health-care system reorganisations.

Assessing the severity of Type 2 diabetes using clinical data-based measures: a systematic review

AIMS

To identify and critically appraise measures that use clinical data to grade the severity of Type 2 diabetes.

METHODS

We searched MEDLINE, Embase and PubMed between inception and June 2018. Studies reporting on clinical data-based diabetes-specific severity measures in adults with Type 2 diabetes were included. We excluded studies conducted solely in participants with other types of diabetes. After independent screening, the characteristics of the eligible measures including design and severity domains, the clinical utility of developed measures, and the relationship between severity levels and health-related outcomes were assessed.

RESULTS

We identified 6798 studies, of which 17 studies reporting 18 different severity measures (32 314 participants in 17 countries) were included: a diabetes severity index (eight studies, 44%); severity categories (seven studies, 39%); complication count (two studies, 11%); and a severity checklist (one study, 6%). Nearly 89% of the measures included diabetes-related complications and/or glycaemic control indicators. Two of the severity measures were validated in a separate study population. More severe diabetes was associated with increased healthcare costs, poorer cognitive function and significantly greater risks of hospitalization and mortality. The identified measures differed greatly in terms of the included domains. One study reported on the use of a severity measure prospectively.

CONCLUSIONS

Health records are suitable for assessment of diabetes severity; however, the clinical uptake of existing measures is limited. The need to advance this research area is fundamental as higher levels of diabetes severity are associated with greater risks of adverse outcomes. Diabetes severity assessment could help identify people requiring targeted and intensive therapies and provide a major benchmark for efficient healthcare services.

General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol

INTRODUCTION

Pressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.

METHODS AND ANALYSIS

The study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service East Midlands-Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation.

TRIAL REGISTRATION NUMBER

ISRCTN51780222.

Conducting a team-based multi-sited focused ethnography in primary care

Focused ethnography is an applied and pragmatic form of ethnography that explores a specific social phenomenon as it occurs in everyday life. Based on the literature a problem-focused research question is formulated before the data collection. The data generation process targets key informants and situations so that relevant results on the pre-defined topic can be obtained within a relatively short time-span. As part of a theory based evaluation of alternative forms of consultation (such as video, phone and email) in primary care we used the focused ethnographic method in a multisite study in general practice across the UK. To date there is a gap in the literature on using focused ethnography in healthcare research.The aim of the paper is to build on the various methodological approaches in health services research by presenting the challenges and benefits we encountered whilst conducing a focused ethnography in British primary care. Our considerations are clustered under three headings: constructing a shared understanding, dividing the tasks within the team, and the functioning of the focused ethnographers within the broader multi-disciplinary team.As a result of using this approach we experienced several advantages, like the ability to collect focused data in several settings simultaneously within in a short time-span. Also, the sharing of experiences and interpretations between the researchers contributed to a more holistic understanding of the research topic. However, mechanisms need to be in place to facilitate and synthesise the observations, guide the analysis, and to ensure that all researchers feel engaged. Reflection, trust and flexibility among the team members were crucial to successfully adopt a team focused ethnographic approach. When used for policy focussed applied healthcare research a team-based multi-sited focused ethnography can uncover practices and understandings that would not be apparent through surveys or interviews alone. If conducted with care, it can provide timely findings within the fast moving context of healthcare policy and research.

Depth of the patient-doctor relationship and content of general practice consultations: cross-sectional study

BACKGROUND

Patient-doctor continuity is valued by both parties, yet the effect of the depth of the patient-doctor relationship on the content of consultations in general practice is unknown.

AIM

To assess whether differences in the depth of relationship between a patient and their GP affects the length of consultations, and the number and type of problems and issues raised during a consultation.

DESIGN AND SETTING

Cross-sectional study in 22 GP practices in the UK.

METHOD

GP consultations (n = 229) were videotaped and the number of problems and aspects of those problems and issues identified. Patients completed the Patient-Doctor Depth of Relationship (PDDR) and General Practice Assessment Questionnaire-communication (GPAQc) scales. Associations were explored using multivariable linear and logistic regression.

RESULTS

Complete data were available on 190 participants consulting 30 GPs. In unadjusted analysis, patients with a deep relationship with their GP discussed more problems (mean 2.8) and issues (mean 4.7) compared with those with a moderate (2.4 problems; 4.0 issues) or shallow (2.3 problems; 3.8 issues) relationship. Patients with deep relationships had consultations that were on average 118 seconds (95% CI = 1 to 236) longer than those with shallow relationships. Adjustment for participant and GP factors attenuated these relationships, although the main trends persisted.

CONCLUSION

A greater number of problems and issues may be raised in a consultation when patients have a deeper relationship with their GP. Over several clinical encounters each year, this may be associated with significant benefits to patients and efficiencies in GP consultations and warrants further investigation.

Telehealth interventions for primary prevention of cardiovascular disease: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of telehealth interventions in the primary prevention of cardiovascular disease in adult patients in community settings.

METHODS

Systematic literature review of randomised controlled trials comparing the effectiveness of telehealth interventions to reduce overall cardiovascular disease (CVD) risk and/or to reduce multiple CVD risk factors compared with a non-telehealth control group was conducted in June 2013. Study quality was assessed using the Cochrane Risk of Bias tool. Fixed and random effects models were combined with a narrative synthesis for meta-analysis of included studies.

RESULTS

Three of 13 included studies measured Framingham 10-year CVD risk scores, and meta-analysis showed no clear evidence of reduction in overall risk (SMD -0.37%, 95% CI -2.08, 1.33). There was weak evidence for a reduction in systolic blood pressure (SMD -1.22 mmHg 95% CI -2.80, 0.35) and total cholesterol (SMD -0.07 mmol/L 95% CI -0.19, 0.06). There was no change in High-Density Lipoprotein cholesterol or smoking rates.

CONCLUSION

There is insufficient evidence to determine the effectiveness of telehealth interventions in reducing overall CVD risk. More studies are needed that consistently measure overall CVD risk, directly compare different telehealth interventions, and determine cost effectiveness of telehealth interventions for prevention of CVD.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of 'PhysioDirect' telephone assessment and advice services for physiotherapy

BACKGROUND

As a result of long delays for physiotherapy for musculoskeletal problems, several areas in the UK have introduced PhysioDirect services in which patients telephone a physiotherapist for initial assessment and treatment advice. However, there is no robust evidence about the effectiveness, cost-effectiveness or acceptability to patients of PhysioDirect.

OBJECTIVE

To investigate whether or not PhysioDirect is equally as clinically effective as and more cost-effective than usual care for patients with musculoskeletal (MSK) problems in primary care.

DESIGN

Pragmatic randomised controlled trial to assess equivalence, incorporating economic evaluation and nested qualitative research. Patients were randomised in 2 : 1 ratio to PhysioDirect or usual care using a remote automated allocation system at the level of the individual, stratifying by physiotherapy site and minimising by sex, age group and site of MSK problem. For the economic analysis, cost consequences included NHS and patient costs, and the cost of lost production. Cost-effectiveness analysis was carried out from the perspective of the NHS. Interviews were conducted with patients, physiotherapists and their managers.

SETTING

Four community physiotherapy services in England.

PARTICIPANTS

Adults referred by general practitioners or self-referred for physiotherapy for a MSK problem.

INTERVENTIONS

Patients allocated to PhysioDirect were invited to telephone a senior physiotherapist for initial assessment and advice using a computerised template, followed by face-to-face care when necessary. Patients allocated to usual care were put on to a waiting list for face-to-face care.

MAIN OUTCOME MEASURES

Primary outcome was the Short Form questionnaire-36 items, version 2 (SF-36v2) Physical Component Score (PCS) at 6 months after randomisation. Secondary outcomes included other measures of health outcome [Measure Yourself Medical Outcomes Profile, European Quality of Life-5 Dimensions (EuroQol health utility measure, EQ-5D), global improvement, response to treatment], wait for treatment, time lost from work and usual activities, patient satisfaction. Data were collected by postal questionnaires at baseline, 6 weeks and 6 months, and from routine records by researchers blind to allocation.

RESULTS

A total of 1506 patients were allocated to PhysioDirect and 743 to usual care. Patients allocated to PhysioDirect had a shorter wait for treatment than those allocated to usual care [median 7 days vs 34 days; arm-time ratio 0.32, 95% confidence interval (CI) 0.29 to 0.35] and had fewer non-attended face-to-face appointments [incidence rate ratio 0.55 (95% CI 0.41 to 0.73)]. The primary outcome at 6 months' follow-up was equivalent between PhysioDirect and usual care [mean PCS 43.50 vs 44.18, adjusted difference in means -0.01 (95% CI -0.80 to 0.79)]. The secondary measures of health outcome all demonstrated equivalence at 6 months, with slightly greater improvement in the PhysioDirect arm at 6 weeks' follow-up. Patients were equally satisfied with access to care but slightly less satisfied overall with PhysioDirect compared with usual care. NHS costs (physiotherapy plus other relevant NHS costs) per patient were similar in the two arms [PhysioDirect £ 198.98 vs usual care £ 179.68, difference in means £ 19.30 (95% CI -£ 37.60 to £ 76.19)], while QALYs gained were also similar [difference in means 0.007 (95% CI -0.003 to 0.016)]. Incremental cost per QALY gained was £ 2889. The probability that PhysioDirect was cost-effective at a £ 20,000 willingness-to-pay threshold was 88%. These conclusions about cost-effectiveness were robust to sensitivity analyses. There was no evidence of difference between trial arms in cost to patients or value of lost production. No adverse events were detected.

CONCLUSIONS

Providing physiotherapy via PhysioDirect is equally clinically effective compared with usual waiting list-based care, provides faster access to treatment, appears to be safe, and is broadly acceptable to patients. PhysioDirect is probably cost-effective compared with usual care.

Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians

OBJECTIVES

Ambulatory or primary care sensitive conditions (ACSCs) are those conditions for which hospital admission could be prevented by interventions in primary care. At present, different definitions of ACSCs are used for research and health policy analysis. This study aimed to explore the impact of different definitions of ACSCs and associated disease codes on analysis of health service activity.

STUDY DESIGN

Retrospective cross-sectional study using Hospital Episode Statistics (HES).

METHODS

All ACSCs identified by a literature search were documented. Conditions and codes were standardized using International Classification of Diseases (ICD) 10. A subset of ACSCs commonly used in England was compared with all 36 ACSCs identified by the search in a retrospective cross-sectional study using HES.

RESULTS

In total, 36 potential ACSCs were identified, which contained numerous subcategories. The most frequently used subset of ACSCs in the NHS only contains 19 ACSCs. There were 4,659,054 emergency admissions in England in 2005/6, of which 1,900,409 were ACSCs using the full set of 36 conditions. The proportion of these admissions attributable to the NHS subset of 19 ASCS was 35%. The underlying ICD10 codes used to define ACSCs vary widely across subsets of ACSCs used in the NHS. This impacts on rates of admission, length of stay and costs attributable to ACSCs.

CONCLUSIONS

Rates of hospital admission for ACSCs are increasingly used as a measure of the effectiveness of primary care. However, different conceptual interpretations of the term 'ACSC' and use of differing definitions and diagnostic codes impact on the proportion of admissions that are attributed as ACSCs. Some resolution of these inconsistencies is required for this measure to be more useful to decision makers.

The multiplicity and interdependency of factors influencing the health of street-based sex workers: a qualitative study

OBJECTIVES

To obtain a detailed understanding of the lives of street-based commercial sex workers (SSWs) and how factors in their lives interrelate to affect their health.

METHODS

In-depth interviews with 22 SSW working in Bristol, England.

RESULTS

The SSWs described their working day as a continuous cycle of selling sex, buying and using drugs, then returning to work. They explained that they placed themselves at risk of sexually transmitted infections, rape, physical assault, verbal abuse and murder when selling sex and physical violence when buying drugs. Most of the women injected drugs and detailed how this behaviour had resulted in life-threatening illnesses, including deep vein thromboses, pulmonary emboli and abscesses. Some interviewees gave accounts of sleeping in crack houses, on friends' floors or car parks, and most participants mentioned that they did not eat, drink or sleep regularly. This self-neglect led to weight loss and physical and mental ill-health. Respondents described pressures that forced them back out to work, such as unstable accommodation, separation from children and other individuals taking their drugs or money.

CONCLUSIONS

SSWs are trapped in a cycle of selling sex and buying and using drugs. Multiple pressures from within and outwith this cycle keep them in this situation. The multiplicity and interdependency of health problems and pressures suggest that this group are best supported with integrated multi-agency services that work flexibly across all areas of their lives. A rigid or punitive approach is likely to be counterproductive and may increase risks to the wellbeing of SSWs.

Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: a cross-sectional survey

OBJECTIVES

To compare the health needs of prostitutes (sex workers) working in massage parlours with that of those working on the streets.

DESIGN

Cross-sectional survey.

SETTING

Inner city, UK.

POPULATION

Women aged 16 years and older selling sex in massage parlours.

METHODS

Interviewer-administered questionnaires were undertaken with 71 parlour workers, and results were compared with our previous findings for street sex workers.

MAIN OUTCOME MEASURES

Self-reported experiences of health and service use.

RESULTS

In comparison with street sex workers, parlour sex workers were less likely to report chronic (43/71 versus 71/71; P < 0.001) and acute (10/71 versus 35/71; P < 0.001) illnesses but more likely to be registered with a GP (67/71 versus 59/71; P = 0.06). They were more likely than street sex workers to have been screened for sexually transmitted infections in the previous year (49/71 versus 33/71; P = 0.011) and more likely to use contraception in addition to condoms (34/71 versus 8/71; P < 0.001). They were less likely to be overdue for cervical screening (5/46 versus 19/48; P = 0.001), and more of those booked for antenatal care in the first trimester attended all follow-up appointments (28/37 versus 14/47; P < 0.001). Fewer parlour sex workers used heroin (4/71 versus 60/71; P < 0.001), crack cocaine (5/71 versus 62/71; P < 0.001) or injected drugs (2/71 versus 41/71 versus; P < 0.001) They reported fewer episodes of intercourse per week (mean 14 versus 22; P < 0.001) with fewer different men (mean 11 versus 19; P < 0.001), less of whom were new (mean 8 versus 13; P < 0.001).

CONCLUSIONS

The two groups had very different health experiences, risk-taking behaviour and use of services. To be effective in improving health, different types of service delivered in different settings for different groups are required.

Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection

OBJECTIVES

To investigate epidemiological, social, diagnostic and economic aspects of chlamydia screening in non-genitourinary medicine settings.

METHODS

Linked studies around a cross-sectional population-based survey of adult men and women invited to collect urine and (for women) vulvovaginal swab specimens at home and mail these to a laboratory for testing for Chlamydia trachomatis. Specimens were used in laboratory evaluations of an amplified enzyme immunoassay (PCE EIA) and two nucleic acid amplification tests [Cobas polymerase chain reaction (PCR), Becton Dickinson strand displacement amplification (SDA)]. Chlamydia-positive cases and two negative controls completed a risk factor questionnaire. Chlamydia-positive cases were invited into a randomised controlled trial of partner notification strategies. Samples of individuals testing negative completed psychological questionnaires before and after screening. In-depth interviews were conducted at all stages of screening. Chlamydia transmission and cost-effectiveness of screening were investigated in a transmission dynamic model.

SETTING AND PARTICIPANTS

General population in the Bristol and Birmingham areas of England. In total, 19,773 women and men aged 16-39 years were randomly selected from 27 general practice lists.

RESULTS

Screening invitations reached 73% (14,382/19,773). Uptake (4731 participants), weighted for sampling, was 39.5% (95% CI 37.7, 40.8%) in women and 29.5% (95% CI 28.0, 31.0%) in men aged 16-39 years. Chlamydia prevalence (219 positive results) in 16-24 year olds was 6.2% (95% CI 4.9, 7.8%) in women and 5.3% (95% CI 4.4, 6.3%) in men. The case-control study did not identify any additional factors that would help target screening. Screening did not adversely affect anxiety, depression or self-esteem. Participants welcomed the convenience and privacy of home-sampling. The relative sensitivity of PCR on male urine specimens was 100% (95% CI 89.1, 100%). The combined relative sensitivities of PCR and SDA using female urine and vulvovaginal swabs were 91.8% (86.1, 95.7, 134/146) and 97.3% (93.1, 99.2%, 142/146). A total of 140 people (74% of eligible) participated in the randomised trial. Compared with referral to a genitourinary medicine clinic, partner notification by practice nurses resulted in 12.4% (95% CI -3.7, 28.6%) more patients with at least one partner treated and 22.0% (95% CI 6.1, 37.8%) more patients with all partners treated. The health service and patients costs (2005 prices) of home-based postal chlamydia screening were 21.47 pounds (95% CI 19.91 pounds, 25.99) per screening invitation and 28.56 pounds (95% CI 22.10 pounds, 30.43) per accepted offer. Preliminary modelling found an incremental cost-effectiveness ratio (2003 prices) comparing screening men and women annually to no screening in the base case of 27,000 pounds/major outcome averted at 8 years. If estimated screening uptake and pelvic inflammatory disease incidence were increased, the cost-effectiveness ratio fell to 3700 pounds/major outcome averted.

CONCLUSIONS

Proactive screening for chlamydia in women and men using home-collected specimens was feasible and acceptable. Chlamydia prevalence rates in men and women in the general population are similar. Nucleic acid amplification tests can be used on first-catch urine specimens and vulvovaginal swabs. The administrative costs of proactive screening were similar to those for opportunistic screening. Using empirical estimates of screening uptake and incidence of complications, screening was not cost-effective.

Preferences for aspects of a dermatology consultation

BACKGROUND

General practitioners with special interests (GPSIs) are increasingly being used to provide dermatology services in the U.K. Little is known about U.K. dermatology patient attitudes to proposed variations in secondary care service delivery or the values they attach to aspects of the care they receive.

OBJECTIVES

To quantify preferences for different attributes of care within dermatology secondary care services.

METHODS

Attributes of care that are important to dermatology patients were derived using in-depth qualitative interviews with 19 patients at different points in the care pathway. A discrete choice experiment using 'best-worst scaling' was sent by post to 119 patients referred to secondary care dermatology services and suitable for GPSI care who had agreed to participate in research.

RESULTS

Four attributes were derived from the qualitative work: waiting, expertise, thorough care and convenience. For the discrete choice experiment, 99 patients returned questionnaires, 93 of which contained sufficient data for analysis. All attributes were found to be quantitatively important. The attribute of greatest importance was expertise of the doctor, while waiting time was of least importance. Respondents were willing to wait longer than the current 3 months maximum to receive care that was thorough, 2.1 months to see a team led by an expert and 1.3 months to attend a consultation that is easy to get to.

CONCLUSIONS

Although the need to reduce outpatient waiting times is a key policy driver behind the expansion of GPSI services, this does not appear to be the most important issue for patients. The thoroughness with which the consultation is provided and the expertise of the clinician seen are higher priorities.

One stop shop versus collaborative integration: what is the best way of delivering sexual health services?

OBJECTIVES

To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses.

METHODS

Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11).

RESULTS

The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory.

CONCLUSION

Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Developing a standard short questionnaire for the assessment of patient satisfaction with out-of-hours primary care

BACKGROUND

Governmental reviews of out-of-hours services in England and Scotland have recommended that a standard questionnaire should be used to assess patient satisfaction. This is important because of the rapid introduction of new forms of care.

OBJECTIVE

To produce a brief, reliable and valid measure of patient satisfaction for use by a wide variety of providers of out-of-hours primary care.

METHODS

The Short Questionnaire for Out-of-Hours care was designed and compared with a longer questionnaire which had been validated and used in earlier research. Questionnaires were sent to 1906 people contacting an out-of-hours GP co-operative. Three versions of the short questionnaire were used with different formats. Analysis compared the response rates, measurement properties, concurrent and construct validity of the short and long questionnaires, and of different versions of the short questionnaire.

RESULTS AND CONCLUSIONS

There was no significant difference in the overall response rates obtained from the short or long questionnaires (45.7% versus 41.9%; P = 0.17). The effective response rate of questionnaires from which all satisfaction scales could be calculated was higher for the short questionnaire (43.0% versus 36.4%; P = 0.01). There were no significant differences in response rates or distribution of responses between different versions of the short questionnaire. There was moderate agreement between items on the short questionnaire and corresponding scales on the long questionnaire. Scores using the short questionnaire showed anticipated relationships with the age and sex of patients and with characteristics of how the service was delivered. The SQOC is valid and reliable for routine service use.

What do other local providers think of NHS walk-in centres? Results of a postal survey

OBJECTIVES

To ascertain the views of other providers of primary and emergency healthcare services about their local walk-in centre.

DESIGN

Postal survey.

SETTING AND PARTICIPANTS

National Health Service healthcare providers (general practitioners (GPs), practice nurses, pharmacists, Accident and Emergency (A and E) consultants) working in close proximity to 20 English walk-in centres.

RESULTS

The overall response rate to the survey was 79% (n = 1591). Nearly one-third of respondents felt that patient expectations had increased since their local walk-in centre opened, although this varied across the different sites. Some providers had noticed a reduction in their workload, but 15% claimed that workloads had increased since their local walk-in centre opened. There was broad agreement that these new centres did address issues of access and that they provided appropriate care of a reasonable quality. Communication between walk-in centres and other local healthcare providers was an area of considerable concern; GPs, in particular, were anxious about the impact of the service on continuity of care. There were clear differences of opinion between different types of health professional, with doctors tending to be more critical and practice nurses being more supportive.

CONCLUSION

It has been suggested that healthcare professionals, notably GPs, are universally opposed to the concept of walk-in centres. This survey shows that opinions were divided, but overall, more local providers were in favour of this new service than were opposed to it. There was more support for centres co-located with A and E departments than "shop-front"-type facilities, but there were concerns that the service offered was too limited. The success or otherwise of the walk-in centre initiative will depend, in part, on building good relationships between the centres and other local providers. Understanding the views of local providers is important for those developing walk-in centres, and for those engaged in planning services in the wider health economies where these services are placed.

The chlamydia screening studies: rationale and design

BACKGROUND

Screening has been recommended to reduce the prevalence and morbidity associated with genital chlamydia infection in the United Kingdom.

METHODS

We describe the rationale and study design of the Chlamydia Screening Studies (ClaSS), a collaborative project designed to evaluate screening outside genitourinary medicine clinics. A non-selective, active screening approach in 16-39 year olds randomly sampled from 27 general practice lists in the Bristol and Birmingham areas formed the basis of interlinked studies: a case-control study was used to investigate factors to improve the targeting of screening; participants with chlamydia were invited to enroll in a randomised controlled trial to evaluate partner notification conducted in primary care; and laboratory based studies were used to assess the best specimens and tests. We also explored psychosocial effects of screening and partner notification and modelled the cost effectiveness of the programme.

CONCLUSION

Results from four pilot practices show that mailing of specimens for chlamydia testing is feasible but that it is difficult to achieve high response rates with postal screening. The high prevalence of asymptomatic infection in men suggests that efforts to screen men for chlamydia should be strengthened.

Perceptions of patient expectation for an antibiotic: a comparison of walk-in centre nurses and GPs

BACKGROUND

Patient expectation for a prescription is a recognized influence on GPs' prescribing, particularly in relation to the prescribing of antibiotics. Nurses are now able to supply antibiotics under a Patient Group Direction (PGD) in NHS walk-in centres and may experience similar pressures in this new role.

OBJECTIVES

Our aim was to compare walk-in centre nurses' and GPs' perceptions of the influence of patient expectation on their supply of an antibiotic to patients with an acute respiratory tract infection presenting with a sore throat or cough.

METHODS

Between June and December 2001, all patients presenting with a sore throat or cough at six walk-in centres and six nearby general practices were eligible to participate in the study. After the health professional-patient consultation, the health professional and the patient each completed a questionnaire.

RESULTS

There were 472 health professional (181 GPs and 291 walk-in centres) and 160 (34%, 160 out of 472) patient questionnaires returned. GPs were more likely to report that the patient expected an antibiotic than nurses (72% of 181 versus 13% of 291, P < 0.001). GPs were also less likely to report that an antibiotic was indicated than nurses (88% of 136 versus 97% of 194, P < 0.001). There was a trend for doctors to prescribe more frequently than nurses, in 74% of 180 patients versus 66% of 291 patients (P = 0.06). GPs were likely to report that the patient expected an antibiotic when the patient reported wanting a prescription (60% of 68, P = 0.05) and to report that the patient expected an antibiotic if the patient thought an antibiotic would be beneficial (62% of 68, P = 0.001). There was a much weaker relationship between nurse perceptions of patient expectation for an antibiotic and, either patient desire for a prescription or the patient's affirmative belief that an antibiotic would be beneficial.

CONCLUSIONS

Nurses may be compensating for a lack of security in their new role as antibiotic suppliers by not acknowledging the influence of patient expectation on their decision making. The acknowledgement of the influence of patient expectation might be beneficial to nurses' development as suppliers of medicines by giving them greater understanding of the consultation process and in the need to discuss patient expectations explicitly in the consultation.

Do NHS walk-in centres in England provide a model of integrated care?

PURPOSE

To undertake a comprehensive evaluation of NHS walk-in centres against criteria of improved access, quality, user satisfaction and efficiency.

CONTEXT

Forty NHS walk-in centres have been opened in England, as part of the UK governments agenda to modernise the NHS. They are intended to improve access to primary care, provide high quality treatment at convenient times, and reduce inappropriate demand on other NHS providers. Care is provided by nurses rather than doctors, using computerised algorithms, and nurses use protocols to supply treatments previously only available from doctors.

DATA SOURCES

Several linked studies were conducted using different sources of data and methodologies. These included routinely collected data, site visits, patient interviews, a survey of users of walk-in centres, a study using simulated patients to assess quality of care, analysis of consultation rates in NHS services near to walk-in centres, and audit of compliance with protocols.

CONCLUSION & DISCUSSION

The findings illustrate many of the issues described in a recent WHO reflective paper on Integrated Care, including tensions between professional judgement and use of protocols, problems with incompatible IT systems, balancing users' demands and needs, the importance of understanding health professionals' roles and issues of technical versus allocative efficiency.

Do children with non-malignant life-threatening conditions receive effective palliative care? A pragmatic evaluation of a local service

INTRODUCTION

A service established in October 1998 aimed to provide nursing and psychological support in the community to families with children who have non-malignant life-threatening illnesses. The purpose of this study was to conduct a pragmatic evaluation of the service.

METHODS

A before and after study design was used. It incorporated an administered questionnaire survey of carers of children at the time of referral and again after six months, a postal survey of health professionals and an audit of nursing and psychology records.

RESULTS

Twenty-nine families were recruited. The children had a wide range of needs. Prior to the service, nearly half were rated by their main carer as experiencing considerable distress. Perceived problems were as frequently due to emotional or practical care needs as due directly to their physical illness. Information and nursing care needs appeared to be improved and distress rating was slightly reduced after the involvement of the service. However, problems with equipment and respite needs were not improved. In general, families were satisfied with central aspects of the service.

CONCLUSIONS

The service appears to meet most of the expectations of both families and health professionals. However, recommendations include improvement of communication, the provision of a 24-h service and of respite care.

The demand for out-of-hours care from GPs: a review

BACKGROUND

The perception of a relentless increase in demand for out-of-hours care has led to the development of new models of organization. A comprehensive review of the evidence about the demand for out-of-hours care has, however, been lacking.

OBJECTIVE

The aim of this study was to review all published work relating to out-of-hours care in UK general practice which included data about the demand for care, and the variation in demand.

METHODS

Searches were conducted in MEDLINE (1966-December 1999) and EMBASE (1988- October 1999). Further references were identified from those cited in papers, and by use of the Science Citation Index to extract articles which cited key papers. Information about night visit fee claims was also obtained from the NHS performance indicators. The review was restricted to research in the UK published since 1959.

RESULTS AND CONCLUSIONS

The activity of GPs has been used as a proxy indicator for the demand for out-of-hours primary care. Most research has been based on claims for night visit fees, which reflect only a small proportion of all out-of-hours care. Night visit rates vary widely between areas, practices and individual doctors, for reasons which remain largely unexplained. There is evidence that levels of provision of out-of-hours care have risen considerably, but the wide variation between areas, and differences between studies in terms of definition and methodology, make it difficult to confirm this finding. The recent use of electronic call management systems by general practice co-operatives allows an accurate assessment to be made from routinely collected data of the total demand for out-of-hours care. This information will make it possible to assess the impact on general practice of new models of service provision, such as NHS Direct and primary care walk-in centres.

Demand for and supply of out of hours care from general practitioners in England and Scotland: observational study based on routinely collected data

OBJECTIVES

To determine the level of demand and supply of out of hours care from a nationally representative sample of general practice cooperatives.

DESIGN

Observational study based on routinely collected data on telephone calls, patient population data from general practices, and information about cooperatives from interviews with managers.

SETTING

20 cooperatives in England and Scotland selected after stratification by region and by size.

SUBJECTS

899 657 out of hours telephone calls over 12 months.

MAIN OUTCOME MEASURES

Numbers and age and sex specific rates of calls; variation in demand and activity in relation to characteristics of the population; timing of calls; proportion of patients consulting at home, at a primary care centre, or on the telephone; response times; hospital admission rates.

RESULTS

The out of hours call rate (excluding bank holidays) was 159 calls per 1000 patients/year, with rates in children aged under 5 years four times higher than for adults. Little variation occurred by day of the week or seasonally. Cooperatives in Scotland experienced higher demand than those in England. Patients living in deprived areas made 70% more calls than those in non-deprived areas, but this had little effect on the overall variation in demand. 45.4% (408 407) of calls were handled by telephone advice, 23.6% (212 550) by a home visit, and 29.8% (267 663) at a centre. Cooperatives responded to 60% of calls within 30 minutes and to 83% within one hour. Hospital admission followed 5.5% (30 743/554 179) of out of hours calls (8 admissions per 1000 patients/year).

CONCLUSIONS

This project provides national baseline data for the planning of services and the analysis of future changes.

The level of need for palliative care: a systematic review of the literature

Palliative care services have developed rapidly over the past 30 years, with little evaluation as to how needs have been met by these new services. As part of a systematic review of palliative care, evidence of the needs of patients and carers has been evaluated from the current literature. Of the total of 673 articles related to the 10 areas within the main review, 64 provided evidence on the need for palliative care services over the period from 1978 to 1997. A further nine articles were added in November 1998 after the end of the study of update the review with more recent research. Need can be assessed in one of two ways: either by adopting an epidemiological approach or by examining health service usage. In the former, evidence is provided on disease-specific mortality, and related to the duration of symptoms prior to the patient's death. As an example of this, it is suggested that services may need to provide pain control for 2800 patients per million (p/M) population dying from cancer each year and 3400 p/M with noncancer terminal illness. Using health service usage as an indicator of need, 700-1800 p/M with cancer and 350-1400 p/M with noncancer terminal illness would require a support team or specialist palliative home care nurse, with 400-700 cancer p/M and 200-700 noncancer p/M requiring inpatient terminal care. Studies indicate that at present usage, palliative care is being provided by 40-50 hospice beds/M. Despite this provision, there remains evidence that in certain areas of care such as pain control, there still remains a high degree of unmet need.

Out-of-hours care. Co-operative society

The last decade has seen a burgeoning of out-of-hours services in a movement characterized by experimentation and innovation that may have implications for all health services. The system needs to be more integrated to remove duplication and fill existing gaps in the service. But resistance from healthcare professionals is a major barrier. A shift from an out-of-hours emergency service towards 24-hour access for routine healthcare would be unsustainable and have limited health gain. NHS Direct should be the single point of access, with open access to A&E services restricted to people unable to telephone and who require urgent specialist care.

The effect of administering long-acting oxytetracycline and tilmicosin either by dart gun or by hand on injection site lesions and drug residues in beef cattle

Forty yearling cattle were injected intramuscularly with long-acting oxytetracycline and subcutaneously with tilmicosin by dart gun or by hand in a chute 28 days prior to slaughter. The drugs caused injection site lesions and antibiotic residues in the neck and thigh that varied by technique, dose, and site.

Patient and carer preference for, and satisfaction with, specialist models of palliative care: a systematic literature review

This systematic literature review examined the impact of specialist models of palliative care on consumer satisfaction, opinion and preference over the past 20 years. From the literature search, 83 relevant papers were identified. Research findings from North America did not reveal any reliable or consistent trends, and this was due primarily to methodological flaws in the research. In the UK, consumers are more satisfied with all types of palliative care, whether provided by inpatient units or in the community, than with palliative care provided by general hospitals. Even though research findings consistently indicate that consumers appreciate the psychosocial climate in hospices, this research was based on small-scale local studies which were mainly focused on a single hospice. The dearth of high quality, comprehensive research was notable on the impact on consumer preference, opinion or satisfaction of hospice home care services, and other forms of palliative care in the community. It was concluded that further research is needed into consumer priorities for patients dying of noncancer diseases, and into the possible impact of patient characteristics on consumer satisfaction, opinion and preference for specialist models of palliative care.

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care of conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

The implementation of evidence-based medicine in general practice prescribing

BACKGROUND

Research on the implementation of evidence-based medicine has focused on how best to influence doctors through information and education strategies. In order to understand the barriers and facilitators to implementation, it may also be important to study the characteristics of those doctors and practices that successfully implement evidence-based changes.

AIM

To determine the relationship between practice and doctor characteristics and the implementation of recommended evidence-based changes in the area of prescribing.

METHOD

Visits were made to 39 practices in southern England. Audits of three key prescribing changes were carried out and amalgamated to produce an 'implementation score' for each practice. These scores were related to a wide range of practice and doctor variables obtained from a questionnaire survey of doctors and practice managers.

RESULTS

There was wide variation between the practices' implementation scores (mean 67%, range 45% to 88%). The only factors that had a significant relationship with implementation of these important prescribing changes were an innovative approach among the doctors (most practitioners were cautious of change), and fundholding status. Use of clinical protocols, disease registers, or computers was not associated with overall implementation score, nor was the doctor's age. Doctors complained of information overload.

CONCLUSIONS

The emphasis on the need for evidence in medicine, and better transmission of information, needs to be balanced by a recognition that most general practitioners are pragmatic, averse to innovation, and already feel overwhelmed with information. Important advances in therapy may be crowded out. More attention should be given to the facilitation of priority changes in practices.

Changes in biochemical markers of joint tissue metabolism in a randomized controlled trial of glucocorticoid in early rheumatoid arthritis

OBJECTIVE

To determine the effects of low-dose prednisolone on joint tissue metabolism in early rheumatoid arthritis (RA).

METHODS

In addition to a range of biochemical markers of cartilage, bone and synovial tissue turnover, levels of pro-matrix metalloproteinase 3 (pro-MMP-3), pro-MMP-1, and cytidine deaminase (CD) were measured in serum from 79 of 128 patients with early RA who took part in the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study. Serum concentrations of joint tissue metabolites on treatment and off treatment were compared using Student's t-test.

RESULTS

Levels of the keratan sulfate epitope, 5D4, and glycosaminoglycan (GAG) were similar on and off treatment. However, the levels of synovium-derived markers, hyaluronate (HA) and N-propeptide of type III procollagen (PIIINP), were reduced by 23.9% (P < 0.01) and 25.2% (P < 0.001), respectively, during treatment with prednisolone. Serum osteocalcin (OC) was reduced by 25.8% (P < 0.001), while the levels of CD and pro-MMP-3 increased by 31.2% (P < 0.01) and 53.7% (P < 0.001) during prednisolone treatment compared with the off-treatment period.

CONCLUSION

Low-dose prednisolone had no significant effect on markers of cartilage turnover (GAG, 5D4) in early RA, suggesting that early erosions do not involve cartilage surfaces. The reduction in the markers of bone turnover (OC) and synovial tissue turnover (HA and PIIINP) support the general view that prednisolone reduces synovitis and suppresses bone turnover.

Relations between synovial fluid and serum concentrations of osteocalcin and other markers of joint tissue turnover in the knee joint compared with peripheral blood

OBJECTIVE

To determine if osteocalcin (OC) is locally produced in the joint and to study the relation between markers of bone, cartilage, and synovial tissue turnover.

METHODS

The concentrations of OC, keratan sulphate epitope (5D4), and hyaluronate (HA) were measured in paired serum and synovial fluid in 10 healthy volunteers and 15 patients with osteoarthritis (OA) and 16 with rheumatoid arthritis (RA). OC was measured with a commercial immunoradiometric assay and concentrations of 5D4 and HA were measured using enzyme linked immunosorbent inhibition assays.

RESULTS

Synovial fluid OC was found to be significantly lower than serum (p < 0.001) in all patients and controls. Synovial fluid OC concentrations were directly correlated with serum concentrations (r = 0.63, p < 0.001) and with age (r = 0.48, p < 0.01). There were also some relations between OC, HA, and 5D4 in patients with OA and RA. The OC concentrations were directly correlated with HA (r = 0.68, p < 0.01) in OA serum and there was a similar correlation in RA synovial fluid (r = 0.69, p < 0.01). A weak negative correlation was found between OC and 5D4 in OA serum (r = -0.55, p = 0.035) while a weak positive correlation was found in RA serum (r = 0.53, p = 0.034).

CONCLUSIONS

These results show that more OC is present in the circulation than in knee joint fluids suggesting that synovial fluid OC may be derived from the blood.

Postal survey of patients' satisfaction with a general practice out of hours cooperative

OBJECTIVE

To assess patients' satisfaction with out of hours care by a general practice cooperative compared with that by a deputising service.

DESIGN

Postal questionnaire survey.

SETTING

A general practice cooperative in London and a deputising service operating in an overlapping area.

SUBJECTS

Weighted samples of patients receiving telephone advice, a home visit, or attending a primary care centre after contacting either service in an eight week period.

MAIN OUTCOME MEASURES

Patients' overall satisfaction and scores for specific aspects of satisfaction. Satisfaction with telephone advice or attendance at centre compared with home visit. Relation between satisfaction and patient's age, sex, ethnic group, car ownership, preference for consulting own doctor, and expectation of a visit.

RESULTS

The overall response rate was 67% (1555/2312). There was little difference in overall satisfaction between patients contacting the cooperative or the deputising service, but patients contacting the latter were less satisfied with the explanation and advice received and the wait for a visit. There were significant differences between patients in different age and ethnic groups, with white patients and those aged over 60 years being more satisfied. Lower scores for overall satisfaction were reported by patients who received telephone advice, those who would have preferred to see their own doctor or who originally wanted a home visit, and those who waited longer for their consultation. Overall levels of patients' satisfaction seemed to be lower than previously reported.

CONCLUSIONS

There were larger differences in satisfaction between different groups of patients than between different models of organisation for out of hours care. A shift to a service based predominantly on telephone advice may lead to increased patient dissatisfaction.