General Practice Level Research Articles

Open-label, cluster randomised controlled trial and economic evaluation of a brief letter from a GP on unscheduled medical contacts associated with the start of the school year: the PLEASANT trial

BackgroundAsthma is seasonal with peaks in exacerbation rates in school-age children associated with the return to school following the summer vacation. A drop in prescription collection in August is associated...

The pattern of prescribing of glucose modulating agents for type 2 diabetes in general practices in England 2016/17.

In the financial year 2016/17 there were 52.0 million items prescribed for diabetes at a total net ingredient cost of £983.7 million - up from 28.9 million prescription items and £572.4 million in 2006/07. Anti-diabetes drugs (British National Formulary section 6.1.2) make up 45.1 per cent of the total £983.7 million net ingredient cost of drugs used in diabetes and account for 72.0 per cent of prescription items for all diabetes prescribing. We examined the way that agents licensed to treat type 2 diabetes were used across GP practices in England in the year 2016/2017. Analysis was at a GP practice level not at the level of patient data. Annual prescribing costs / patient / medication type for monotherapy varied considerable from £11/year for gliclazide and glimepiride to £885/year for Liraglutide. The use of SGLT-2i agents grew strongly at 70% per annum to around 100,000 DDD with prescriptions seen in 95% of GP practices. Liraglutide expenditure (11% of total) was high for a relatively small number of patients (1.3% of Defined Daily Doses), with still significant spend on exenatide. Liraglutide use significantly exceeded that of other glucagon-like peptide-1 (GLP-1) agonists. Our work demonstrates the significant cost of medication to modulate tissue glucose levels in type 2 diabetes and the dominance of some non-generic preparations in terms of number of prescriptions and overall spend. There are some older sulphonylureas in use, which should not generally be prescribed. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications and of their cost effectiveness.

Impact of the phased abolition of co-payments on the utilisation of selected prescription medicines in Wales.

We have taken advantage of a natural experiment to measure the impact of the phased abolition of prescription co-payments in Wales. We investigated 3 study periods covering the phased abolition: from £6 to £4, £4 to £3, and £3 to £0. A difference-in-difference modelling was adopted and applied to monthly UK general practice level dispensing data on 14 selected medicines which had the highest percentage of items dispensed subject to a co-payment prior to abolition. Dispensing from a comparator region (North East of England) with similar health and socio-economic characteristics to Wales, and where prescription co-payments continued during the study periods, was used to isolate any non-price effects on dispensing in Wales. Results show a small increase in dispensing of 14 selected medicines versus the comparator. Compared with NE England, monthly average Welsh dispensing was increased by 11.93 items (7.67%; 95% CI [7.2%, 8.1%]), 6.37 items (3.38%; 95% CI [2.9%, 3.7%]) and 9.18 items (4.54%; 95% CI [4.2%, 4.9%]) per practice per 1,000 population during the periods when co-payment was reduced. Price elasticities of the selected medicines utilisation were -0.23, -0.13, and -0.04 in 3 analyses, suggesting the abolition of co-payment had small effect on Welsh dispensing.

An investigation into the association between demographic and morbidity factors, and sleep disturbance

The recognition of sleep disorders is important because in the long term, they are associated with numerous deleterious health outcomes. Despite the high prevalence of sleep disorders, they are widely under-diagnosed at general practice level. This study aims to investigate the association between demographic and morbidity factors, and self-reported sleep disturbance symptoms. A quantitative cross-sectional study design was used. The data collection tool was an anonymous questionnaire consisting of 22 sleep symptoms categorised into four subscales: 1. Insomnia, 2. Daytime Distress, 3. Sleep Disorder, 4. Psychological Distress. Participants were adults ≥18 years of age attending their general practitioner. A total of 281 questionnaires were analysed (70.3% response rate). Participants with a diagnosis of depression and those who experienced low mood 'very frequently' had significantly higher median scores on all four subscales. Those with a body mass index (BMI) >30kg/m2 had a higher median score on subscale 3, compared to those with lower BMIs. Smokers had higher median scores on subscales 1-3 compared to non-smokers. Participants >65 years of age had lower median scores on all subscales compared to younger participants. Married participants had lower median scores on subscales 1-3 compared to unmarried participants. A total of 37% reported that they would be willing to participate in an overnight sleep study, and 5.3% had been formally diagnosed with a sleep disorder. A number of factors are significantly associated with sleep disturbance, particularly depression, low mood, elevated BMI and smoking. General practitioners should consider these factors to increase recognition of patients who would benefit from sleep disorder investigation.

Using Patient Flow Information to Determine Risk of Hospital Presentation: Protocol for a Proof-of-Concept Study.

BackgroundEvery day, patients are admitted to the hospital with conditions that could have been effectively managed in the primary care sector. These admissions are expensive and in many cases are possible to avoid if early intervention occurs. General practitioners are in the best position to identify those at risk of imminent hospital presentation and admission; however, it is not always possible for all the factors to be considered. A lack of shared information contributes significantly to the challenge of understanding a patient’s full medical history. Some health care systems around the world use algorithms to analyze patient data in order to predict events such as emergency presentation; however, those responsible for the design and use of such systems readily admit that the algorithms can only be used to assess the populations used to design the algorithm in the first place. The United Kingdom health care system has contributed data toward algorithm development, which is possible through the unified health care system in place there. The lack of unified patient records in Australia has made building an algorithm for local use a significant challenge.ObjectiveOur objective is to use linked patient records to track patient flow through primary and secondary health care in order to develop a tool that can be applied in real time at the general practice level. This algorithm will allow the generation of reports for general practitioners that indicate the relative risk of patients presenting to an emergency department.MethodsA previously designed tool was used to deidentify the general practice and hospital records of approximately 100,000 patients. Records were pooled for patients who had attended emergency departments within the Eastern Health Network of hospitals and general practices within the Eastern Health Network catchment. The next phase will involve development of a model using a predictive analytic machine learning algorithm. The model will be developed iteratively, testing the combination of variables that will provide the best predictive model.ResultsRecords of approximately 97,000 patients who have attended both a general practice and an emergency department have been identified within the database. These records are currently being used to develop the predictive model.ConclusionsRecords from general practice and emergency department visits have been identified and pooled for development of the algorithm. The next phase in the project will see validation and live testing of the algorithm in a practice setting. The algorithm will underpin a clinical decision support tool for general practitioners which will be tested for face validity in this initial study into its efficacy.

Community-related factors militating against effective management of neonatal jaundice in resource-limited settings

Neonatal jaundice is a leading cause of neonatal admission and deaths in most parts of the low and middle income countries (LMICs). The burden of this condition is less significant in the developed world where the health system is efficient in the prevention, early detection and prompt treatment of neonatal hyperbilirubinaemia. In the less developed parts of the world with high rates of out-of-hospital delivery,many affected babies often reach the health facility only when complications of hyperbilirubinaemia have already set in. Such children go on to develop various neurologic deficits and serious handicapping conditions that adversely affect quality of life. Therefore, there is a gap in care that needs to be addressed in order to reduce the burden of neonatal hyperbilirubinaemia and its complications in the resource-constrained parts of the world. The gap is created by failure of early detection of jaundice in the newborn, poor perception of the potential seriousness of the condition and delay in seeking appropriate care. This review addresses the various factors contributing to this gap, including inadequate knowledge of mothers and healthcare providers at both the primary health care and general practice levels, as well as weak health system at the peripheral levels of health care. It also aims to highlight some of the measures which may be adopted to improve the knowledge and capability of significant participants in newborn care such as female education, mass media campaigns, development of national guidelines for the management of neonatal jaundice, and the new concepts of knowledge translation and task analysis with the overall objective of strengthening the health system to appropriately manage newborn infants with hyperbilirubinaemia in developing countries of the world. Key words: Acute Bilirubin Encephalopathy, Care-seeking behaviour, Jaundice, Low and Middle Income Countries, Maternal Knowledge, Newborn care.

The effect of direct access to CT scan in early lung cancer detection: an unblinded, cluster-randomised trial.

BackgroundLower lung cancer survival rates in Britain and Denmark compared with surrounding countries may, in part, be due to late diagnosis. The aim of this study was to evaluate the effect of direct access to low-dose computed tomography (LDCT) from general practice in early lung cancer detection on time to diagnosis and stage at diagnosis.MethodsWe conducted a cluster-randomised, controlled trial including all incident lung cancer patients (in 19-month period) listed with general practice in the municipality of Aarhus (300,000 citizens), Denmark. Randomisation and intervention were applied at general practice level. A total of 266 GPs from 119 general practices. In the study period, 331 lung cancer patients were included. The intervention included direct access to low-dose CT from primary care combined with a 1 h lung cancer update meeting. Indication for LDCT was symptoms or signs that raised the GP’s suspicion of lung cancer, but fell short of satisfying the fast-track referral criteria on red flag’ symptoms. ResultsThe intervention did not significantly influence stage at diagnosis and had limited impact on time to diagnosis. However, when correcting for non-compliance, we found that the patients were at higher risk of experiencing a long diagnostic interval if their GPs were in the control group.ConclusionDirect low-dose CT from primary care did not statistically significantly decrease time to diagnosis or change stage at diagnosis in lung cancer patients. Case finding with direct access to LDCT may be an alternative to lung cancer screening. Furthermore, a recommendation of low-dose CT screening should consider offering symptomatic, unscreened patients an access to CT directly from primary care.Trial registrationwww.clinicaltrials.gov, registration ID number NCT01527214.

A framework for developing rural academic general practices: a qualitative case study in rural Victoria

There is increasing pressure for Australian rural general practices to engage in educational delivery as a means of addressing workforce issues and accommodating substantial increases in learners. For practices that have now developed a strong focus on education, there is the challenge to complement this by engaging in research activity. This study develops a rural academic general practice framework to assist rural practices in developing both comprehensive educational activity and a strong research focus thus moving towards functioning as mature academic units. A case study research design was used with the unit of analysis at the level of the rural general practice. Purposively sampled practices were recruited and individual interviews conducted with staff (supervisors, practice managers, nurses), learners (medical students, interns and registrars) and patients. Three practices hosted 'multi-level learners', two practices hosted one learner group and one had no learners. Forty-four individual interviews were conducted with staff, learners and patients. Audio recordings were transcribed for thematic analysis. After initial inductive coding, deductive analysis was undertaken with reference to recent literature and the expertise of the research team resulting in the rural academic general practice framework. Three key themes emerged with embedded subthemes. For the first theme, organisational considerations, subthemes were values/vision/culture, patient population and clinical services, staffing, physical infrastructure/equipment, funding streams and governance. For the second theme, educational considerations, subthemes were processes, clinical supervision, educational networks and learner presence. Third, for research considerations, there were the subthemes of attitude to research and research activity. The framework maps the development of a rural academic practice across these themes in four progressive stages: beginning, emerging, consolidating and established. The data enabled a framework to be constructed to map rural general practice activity with respect to activity characteristic of an academic general practice. The framework offers guidance to practices seeking to transition towards becoming a mature academic practice. The framework also offers guidance to educational institutions and funding bodies to support the development of academic activity in rural general practices. The strengths and limitations of the study design are outlined.

The dynamics of quality: a national panel study of evidence-based standards

BackgroundShortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health.ObjectivesTo assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment.Setting and participantsInformation on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11.Main outcome measuresPercentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators.AnalysisChanges in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality.ResultsAchievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3).ConclusionsShortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

CarePoint Integrated Care Program

Expenditure on healthcare in Australia is increasing at an unprecedented rate as the population ages, chronic disease becomes more prevalent, and technological development accelerates. A small proportion of patients with complex, chronic health conditions utilize a hugely disproportionate burden. The current Australian healthcare system, with its fragmented structure and fee for service model, is reactive not proactive and rewards quantity not quality. It does not incentivise cost and utilisation management, nor does it focus on the consumer experience and engagement. It is failing in secondary prevention and cost effective management of chronic disease. CarePoint is a program designed test the effectiveness and efficacy of a care planning and facilitation model in primary care for patients with chronic disease resulting in poor health, frequent hospitalisations and high healthcare costs. Multiple interventions will be used at the General Practice level for patients with complex, chronic health conditions, including enhanced care planning use of a specialized IT platform, case managers, home assessments, improved communication between care providers, and increased education and engagement of General Practitioners. It is postulated that these interventions would result in a reduction in hospital admissions and readmissions by 25%, reduced length of stay, and a reduction in emergency department attendances. Better care coordination of care will improve patient experience, improve health outcomes and significantly reduce cost to the health system. CarePoint is a longitudinal case-control cohort study including both public and privately insured patients. 2000 patients in Southern and Eastern Melbourne, who have had frequent recent hospitalizations as a result of chronic disease, will be recruited from General Practice. The Program is a jointly funded initiative between the Victorian Department of Health and Medibank Private. There has been active engagement with local hospital networks, local service providers and GP practices. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116673– http://www.ijic.org/ Patients will be recruited over a 6 month timeframe with the intervention being applied for a period of 2 years for every patient. The program commenced recruitment in July 2014. Data evaluation will be performed by an independent body at baseline and program end. CarePoint has been designed around successful integrated care programs in place for many years internationally. A model of integrative care directed at the general practice level is innovative and breaking new ground in Australian healthcare. It has the potential to reduce hospital and other healthcare costs dramatically, remove inefficiencies and duplication of service, along with improving population heath, and the experience and satisfaction of patients and healthcare providers alike. The program is sustainable, the cost being minimal compared with the savings gained from reduced preventable hospitalizations and other healthcare costs. It is easily transferable to all of Australia, given General Practice is structured and funded consistently across all states and territories. The program is a simple structure utilizing existing services and aligning with but enhancing current models of care. This program is in the initial stages of recruitment. Conclusions including key findings are not available at this point.

A telephone reminder intervention to improve breast screening information and access

ObjectivesIn the UK, women aged 50–70 are offered breast cancer screening every three years. Screening participation rates in London have been particularly low. Low rates have been associated with low socio-economic status, and some ethnic groups have been observed to be underserved by cancer screening. This paper reports on a telephone reminder intervention in London Newham, an area of high deprivation and ethnic diversity. Study DesignObservational study of planned intervention. MethodsWomen invited for breast screening were telephoned to confirm receipt of the invitation letter, remind invitees of their upcoming appointment, and to provide further information. Aggregate data at general practice level on invitation to and attendance at breast screening and on numbers reached by telephone were analysed by logistic regression. ResultsFor the 29 participating GP practices (10,928 invitees) overall uptake in 2010 was higher compared to the previous screening round in 2007 (67% vs. 51%; p < 0.001). On average 59% of invitees were reached by the reminder calls. A 10% increase in women reached resulted in an 8% increase in the odds of women attending their screening appointment (95% CI: 5%–11%), after adjusting for 2007 attendance rates. Practices with a higher proportion of South Asian women were associated with a larger uptake adjusted for 2007 uptake and population reached by the telephone intervention, (4% increase in odds of attendance per 10% increase in South Asian population, CI 1%–7%, p = 0.003) while practices with a higher proportion of black women were associated with a smaller uptake similarly adjusted. (11% decrease in odds of attendance per 10% increase in black population, CI 9%–16%, p < 0.001). ConclusionsA language- and culture-sensitive programme of reminder calls substantially improved breast cancer screening uptake.

Models and algorithms for health and social care of adolescents with addictive behavior, who use psychoactive substances

Background. The use of various psychoactive substances by adolescents and young people is the actual medical, psychological and social problem, which, unfortunately, has not yet been properly addressed. It should be noted that early diagnosis and treatment of mental disorders that occur the use of psychoactive substances (both episodic and systematic ones) for this contingent of respondents is a very complex issue, closely related to the destigmatization of psychiatric care, the success of psychoeducational projects on microsocial and family macrosocial (staff of educational institutions, social services, general practice) levels. It is periodically detection and early care in the vast majority of cases which have been determined the prognosis of mental illnesses and social consequences.&#x0D; Objective – based on a systematic, interdisciplinary approach we have the purpose to develop a model and the algorithm for providing medical and social care to adolescents with addictive behavior who use psychoactive substances.&#x0D; Materials and methods. A systematic, interdisciplinary approach is used.&#x0D; Results. Trends in the use of psychoactive substances by adolescents and young people will be described in such a way. Most of the respondents when taking various psychoactive substances were mainly in the area of relatively “safe” (1-7 points) or “dangerous use” (8-15 points), but without harmful effects or states of dependence. For adolescents with addictive behavior who used psychoactive substances, depending on the degree of use, we developed a model and the algorithm for medical and social care. Proposed measures were mainly psychotherapeutic and psychocorrectional in their nature.&#x0D; Conclusions. Based on the obtained data, the study and testing of addictive behavior of adolescents, the influence of social factors, premorbid mental disorders were developed and a model and the algorithm for providing medical and social care to adolescents who use psychoactive substances at different levels of care were tested.

The burden of adult asthma in a high GDP per capita country: the QASMA study

BackgroundAsthma is a major health problem worldwide. Suboptimal asthma care and poor asthma control are common even in developed countries. Qatar has the highest gross domestic product per capita in the world and high per capita health expenditure. No prior study has assessed the burden of adult asthma in this country. ObjectivesTo assess asthma control, patients' level of education about asthma, and level of asthma care in a country with the highest gross domestic product per capita in the world. MethodsA face-to-face, cross-sectional study of 520 adults with physician-diagnosed asthma conducted in various health care facilities in Qatar. ResultsThirty-three percent, 41%, and 26% of patients had uncontrolled, controlled, and partly controlled asthma, respectively. Only 4.9% of patients had previously received a written asthma management plan, 3.5% had a flow meter at home, and 37.2% had a spirometry performed in the previous 5 years. In addition, 42.9% misunderstood the role of reliever and controller medications. Inhaler technique was incorrect in 47% of these patients. There was a significant association between the type of physician practice and level of asthma control, with worst control being at the general practice level. Moreover, 57.3% of patients had at least 1 asthma-related visit to the emergency department in 1 year and 18.7% had more than 3 visits. ConclusionThe very high gross domestic product per capita in Qatar and the high health expenditure per capita do not seem to have led to better asthma care and control. A comprehensive national asthma service improvement program is much needed.

The Improving Rural Cancer Outcomes (IRCO) Trial: a factorial cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural patients with cancer in Western Australia: a study protocol.

IntroductionWhile overall survival for most common cancers in Australia is improving, the rural–urban differential has been widening, with significant excess deaths due to lung, colorectal, breast and prostate cancer in regional Australia. Internationally a major focus on understanding variations in cancer outcomes has been later presentation to healthcare and later diagnosis. Approaches to reducing time to diagnosis of symptomatic cancer include public symptom awareness campaigns and interventions in primary care to improve early cancer detection. This paper reports the protocol of a factorial cluster-randomised trial of community and general practice (GP) level interventions to reduce the time to diagnosis of cancer in rural Western Australia (WA).Methods and analysisThe community intervention is a symptom awareness campaign tailored for rural Australians delivered through a community engagement model. The GP intervention includes a resource card with symptom risk assessment charts and local referral pathways implemented through multiple academic detailing visits and case studies. Participants are eligible if recently diagnosed with breast, colorectal, lung or prostate cancer who reside in specific regions of rural WA with a planned sample size of 1350. The primary outcome is the Total Diagnostic Interval, defined as the duration from first symptom (or date of cancer screening test) to cancer diagnosis. Secondary outcomes include cancer stage, healthcare utilisation, disease-free status, survival at 2 and 5 years and cost-effectiveness.Ethics and disseminationEthics approval has been granted by the University of Western Australia and from all relevant hospital recruitment sites in WA.ResultsResults of this trial will be reported in peer-reviewed publications and in conference presentations.Trial registration numberAustralian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12610000872033.

The contribution of British general practice to our knowledge of epilepsy and its effects on people

British general practice is a good base for epidemiological research which is evidenced by the study of epilepsy. A comprehensive search of PubMed using various keywords for articles on epilepsy research performed in British general practice. Studies in the setting of general practice have contributed significantly to knowledge in the field of epilepsy, especially in relation to epidemiology, studies of prognosis and treatment patterns and psychosocial aspects. The extent to which epilepsy can be managed in general practice. The importance of primary care research and the importance of collaborative studies between general practice, hospital and university departments. The effects of interventions at general practice level on seizure control, morbidity and mortality.

Psychosocial Interventions for Alcohol Use Among Problem Drug Users: Protocol for a Feasibility Study in Primary Care

BackgroundAlcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users.ObjectiveThe objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use.MethodsPsychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an “assessment-only” control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment.ResultsThis study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care.ConclusionsThis is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.

Informatics as Tool for Quality Improvement: Rapid Implementation of Guidance for the Management of Chronic Kidney Disease in England as an Exemplar

ObjectivesChronic kidney disease (CKD) is an important cause of excess cardiovascular mortality and morbidity; as well as being associated with progression to end stage renal disease. This condition was largely unheard of in English primary care prior to the introduction of pay-for-performance targets for management in 2006. A realist review of how informatics has been a mechanism for national implementation of guidance for the improved management of CKD.MethodsRealist review of context, the English National Health Service with a drive to implement explicit national quality standards; mechanism, the informatics infrastructure and its alignment with policy objectives; and outcomes are describe at the micro-data and messaging, meso-patient care and quality improvement initiatives, and marco-national policy levels.ResultsAt the micro-level computerised medical records can be used to reliably identify people with CKD; though differences in creatinine assays, fluctuation in renal function, and errors in diabetes coding were less well understood. At the meso-level more aggressive management of blood pressure (BP) in individual patients appears to slow or reverse decline in renal function; technology can support case finding and quality improvement at the general practice level. At the macro-level informaticians can help ensure that leverage from informatics is incorporated in policy, and ecological investigations inform if there is any association with improved health outcomes.ConclusionsIn the right policy context informatics appears to be an enabler of rapid quality improvement. However, a causal relationship or generalisability of these findings has not been demonstrated.

Pharmacists’ perceived integration into practice of over-the-counter simvastatin five years post reclassification

Simvastatin 10 mg was reclassified in 2004 to over-the-counter (OTC) status in the UK, indicated for the prevention of a first major coronary event in individuals at moderate risk of the event. The primary reason behind the reclassification was to reduce the burden of disease management in general practice. Community pharmacists' adoption of OTC simvastatin into practice immediately post reclassification was reported to below but there has been no systematic update on current practice. The aim was to investigate pharmacists' adoption into practice, and attitudes to, OTC simvastatin 5 years post reclassification in the UK. Community pharmacists at all community pharmacies in Scotland. A pre-piloted postal questionnaire was distributed to all community pharmacies in Scotland (N = 1138). Self rated adoption was measured on a five point scale. Factors associated with decision making were investigated using a 24-item Likert-type agreement scale. Pharmacists' perceived integration of reclassified simvastatin; factors associated with decision making. Response rate was 49.5 % (n = 563). A high majority reported not supplying the reclassified medicine mainly owing to a perceived lack of evidence, low patient demand, customer complaints about the retail price and lack of access to patient medical records. A minority agreed to reclassification being an opportunity for their role development. Community Pharmacists' views of reclassified simvastatin supply 5 years post reclassification, as compared to the time it was newly reclassified, suggest low uptake. This lack of progress over time suggests that, against policy initiatives, OTC availability is unlikely to have impacted on the level of general practice led management of patients at risk of coronary events.

The influence of population characteristics on variation in general practice based morbidity estimations

BackgroundGeneral practice based registration networks (GPRNs) provide information on morbidity rates in the population. Morbidity rate estimates from different GPRNs, however, reveal considerable, unexplained differences. We studied the range and variation in morbidity estimates, as well as the extent to which the differences in morbidity rates between general practices and networks change if socio-demographic characteristics of the listed patient populations are taken into account.MethodsThe variation in incidence and prevalence rates of thirteen diseases among six Dutch GPRNs and the influence of age, gender, socio economic status (SES), urbanization level, and ethnicity are analyzed using multilevel logistic regression analysis. Results are expressed in median odds ratios (MOR).ResultsWe observed large differences in morbidity rate estimates both on the level of general practices as on the level of networks. The differences in SES, urbanization level and ethnicity distribution among the networks' practice populations are substantial. The variation in morbidity rate estimates among networks did not decrease after adjusting for these socio-demographic characteristics.ConclusionSocio-demographic characteristics of populations do not explain the differences in morbidity estimations among GPRNs.

Early detection of colorectal cancer: barriers to screening in the primary care setting

their patients. 4 There is an ongoing debate about the role of GPs and primary care physicians (PCPs) and their potential contribution to the effective implementation of screening programmes, both opportunistic and populationbased. In addition to the assessment of the risk of developing CRC, in general, the involvement and the role of the GPs and PCPs in convincing patients to participate and initiate CRC screening should be further explored and elucidated, as it is of key importance in cultural and organizational context and health policy issues. 5 This editorial highlights certain issues that have an impact on the early detection of CRC and focuses on barriers to screening at primary care and general practice levels.