General Practitioner Assessment Research Articles

Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General Practitioner assessment of Cognition’ tools in a rural aging population in Greece

Background: Under conditions of high demand for primary care services in a setting of low financial resources, there is need for brief, easily administered cognitive screening tools for use in the primary care setting, especially in rural areas. However, interpretation of these cognitive tests’ results requires knowledge on their susceptibility to cultural, educational and demographic patient characteristics.Objectives: To assess the clinical validity of the ‘Test Your Memory’ (TYM) and ‘General Practitioner assessment of Cognition’ (GPCog) which was specifically designed for primary care practice, in a rural primary care setting in Greece, utilizing the ‘Mini Mental State Examination’ (MMSE) as a reference standard.Methods: The MMSE, TYM, and GPCog were administered to a random sample of 319 community dwelling Greek adults aged 60 to 89 years in 11 rural Primary Healthcare Centres of the Prefecture of Heraklion on the island of Crete, Greece. Analyses examined (a) The association of each instrument with demographic factors and MMSE and (b) optimal cut-off scores, sensitivity and specificity against MMSE-based cognitive impairment risk using ROC analyses with the MMSE 23/24 point cut-off as a reference standard.Results: We found a sensitivity of 80% and a specificity of 77% for TYM (35/36 or 38/39 cut-off, depending on education). Corresponding values were 89% and 61% for GPCog (7/8 cut-off), respectively.Conclusion: The TYM and GPCog instruments appear to be suitable for routine use in the primary care setting as tools for cognitive impairment risk detection in elderly rural populations.

The comparative diagnostic accuracy of the Mini Mental State Examination (MMSE) and the General Practitioner assessment of Cognition (GPCOG) for identifying dementia in primary care: a systematic review protocol

BackgroundImproved dementia identification is a global health priority, and general practitioners (GPs) are often the first point of contact for people with concerns about their cognition. However, GPs often express uncertainty in using assessment tools and the evidence based on which tests are most accurate in identifying dementia is unclear. In particular, there is little certainty around how the accuracy of available brief cognitive assessments compares within a clinical family practice setting.Grounded in existing brief cognitive assessment evidence, we will compare the diagnostic test accuracy of the Mini Mental State Examination (MMSE) to the General Practitioner Assessment of Cognition (GPCOG) against the best available reference standard when used within a family practice setting.MethodsWe will employ robust systematic review methods to assess studies of diagnostic accuracy where both the MMSE and GPCOG have been evaluated as direct comparisons, i.e. within the same study population. This approach will enable us to minimise between-study heterogeneity, to eliminate the risk of bias due to confounding and increase the opportunity to make clinically useful and useable comparisons of diagnostic accuracy across both the MMSE and GPCOG. This systematic review will be conducted using a pragmatic search strategy, refining searches that build upon studies identified as part of our overview of systematic reviews of the diagnostic accuracy of brief cognitive assessments for identifying dementia in primary care.DiscussionThrough this systematic review, we aim to improve existing evidence on how the diagnostic accuracy of MMSE and GPCOG compares when used to identify dementia within the family practice setting. We also aim to make clinical practice recommendations based upon the variations in diagnostic accuracy identified between the MMSE and GPCOG.

Can a partnership between general practitioners and ambulance services reduce conveyance to emergency care?

BackgroundEmergency services are facing increasing workload pressures, and new models of care are needed. We evaluate the impact of a service development involving a partnership between emergency ambulance crews and...

Cost effectiveness of using cognitive screening tests for detecting dementia and mild cognitive impairment in primary care.

We estimated the cost effectiveness of different cognitive screening tests for use by General Practitioners (GPs) to detect cognitive impairment in England. A patient-level cost-effectiveness model was developed using a simulated cohort that represents the elderly population in England (65 years and older). Each patient was followed over a lifetime period. Data from published sources were used to populate the model. The costs include government funded health and social care, private social care and informal care. Patient health benefit was measured and valued in Quality Adjusted Life Years (QALYs). Base-case analyses found that adopting any of the three cognitive tests (Mini-Mental State Examination, 6-Item Cognitive Impairment Test or GPCOG (General Practitioner Assessment of Cognition)) delivered more QALYs for patients over their lifetime and made savings across sectors including healthcare, social care and informal care compared with GP unassisted judgement. The benefits were due to early access to medications. Among the three cognitive tests, adopting the GPCOG was considered the most cost-effective option with the highest Incremental Net Benefit (INB) at the threshold of £30 000 per QALY from both the National Health Service and Personal Social Service (NHS PSS) perspective (£195 034 per 1000 patients) and the broader perspective that includes private social care and informal care (£196 251 per 1000 patients). Uncertainty was assessed in both deterministic and probabilistic sensitivity analyses. Our analyses indicate that the use of any of the three cognitive tests could be considered a cost-effective strategy compared with GP unassisted judgement. The most cost-effective option in the base-case was the GPCOG. Copyright © 2016 John Wiley & Sons, Ltd.

Screening for Dementia in Primary Care: A Comparison of the GPCOG and the MMSE

Background/Aims: The General Practitioner Assessment of Cognition (GPCOG) is a brief cognitive test. This study compared the GPCOG to the Mini-Mental State Examination (MMSE), the most widely used test, in terms of their ability to detect likely dementia in primary care. Methods: General practitioners across three states in Australia recruited 2,028 elderly patients from the community. A research nurse administered the GPCOG and the MMSE, as well as the Cambridge Examination for Mental Disorders of the Elderly Cognitive Scale-Revised that we used to define likely dementia. Results: Overall, the GPCOG and the MMSE were similarly effective at detecting likely dementia. The GPCOG, however, had a higher sensitivity than the MMSE when using published cutpoints. Conclusion: The GPCOG is an effective screening tool for dementia in primary care. It appears to be a viable alternative to the MMSE, whilst also requiring less time to administer.

Errors in the Scoring and Reporting of Cognitive Screening Instruments Administered in Primary Care

To measure the frequency of scoring and reporting errors in cognitive screening instruments administered in the primary care setting in consecutive referrals to a dedicated secondary care memory clinic. Using a simple ad hoc classification, referral letters from primary care mentioning cognitive screening instrument use were classified as: unequivocal, incorrect/ambiguous or incomplete. Overall, reported test scores were either ambiguous/incorrect or incomplete in 23% of cases, with higher individual frequencies for two screening instruments recommended for use in primary care, the Six-item Cognitive Impairment Test (26%) and the General Practitioner Assessment of Cognition (32%). Errors are not infrequent in the scoring and reporting of cognitive screening instruments administered in primary care. More training in their correct use and scoring is required.

Why didn't I know? Perspectives from adult children of elderly parents with dementia.

Approximately 27 million adults are living with undiagnosed dementia worldwide. The purpose of this study was to learn about the experiences of adult children of elderly parents who were ultimately diagnosed with dementia. A descriptive qualitative design was used for identifying if there were prodromal signs or symptoms that preceded the more commonly known warning signs of dementia. Twelve, 60-min interviews were conducted over the telephone. The overarching theme was: "Why didn't I know?" Subthemes were "We ignored it because we didn't want it to be," "We thought it was grief," and "They wouldn't diagnose dementia." Normal aging changes often mask the identification of mild cognitive impairment (MCI) and dementia. Healthcare providers should screen patients for dementia when cognitive concerns or changes become apparent. The General Practitioner Assessment of Cognition and the Mini-Cog can be used for screening cognitive changes. Since depression may be misinterpreted as dementia, screening for depression should also be included if there is a potential for overlap. This is important in those patients who are experiencing grief, as many signs and symptoms of early grief are the same as early dementia.

The league of extraordinary generalists: a qualitative study of professional identity and perceptions of role of GPs working on a national after hours helpline in Australia

BackgroundTelephone triage and advice services (TTAS) have become commonplace in western health care systems particularly as an aid to patient access and demand management in the after hours period. In 2011 an after hours general practitioner (GP) helpline was established as a supplementary service to existing 24-h nurse-TTAS in Australia. Callers to the service in the after hours period who are triaged by a nurse as needing to see a GP immediately or within 24 h may speak with a GP on the line to obtain further assessment and advice.While much research has been undertaken on the roles of nurses in TTAS and the professional identities and attitudes to new technology of community-based GPs, little is known of the perceptions of role and identity of GPs providing after hours advice on primary care helplines. This qualitative study explored the perceptions of professional identity and role, motivations and contributions to the health system of GPs employed on the Australian afterhours GP helpline in 2011–2013.MethodsThe study took a phenomenographic approach seeking to understand the essence of being a telephone GP, probing professional identity while also exploring role tensions. Twelve GPs, or 15 % of the helpline GP workforce participated in the qualitative study.ResultsThe GPs experienced both personal and professional benefits and believed they were strengthening patient care and the Australian health system. However the role required a re-alignment of practice that challenged professional autonomy, the doctor-patient relationship and commitment to continuity of care. Some GPs made this role realignment more readily than others and were well suited to the helpline role. There was a strong collegial bond amongst the helpline GPs which facilitated the maintenance of professional autonomy.ConclusionsTelephone GP assessment and advice does not demonstrate the same breadth as face-to-face practice and provides little opportunity for continuity of care, but this has not prevented those performing the role from identifying as a new form of generalist. The establishment of an after hours GP helpline in Australia has seen the emergence of a new generalist primary care identity as telehealth innovators.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1387-5) contains supplementary material, which is available to authorized users.

An evaluation of the additional benefit of population screening for dementia beyond a passive case-finding approach.

General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the "Ageing in General Practice" study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding. Patients were classified as "case-finding" (n = 425) or "screening" (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome. The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected. There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.

Symptoms as the main problem: a cross- sectional study of patient experience in primary care.

BackgroundSymptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation.MethodCross-sectional study based on a questionnaire survey conducted in 2008–2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering.ResultsA higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06–1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14–1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with ‘symptoms only’ and patients given a specific diagnosis.ConclusionGPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having ‘symptoms only’ at the end of a consultation and not only for the minority group with ‘medically unexplained symptoms’. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0429-8) contains supplementary material, which is available to authorized users.

General practitioners Assessment of Continuing Education Programs in Golestan University of Medical Sciences

مقدمه: با توجه به اهمیت برنامه ­ های آموزش مداوم برای پزشکان و این­که برگزاری برنامه­های بازآموزی برای پزشکان و بروزرسانی اطلاعات پزشکی آنان یکی از مهم­ترین وظایف دفتر آموزش مداوم دانشگاه است، مطالعه حاضر با هدف ارزیابی برنامه­های آموزش مداوم برگزار شده توسط دانشگاه علوم پزشکی گلستان درسال 1390 ازدیدگاه پزشکان عمومی، به منظور رفع نقایص و تقویت نقاط قوت آن­ها انجام گرفت. روش­ها: این پژوهش توصیفی- مقطعی با همکاری پزشکان عمومی شرکت کننده درپنج برنامه مدون که در نیمه دوم سال 1390 توسط آموزش مداوم دانشگاه علوم پزشکی گلستان، برگزار گردید، انجام شد. نمونه ­ گیری به روش سرشماری و ابزار انجام پژوهش پرسشنامه مورد استفاده اداره کل آموزش مداوم بود. پرسشنامه از دو بخش مشخصات دموگرافیک و زمینه ای و 10 سوال در مورد برنامه­های اجراشده که بر اساس مقیاس پنج درجه ­ ای لیکرت تنظیم شده بود. پرسشنامه­ها بین تمامی پزشکان شرکت ­ کننده در برنامه ­ ها توزیع شد، 333 پرسشنامه تکمیل شد. نتایج حاصل با استفاده از نرم ­ افزار آماری SPSS بر مبنای آمار توصیفی مورد تجزیه و تحلیل قرارگرفت. یافته ­ ها: میانگین سنی شرکت ­ کنندگان در پژوهش 2/6 ± 40 و میانگین سابقه طبابت آنان 9/5 ± 13 بود. میزان پاسخگویی به پرسشنامه­ها نیز83 درصد اعلام شد. در این مطالعه 7/62 درصد از شرکت­کنندگان، متناسب بودن محتوای برنامه­ها با نیازهای شغلی­شان را زیاد و خیلی زیاد ارزیابی کردند. 3/91 درصد از شرکت­کنندگان موفقیت برنامه از نظر ارائه مطالب جدید علمی را متوسط و به بالا عنوان کردند درحالی که 3/62 درصد آن­ها مشارکت فعال در بحث­ها (پرسش و پاسخ - بحث و برگزاری پانل) را متوسط به پایین بیان کردند. نتیجه ­ گیری: بیشتر شرکت ­ کنندگان در برنامه­های آموزش مداوم، از محتوای برنامه­ها از نظر مطالب جدید علمی و متناسب بودن آن­ها با نیازهای شغلی­شان، رضایت داشتند. پیشنهاد می­شود جهت هرچه موثرتر واقع شدن برنامه­های آموزشی در انتخاب شیوه­های آموزشی اصول یادگیری بزرگسالان (آندراگوژی) در نظر گرفته شود .

Neurocognitive Improvement in Patients Undergoing Carotid Endarterectomy for Atherosclerotic Occlusive Carotid Artery Disease.

Objectives: To assess the improvement in neurocognitive functions after carotid endarterectomy (CEA) under local anesthesia (LA) in patients with carotid bifurcation occlusive disease. Place and duration of study: Department of Vascular Surgery, Combined Military Hospital Lahore from January 2013 to January 2015. Patients and Methods: A total of 79 patients with carotid artery occlusive disease, having no history of major stroke, depression, or dementia underwent CEA under LA. Cognitive functions were assessed 3 days before surgery and then 4 weeks and 12 weeks after the surgery using the Addenbrookes cognitive examination (ACE) score and General Practitioner Assessment of Cognition (GPCOG) Score. Results: In ACE score, Attention, Memory, Fluency, Language, and Visuospatial orientation improved by 33.3%, 30.7%, 21.4%, 38.4%, and 31.2%, respectively, by the end of 12 weeks. An overall improvement in neurocognition was 32% (P = 0.03). In GPCOG score, Orientation, Recall, and Memory improved by 33%, 20%, and 100%, respectively, with an overall improvement of 33.3% at the end of 12 weeks (P = 0.02). Conclusion: Both scoring systems show an overall improvement in neurocognition as well as improvements in all the subcategories in each system. Hence, we conclude statistically significant improvement in neurocognitive functions after CEA.

General Practitioner Assessment of Cognition: use inprimary care prior to memory clinic referral.

To measure current and comparative frequencies of use of the General Practitioner Assessment of Cognition (GPCOG) scale in consecutive primary care referrals to a dedicated secondary care memory clinic. Over 6 months (January-June 2015), referral letters from primary care (n = 121) were examined for mention of GPCOG use. The proportionof patients administered any cognitive screening instrument before referral was 41.3%, with 11.6% administered the GPCOG, a significant increase compared with prior cohorts. However, GPCOG was incorrectly used or documented in 29% of cases. GPCOG use is increasing in primary care settings, but training in its correct use and scoring may be required to ensure that its administration makes meaningful information available.

Development and implementation of Persian test of Elderly for Assessment of Cognition and Executive function (PEACE).

IntroductionA considerable segment of the elderly population in Iran is illiterate, and it seems the existing neuropsychological screening tests are not very useful for detecting dementia in illiterate participants. The purpose of this study was to develop and validate a tool called Persian test of Elderly for Assessment of Cognition and Executive function (PEACE) for detecting dementia in both illiterate and literate participants.MethodsFirst, in order to design some of the cognitive aspects of the PEACE assay, we considered other prevalent neuropsychological instruments, such as the General Practitioner assessment of Cognition (GPCOG), Functional Assessment Staging (FAST), Mini Mental State Examination (MMSE), and Wechsler Memory scale. The other domains of PEACE were designed according to our clinical proficiencies and the culture of the society. In the next step, the participants were classified into three distinct groups, i.e., the control group (n=33), the Mild Cognitive Impairment (MCI) group (n=30), and the Alzheimer’s group (n=38). All of the participants in each group were divided according to their educational level, i.e., illiterate, semi-literate, and literate.ResultsWe developed PEACE consisting of 14 items, each of which represents a specific cognitive function, with a maximum score of 91. The 14 items are Orientation, Praxis, Attention and Concentration, Attention and Calculation, Memory, Similarity, Thinking, General Information, Language, Judgment, Gnosis, Planning (Sequencing), Problem Solving, and Animal Naming. PEACE scores are highly correlated with those of the MMSE (r=0.78). The optimal cut-off point of PEACE chosen for diagnosis of Alzheimer’s disease was 67.5 (sensitivity: 75.8%, specificity: 97.4%). The PEACE scores showed a significant difference between Participants with Alzheimer’s disease and the control group (p=0.0000) and the MCI group (p=0.003). In addition, there was no significant difference between illiterate and literate participants in the Alzheimer’s group. However, the PEACE scores differed significantly (p=0.0000) between illiterate and literate participants in the control group.ConclusionThe PEACE addresses the limitations of existing tests and is appropriate for use in countries that have high rates of illiteracy. It is a valid screening mechanism for the detection of dementia in both illiterate and literate participants.

Development of processes allowing near real-time refinement and validation of triage tools during the early stage of an outbreak in readiness for surge: the FLU-CATs Study.

During pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circumstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study. (1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools 'Community Assessment Tools' and 'Pandemic Medical Early Warning Score' to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons. Prospective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs. Thirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink. All people presenting with ILI. None. Study outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital - if admitted, the need for higher levels of care and length of hospital stay. Linked anonymised data from a web-based structured clinical assessment and primary care EHRs. In the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation. We have developed processes that allow capture and near real-time automated analysis of GP's clinical assessments and management decisions of people presenting with ILI. We will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak. This study is registered as ISRCTN87130712 and UK Clinical Research Network 12827. The National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections.

Cognitive Impairment in Diabetes: Rationale and Design Protocol of the Cog-ID Study.

BackgroundCognitive impairment frequently co-occurs with type 2 diabetes but is often undiagnosed. Cognitive impairment affects self-management leading to treatment-related complications.ObjectiveThe aim of this study is to develop a stepped diagnostic procedure, consisting of a screening test complemented by an evaluation by a general practitioner (GP), to detect undiagnosed cognitive impairment in older people with type 2 diabetes.MethodsThe accuracy of two self-administered cognitive tests, the “Test Your Memory” (TYM) and “Self-Administered Gerocognitive Examination” (SAGE) alone, and in combination with an evaluation by a GP will be assessed. A diagnosis of mild cognitive impairment (MCI) or dementia at a memory clinic will serve as reference standard. This cognitive impairment in diabetes (Cog-ID) study will include 513 people from primary care facilities aged ≥70 with type 2 diabetes. The participants will first fill out the TYM and SAGE tests, followed by a standardized GP evaluation for cognitive impairment, including a mini mental state examination (MMSE). Subsequently, participants suspected of cognitive impairment (on either test or the GP assessment) and a random sample of 15% (65/435) of participants without suspected cognitive impairment will be referred to the memory clinic. At the memory clinic, a medical examination, neuropsychological examination, and magnetic resonance imaging (MRI) of the brain will be performed. Participants will also fill out questionnaires assessing health status and depressive symptoms at baseline and after 6 and 24 months.ResultsThis research obtained funding and ethical approval. Enrolment started in August, 2012, and all study-related activities will be completed in September, 2016.ConclusionsWith the results from this study, physicians will be able to detect cognitive impairment affecting type 2 diabetes patients through case-finding, and can use tailored care to reduce associated complications. Additionally, the results may stimulate discussions about cognitive impairment and whether early recognition is desirable.

Missed opportunities: general practitioner identification of their patients’ smoking status

BackgroundIn order to provide smoking cessation support to their patients in line with clinical practice guidelines, general practitioners must first ascertain whether their patients’ use tobacco. This study examined (i) the sensitivity, specificity, positive predictive value and negative predictive value of general practitioner detection of smoking, and (ii) the general practitioner and patient characteristics associated with detection of tobacco use.MethodsEligible patients completed a touchscreen computer survey while waiting for an appointment with their general practitioner. Patients self-reported demographic characteristics, medical history, and current smoking status. Following the patient’s consultation, their general practitioner was asked to indicate whether the patient was a current smoker (yes/no/unsure/not applicable). Smoking prevalence, sensitivity, specificity, positive predictive value and negative predictive values (with 95% confidence intervals) were calculated using patient self-report of smoking status as the gold standard. Generalised estimating equations were used to examine the general practitioner and patient characteristics associated with detection of tobacco use.ResultsFifty-one general practitioners and 1,573 patients in twelve general practices participated. Patient self-report of smoking was 11.3% compared to general practitioner estimated prevalence of 9.5%. Sensitivity of general practitioner assessment was 66% [95% CI 59–73] while specificity was 98% [95% CI 97–98]. Positive predictive value was 78% [95% CI 71–85] and negative predictive value was 96% [95% CI 95–97]. No general practitioner factors were associated with detection of smoking. Patients with a higher level of education or who responded ‘Other’ were less likely to be detected as smokers than patients who had completed a high school or below level of education.ConclusionDespite the important role general practitioners play in providing smoking cessation advice and support, a substantial proportion of general practitioners do not know their patient’s smoking status. This represents a significant missed opportunity in the provision of preventive healthcare. Electronic waiting room assessments may assist general practitioners in improving the identification of smokers.

Findings from the National Memory Screening Day program.

To report experience with a large, nation-wide public memory screening program. Descriptive study of community-dwelling elderly adults. Local community sites (48 sites agreed to provide data) throughout the United States participating in National Memory Screening Day in November 2010. Of 4,369 reported participants, 3,064 had complete data records and are included in this report. Participants completed a questionnaire that included basic demographic information and a question about subjective memory concerns. Each site selected one of seven validated cognitive screening tests: Mini-Cog, General Practitioner assessment of Cognition, Memory Impairment Screen, Kokmen Short Test of Mental Status, Mini-Mental State Examination, Montreal Cognitive Assessment, Saint Louis University Mental Status Examination. Overall, 11.7% failed one of the seven screening tests. As expected, failure rates were higher in older and less-educated participants (P's < .05). Subjective memory concerns were associated with a 40% greater failure rate for persons of similar age and education but no memory concerns (odds ratio = 1.4, 95% confidence interval = 1.07-1.78), although only 11.9% of those who reported memory concerns (75% of all participants) had detectible memory problems. Screening for cognitive impairment in community settings yielded results consistent with expected effects of age and education. The event attracted a large proportion of individuals with memory concerns; 88.1% were told that they did not have memory problems detectible with the tests used. Further studies are needed to assess how participants respond to and use screening information, whether this information ultimately influences decision-making or outcomes, and whether memory screening programs outside healthcare settings have public health value.

A study of automated self-assessment in a primary care student health centre setting

We evaluated the advice given by a prototype self-assessment triage system in a university student health centre. Students attending the health centre with a new problem used the automated self-assessment system prior to a face-to-face consultation with the general practitioner (GP). The system’s rating of urgency was available to the GP, and following the consultation, the GP recorded their own rating of the urgency of the patient’s presentation. Full data were available for 154 of the 207 consultations. Perfect agreement, where both the GP and the self-assessment system selected the same category of advice, occurred in 39% of consultations. The association between the GP assessment and the self-assessment rankings of urgency was low but significant (rho = 0.19, P = 0.016). The self-assessment system tended to be risk averse compared to the GP assessments, with advice for more urgent level of care seeking being recommended in 86 consultations (56%) and less urgent advice in only 8 (5%). This difference in assessment of urgency was significant (P < 0.001). The agreement between self-assessed and GP-assessed urgency was not associated with symptom site or socio-demographic characteristics of the user. Although the self-assessment system was more risk averse than the GPs, which resulted in a high proportion of patients being triaged as needing emergency or immediate care, the self-assessment system successfully identified a proportion of patients who were felt by the GP to have a self-limiting condition that did not need a consultation. In its prototype form, the self-assessment system was not a replacement for clinician assessment and further refinement is necessary.

Early intervention and dementia care: innovation and impact

Purpose– This study aims to systematically evaluate the impact and effectiveness of two early intervention services in NW Kent.Design/methodology/approach– Data were gathered via evaluation questionnaires for both projects; these included quantitative post-intervention data and qualitative comments. Data on referrals to secondary care and a specialist third sector organisation were also collected for the primary care project.Findings– Findings from the primary care project indicate that targeting a specific age cohort of patients can be effective in terms of: early identification of dementia-related concerns, the provision of support, appropriate referrals to secondary care, and increased referrals to a third sector dementia service. At the end of the project most practitioners felt they were better informed about dementia, more committed to facilitating early diagnosis, and had gained confidence in using a screening tool (the General Practitioner Assessment of Cognition Test). Evidence from evaluating the Carers Group suggests that attendance helped members manage emotional difficulties, increased understanding of dementia, and enhanced coping skills. They also felt less isolated and knew how to access support services.Practical implications– The projects offer two models of intervention: how a proactive third sector agency can work with primary care professionals to enhance commitment to dementia case finding and the provision of group support to relatives of those in receipt of a recent dementia diagnosis.Originality/value– The study provides insights into early intervention in dementia care how to evaluate impact of effectiveness.