London General Practice Research Articles

Emergency department attendances and GP patient satisfaction.

BackgroundDespite invaluable national data, reasons for the relentless rise in England’s emergency department (ED) attendances remain elusive.SettingAll EDs and general practices in England.QuestionAre rising ED attendances related to general practice patient satisfaction, i.e. if patients are unable to get a convenient appointment with their general practitioner (GP), then do they attend their local ED for diagnosis, treatment and care instead?MethodGP patient satisfaction and ED attendance data were extracted from national data warehouses and organised into two groups: (i) England clinical commissioning group (CCG) areas and (ii) a London CCG subset. Data from London CCGs were compared with CCGs outside London.ResultsED attendances were strongly correlated with GP patient satisfaction data in non-London CCGs, e.g. if patients said they had difficulty obtaining a convenient appointment at their general practice, then local ED attendances increased. Associations were repeated when other GP perception data were explored, e.g. if patients were satisfied with GPs and practice nurses, then they were less likely to attend their local EDs. However, these associations were not found in the London CCG subset despite lower satisfaction with London GP services.Discussion and ConclusionsAlthough our study generates valuable insights into ED attendances, the reasons why London general practice patient and ED attendance data don’t show the same associations found outside London warrants further study. Diverting patients from EDs to primary care services may not be straight forward as many would like to believe.

Hospital readmissions for COPD: a retrospective longitudinal study

Prevention of chronic obstructive pulmonary disease hospital readmissions is an international priority aimed to slow disease progression and limit costs. Evidence of the risk of readmission and of interventions that might prevent it is lacking. We aimed to determine readmission risk for chronic obstructive pulmonary disease, factors influencing that risk, and variation in readmission risk between hospitals across 7.5 million people in London. This retrospective longitudinal observational study included all chronic obstructive pulmonary disease admissions to any hospital in the United Kingdom among patients registered at London general practices who had emergency National Health Service chronic obstructive pulmonary disease hospital admissions between April 2006 and March 2010. Influence of patient characteristics, geographical deprivation score, length of stay, day of week of admission or of discharge, and admitting hospital, were assessed using multiple logistic regression. 38,894 chronic obstructive pulmonary disease admissions of 20,932 patients aged ≥ 45 years registered with London general practices were recorded. 6295 patients (32.2%) had at least one chronic obstructive pulmonary disease readmission within 1 year. 1993 patients (10.2%) were readmitted within 30 days and 3471 patients (17.8%) were readmitted within 90 days. Age and patient geographical deprivation score were very weak predictors of readmission. Rates of chronic obstructive pulmonary disease readmissions within 30 days and within 90 days did not vary among the majority of hospitals. The finding of lower chronic obstructive pulmonary disease readmission rates than was previously estimated and the limited variation in these rates between hospitals suggests that the opportunity to reduce chronic obstructive pulmonary disease readmission risk is small.

Text-message Reminders in Colorectal Cancer Screening (TRICCS): a randomised controlled trial

Background:We investigated the effectiveness of a text-message reminder to improve uptake of the English Bowel Cancer Screening programme in London.Methods:We performed a randomised controlled trial across 141 general practices in London. Eight thousand two hundred sixty-nine screening-eligible adults (aged 60–74 years) were randomised in a 1 : 1 ratio to receive either a text-message reminder (n=4134) or no text-message reminder (n=4135) if they had not returned their faecal occult blood test kit within 8 weeks of initial invitation. The primary outcome was the proportion of adults returning a test kit at the end of an 18-week screening episode (intention-to-treat analysis). A subgroup analysis was conducted for individuals receiving an invitation for the first time.Results:Uptake was 39.9% in the control group and 40.5% in the intervention group. Uptake did not differ significantly between groups for the whole study population of older adults (adjusted odds ratio (OR) 1.03, 95% confidence interval (CI) 0.94–1.12; P=0.56) but did vary between the groups for first-time invitees (uptake was 34.9% in the control and 40.5% in the intervention; adjusted OR 1.29, 95% CI 1.04–1.58; P=0.02).Conclusions:Although text-message reminders did not significantly increase uptake of the overall population, the improvement among first-time invitees is encouraging.

Service use of older people who participate in primary care health promotion: a latent class analysis

BackgroundRecruiting patients to health promotion programmes who will benefit is crucial to success. A key policy driver for health promotion in older people is to reduce health and social care use. Our aim was to describe service use among older people taking part in the Multi-dimensional Risk Appraisal for Older people primary care health promotion programme.MethodsA random sample of 1 in 3 older people (≥65 years old) was invited to participate in the Multi-dimensional Risk Appraisal for Older people project across five general practices in London and Hertfordshire. Data collected included socio-demographic characteristics, well-being and functional ability, lifestyle factors and service use.Latent class analysis (LCA) was used to identify groups based on use of the following: secondary health care, primary health care, community health care, paid care, unpaid care, leisure and local authority resources. Differences in group characteristics were assessed using univariate logistic regression, weighted by probability of class assignation and clustered by GP practice.ResultsResponse rate was 34% (526/1550) with 447 participants presenting sufficient data for analysis. LCA using three groups gave the most meaningful interpretation and best model fit. About a third (active well) were fit and active with low service use. Just under a third (high NHS users) had high impairments with high primary, secondary and community health care contact, but low non-health services use. Just over a third (community service users) with high impairments used community health and other services without much hospital use.ConclusionOlder people taking part in the Multi-dimensional Risk Appraisal for Older people primary care health promotion can be described as three groups: active well, high NHS users, and community service users.

Health risk appraisal in older people 7: long-acting benzodiazepine use in community-dwelling older adults in London: is it related to physical or psychological factors?

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors. Secondary analysis of baseline data from a study of 1059 community-dwelling non-disabled people aged 65 years and over recruited from three general practices in London. For this analysis, use of long-acting benzodiazepines was defined as any self-reported use of diazepam or nitrazepam in the last four weeks. Associations between demographic factors, health service use, and physical and psychological characteristics and benzodiazepine use were investigated. Findings The prevalence of benzodiazepine use in this sample was 3.3% (35/1059). In univariate analyses, benzodiazepine use was associated with female gender, low income, high consultation rates, physical factors (medication for arthritis or joint pain, polypharmacy, difficulties in instrumental activities of daily living, recent pain) and psychological factors (poor self-perceived health, social isolation, and symptoms of anxiety or agitation). In a multivariate logistic regression analysis only two factors retained statistically significant independent associations with benzodiazepine use: receiving only the state pension (OR=4.0, 95% CI: 1.70, 9.80) and pain in the past four weeks (OR=3.79, 95% CI: 1.36, 10.54).

Does attending general practice prior to the emergency department change patient outcomes? A descriptive, observational study of one central London general practice.

BackgroundThe challenge of keeping Emergency Department (ED) attendances down continues and timely access to general practice (GP) is often portrayed as a potential solution.SettingOne London general practice (registered population = 4900)QuestionDoes seeing a GP before attending the ED affect the outcome of a patient’s ED care?MethodsRoutine clinical data were extracted using SystmOne primary care computer system for all registered patients with an ED attendance between 1 October 2014 and 31 September 2015. The scanned discharge summaries from the ED and GP notes were reviewed and outcome measures extracted.Results227 patients (121 female; 104 male) attended the ED. The most common presentation was abdominal pain (n = 11). 25% of patients had seen (n = 50), or contacted by phone (n = 6), a GP about the same presenting complaint before attending the ED. Of those, 73% (n = 41/56) were referred to the ED and 49% (n = 20/41) were admitted versus 33% (n = 60/184) who self-presented (statistically significant, p = 0.05). An additional 32% of those who saw the GP first (n = 13/41) received specialist ED treatment.Discussion/ConclusionOnly 25% of patients see their GP prior to attending the ED. The majority of patients who were referred by their GP required admission or specialised ED treatment. It remains unclear why the majority of patients did not choose to contact their GP prior to attending the ED, despite urgent appointments being offered; research into patients’ health beliefs in this group is required for greater understanding.

Chlamydia related bacteria (Chlamydiales) in early pregnancy: community-based cohort study

ObjectivesSerological case–control studies suggest that certain chlamydia-related bacteria (Chlamydiales) which cause cows to abort may do the same in humans. Chlamydiales include Waddlia chondrophila, Chlamydia abortus and Chlamydia trachomatis. Data on prevalence of Chlamydiales in pregnancy are sparse. Using stored urine samples from a carefully characterised cohort of 847 newly pregnant women recruited from 37 general practices in London, UK, we aimed to investigate the prevalence and types of Chlamydiales infections. We also explored possible associations with miscarriage or spontaneous preterm birth. MethodsSamples were tested using W. chondrophila and pan-Chlamydiales specific real-time PCRs targeting the 16S rRNA gene. Samples positive on either PCR were subjected to DNA sequencing and C. trachomatis PCR. ResultsThe overall prevalence of Chlamydiales was 4.3% (36/847, 95% CI 3.0% to 5.8%). The prevalence of W. chondrophila was 0.6% (n = 5), C. trachomatis 1.7% (n = 14), and other Chlamydiales species 2.0% (n = 17). Infection with C. trachomatis was more common in women aged <25, of black ethnicity or with bacterial vaginosis, but this did not apply to W. chondrophila or other Chlamydiales.Follow up was 99.9% at 16 weeks gestation and 90% at term. No infection was significantly associated with miscarriage at ≤12 weeks (prevalence 10%, 81/827) or preterm birth <37 weeks (prevalence 4%, 23/628). Of 25 samples sequenced, seven (28%) were positive for Chlamydiales bacterium sequences associated with respiratory tract infections in children. ConclusionIn the first study to use the pan-Chlamydiales assay on female urine samples, 4% of pregnant women tested positive for Chlamydiales, including species known to be pathogenic in mothers and neonates.

Prostate-specific antigen testing in inner London general practices: are those at higher risk most likely to get tested?

ObjectivesTo investigate the association between factors influencing prostate-specific antigen (PSA) testing prevalence including prostate cancer risk factors (age, ethnicity, obesity) and non-risk factors (social deprivation and comorbidity).SettingA cross-sectional database of 136 inner London general practices from 1 August 2009 to 31 July 2014.ParticipantsMen aged ≥40 years without prostate cancer were included (n=150 481).Primary outcomeLogistic regression analyses were used to estimate the association between PSA testing and age, ethnicity, social deprivation, body mass index (BMI) and comorbidity while adjusting for age, benign prostatic hypertrophy, prostatitis and tamsulosin or finasteride use.ResultsPSA testing prevalence was 8.2% (2013–2014), and the mean age was 54 years (SD 11). PSA testing was positively associated with age (OR 70–74 years compared to 40–44 years: 7.34 (95% CI 6.82 to 7.90)), ethnicity (black) (OR compared to white: 1.78 (95% CI 1.71 to 1.85)), increasing BMI and cardiovascular comorbidity. Testing was negatively associated with Chinese ethnicity and with increasing social deprivation.ConclusionsPSA testing among black patients was higher compared to that among white patients, which differs from lower testing rates seen in previous studies. PSA testing was positively associated with prostate cancer risk factors and non-risk factors. Association with non-risk factors may increase the risk of unnecessary invasive diagnostic procedures.

Exploration of the psychological impact and adaptation to cardiac events in South Asians in the UK: a qualitative study

ObjectiveThere is little research on how different ethnic groups adapt after an acute cardiac event. This qualitative study explores between-ethnicity and within-ethnicity variation in adaptation, and the psychological impact of...

Offering self-sampling to cervical screening non-attenders in primary care.

Objectives To assess the feasibility and acceptability of offering self-sampling for Human Papillomavirus (HPV) testing to cervical screening non-attenders when they consult primary care for any reason. Methods In a pilot implementation study, six general practices in London, UK, offered self-sampling kits during consultation to women aged 25-64 who were at least six months overdue for cervical screening (no cytology test recorded in the past 3.5 years if aged 25-49, or 5.5 years if aged 50-64). Eligible women were identified using an automated real-time search (during consultation) of the general practice electronic medical record system. Women collected samples either in clinic or at home (dry flocked swabs analysed using Roche Cobas®4800). Results Of approximately 5000 eligible women, 3131 consulted primary care between January and December 2014 (mean recruitment period 9.5 months). Of these, 21% (652) were offered kits, 14% (443) accepted, and 9% (292) returned a self-sample. The proportion of eligible women offered kits varied considerably among practices (11-36%). Sample return rates increased with kit offered rates ( r = 0.8, p = 0.04). Of 39 HPV positive women 85% (33) attended follow-up, including two with invasive cancers (stage 2A1 and 1A1). Conclusions Offering self-sampling to cervical screening non-attenders opportunistically in primary care is feasible. Return rates could be increased if more women were offered kits. A large trial is needed to identify how self-sampling is best integrated into the national screening programme, and to identify determinants of uptake.

Text Reminders in Colorectal Cancer Screening (TRICCS): Protocol for a randomised controlled trial.

BackgroundScreening with the guaiac faecal occult blood test (gFOBt) is associated with improved colorectal cancer (CRC) survival, and is offered biennially to men and women aged 60–74 years in England’s national Bowel Cancer Screening Programme (BCSP). Uptake of the gFOBt is low, with only 54 % of the eligible population completing the test. Text-message reminders could improve uptake of gFOBt.Methods/designThis paper describes the protocol for a randomised controlled trial, which will examine the effectiveness of a text-message reminder to promote uptake of gFOBt screening in the BCSP. Individual mobile telephone data from 180 general practices in London with existing mobile-health services will be linked to the national BCSP information system via a secure on-line network. All screening-eligible adults registered with a participating practice will be randomised, to receive either usual care (N = 1600) or usual care plus a text-message reminder to self-complete and return their kit eight weeks after their initial invitation (N = 1600). The primary outcome will be the proportion of individuals who return an adequately completed gFOBt kit within 18 weeks of the initial invitation. Differences in uptake between groups will be evaluated using a logistic regression analysis, adjusting for individual-level and area-level socio-demographic variables.DiscussionThis will be the first large-scale randomised trial of a text-message reminder in a national screening programme for CRC. If effective, this study provides a cost-effective means to promote uptake of CRC screening in an organised programme.Trial registrationCurrent Controlled Trials ISRCTN70904476 (18/09/2015).

How common are chlamydia-related bacteria in early pregnancy and are they associated with miscarriage or preterm birth? Community-based prospective cohort study

BackgroundSerological case-control studies suggest that certain chlamydia-related bacteria (Chlamydiales) that cause cows to miscarry might do the same in human beings. Included in the order Chlamydiales are Waddlia chondrophila, Chlamydophila abortus, and Chlamydia trachomatis. We aimed to investigate the prevalence of Chlamydiales in pregnant women, and possible associations with miscarriage or preterm birth. MethodsWe tested stored urine samples from a carefully characterised cohort of 847 pregnant women recruited at mean 49·3 (SD 10·1) days’ gestation from 37 general practices in London, UK. Previous repeat testing of samples positive for Mycoplasma genitalium confirmed bacterial DNA integrity after storage. W chondrophila and pan-Chlamydiales specific real-time PCRs targeting the 16s rRNA gene were used to test samples. Samples positive on either of the two PCRs were subjected to DNA sequencing and Chlamydia trachomatis PCR. Outcomes were compared between infected and uninfected women with Fisher's exact test. Ethics review was conducted by Wandsworth, Croydon, and Riverside Research Ethics Committees. FindingsThe overall prevalence of Chlamydiales was 4·3% (36/847, 95% CI 3·0–5·8). Prevalence of W chondrophila was 0·6% (5/847, 0·2–1·4), Chlamydia trachomatis 1·7% (14/847, 0·9–2·8), and other Chlamydiales species 2·0% (17/847, 1·2–3·2). Infection with Chlamydia trachomatis (but not with other Chlamydiales or W chondrophila) was more common in women younger than 25 years, of black ethnicity, or with bacterial vaginosis. Follow-up was 99·9% (846/847) at 16 weeks’ gestation and 89·6% (759/847) at term. No infection was significantly associated with miscarriage (prevalence 10%, 84/827) or spontaneous preterm birth before 37 weeks’ (4%, 23/628) but numbers were small. One of three (33%) followed-up women infected with W chondrophila had a preterm birth compared with 22 (4%) of 625 uninfected women (p=0·11). Sequencing of 25 samples that were positive on W chondrophila or pan-Chlamydiales PCR revealed seven samples (28%) positive for Chlamydiales bacterium sequences that have been associated with respiratory tract infections in children. Interpretation4% of newly pregnant women tested positive for Chlamydiales, including species known to be pathogenic in mothers and neonates. Higher rates might have been found in vaginal samples and the study lacked power to test associations. Although W chondrophila might be associated with preterm birth, the prevalence was very low in this urban, community-based sample, suggesting that screening is unlikely to be cost-effective in such a population. FundingMedical Research Council.

Promoting physical activity in older people in general practice: ProAct65+ cluster randomised controlled trial.

Regular physical activity reduces falls, hip fractures, and all-cause mortality, but physical activity levels are low in older age groups. To evaluate two exercise programmes promoting physical activity among older people. Pragmatic three-arm, parallel-design cluster randomised controlled trial involving 1256 people aged ≥65 years (of 20 507 invited) recruited from 43 general practices in London, Nottingham, and Derby. Practices were randomised to the class-based Falls Management Exercise programme (FaME), the home-based Otago Exercise Program (OEP), or usual care. The primary outcome was the proportion reaching the recommended physical activity target 12 months post-intervention. Secondary outcomes included falls, quality of life, balance confidence, and costs. In total, 49% of FaME participants reached the physical activity target compared with 38% for usual care (adjusted odds ratio 1.78, 95% confidence interval [CI] =1.11 to 2.87, P = 0.02). Differences between FaME and usual care persisted 24 months after intervention. There was no significant difference comparing those in the OEP (43% reaching target at 12 months) and usual-care arms. Participants in the FaME arm added around 15 minutes of moderate-to-vigorous physical activity per day to their baseline level; this group also had a significantly lower rate of falls (incident rate ratio 0.74, 95% CI = 0.55 to 0.99, P = 0.042). Balance confidence was significantly improved in both intervention arms. The mean cost per extra person achieving the physical activity target was £1740. Attrition and rates of adverse reactions were similar. The FaME programme increases self-reported physical activity for at least 12 months post-intervention and reduces falls in people aged ≥65 years, but uptake is low. There was no statistically significant difference in reaching the target, or in falls, between the OEP and usual-care arms.

The experiences of student nurses on placements with practice nurses: A pilot study

To prepare the registered nurse of tomorrow in the United Kingdom (UK) to care for patients in general practice (GP)-led services, today's student nurses need to have the opportunity to experience placements with practice nurses to enable them to make positive career choices to become practice nurses in the future. The role of the practice nurse is described in the article. As a pilot project, seventeen students undertook placements with practice nurses in one of seven GP practices selected by the London GP Deanery and the university as having fulfilled the criteria to support student nurses in placements. A mentorship preparation programme was provided to prepare practice nurses for mentoring these students. An evaluation study was undertaken of this pilot project. Findings showed that students were highly positive about the experience; the majority rated this placement as being as good as or better than previous placement experiences. The evaluation also explored the impact on student learning and the value that the placement had. There was a positive impact on students' knowledge and skills in certain clinical areas especially related to health promotion. Students also indicated that they would like to have additional placements with practice nurses and would consider a career as a practice nurse in the future.

Emergency Admissions for COPD in an Urban Population: The Role of Population and Primary Care Factors

COPD is a major cause of emergency admissions worldwide. In many countries the majority of COPD care is provided by primary care teams. This study examined variation between primary care teams in rates of COPD admission and assessed the role of prevalence, deprivation, practice performance, and general practitioner (GP) and nurse supply on risk of COPD admission. Retrospective observational study of National Health Service admissions for COPD of patients registered with London general practices over four years (2006–2009). We sought associations using negative binomial regression between COPD admissions and population factors, practice organization and practice performance. Trends in rates of COPD admissions across London were stable between 2006 and 2009. COPD admission rates varied substantially between practices (2006/7: median 13.68/10,000 population (IQR 7.83–22.70)), with almost a 3-fold difference across the interquartile range each year. Practice characteristics varied to a similar extent. Variation in practice COPD admission rates was associated with diagnosed prevalence of COPD (Rate Ratio 2.06, 95% CI 1.84–2.3) and increasing levels of deprivation (RR 1.01, 1.006–1.01). Other practice characteristics, including GP and nurse supply, and practice performance scores were not predictive of practice level COPD admission rates, when controlling for COPD prevalence and socio-economic status. Main predictors of variation in rates of COPD admissions were prevalence of diagnosed COPD and socioeconomic status. The absence of evidence that variation in primary care services for COPD was associated with rates of COPD admission emphasizes the importance of primary prevention of COPD if COPD admission rates are to fall.

Practices used for recommending sickness certification by general practitioners: A conversation analytic study of UK primary care consultations

Existing research indicates that many patients and doctors find the process of negotiating sickness certification for time off work to be a difficult one. This study examined how patients and general practitioners (GPs) managed these negotiations in a sample of UK primary care consultations. The study made use of an existing dataset of audio-recorded consultations between 13 GPs and 506 unselected adult patients in five general practices in London. Forty-nine consultations included discussions for both initial and repeat sickness certification across a wide range of conditions. Here we report our findings on doctor practices for recommending, as opposed to patient practices for advocating for, sickness certification (n = 26 cases). All cases were transcribed in detail and analysed using conversation analytic methods. Four main communication practices were observed: (1) declarative statements of need for sickness certification; (2) ‘do you need’ offers for sickness certification; (3) ‘do you want’ offers for sickness certification; and (4) conditional ‘If X, Y’ offers for sickness certification. These different communication practices indexed doctor agency, doctor endorsement and patient entitlement to varying degrees. In the main, recommendations to patients presenting with biomedical problems or a repeat occurrence of a psychosocial problem displayed stronger doctor endorsement and patient entitlement. Contrastingly, recommendations to patients presenting with new psychosocial and biopsychosocial problems, displayed weaker endorsement and patient entitlement. This study offers new evidence to support the Parsonian argument that becoming sick involves entering a social role with special rights and obligations. Through documenting doctors' orientations to their gatekeeping role as well as patients' orientations to differential rights vis à vis legitimacy, we demonstrate the contrasting stances of doctors in situ when giving sick notes for biomedical problems as opposed to difficulties of a more psychosocial nature.

Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care

Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements. To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years. The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care. Forty-three UK-based general practices in London and Nottingham/Derby. A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial. The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking. The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial. In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants. The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93). The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms. This trial is registered as ISRCTN43453770. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 49. See the NIHR Journals Library website for further project information.

UPBEAT study patients’ perceptions of the effect of coronary heart disease on their lives: A cross-sectional sub-study

BackgroundPatients can report positive effects of myocardial infarction. It is unknown whether these effects are sustained or what factors influence adaptation. ObjectivesTo explore primary care patients’ perceptions of the effect of coronary heart disease and to identify possible modifiable predictors of adaptation. Design and settingCross-sectional, sub-study of UPBEAT cohort participants. Patients were recruited from coronary heart disease Registers in South London General Practices. Method548 participants were asked “Has having heart disease changed your life? If so, was that change for the better, worse, both or neither?” Participants were asked to explain their response; explanations were subjected to content analysis. Associations between response and lifestyle, demographic, mood and coronary heart disease variables were tested. ResultsRespondents (394 male, 72%) were aged 27–98 years and had had heart disease for a mean of 12.4 SD±8.4 years. 120 (22%) reported that life was better and 200 (37%) said it was worse. The explanations of those who said ‘better’ were categorised as ‘Healthier Living’, ‘Recognised Mortality’ and ‘Stress Reduction’. For those saying ‘worse’, categories were ‘Restricted Lifestyle’, ‘Recognised Mortality’, ‘Loss and Burden’. More anxiety symptoms (RRR 1.56, 95% CI 1.12, 2.17), lower functional status (RRR 2.46, 95% CI 1.21, 4.98) and self-reported chest pain (RRR 2.24, 95% CI 1.34, 3.77) were associated with saying ‘worse’. ConclusionsMany primary care patients are ambivalent to the effects of coronary heart disease, but some report positive effects. Negative perceptions are associated with reported functional impairment, chest pain and anxiety, but not illness severity or patient characteristics. Future work will track the implications of these perceptions, but nurses managing patients with coronary heart disease should consider these effects as they may be modifiable predictors of adaptation.

PACE-UP (Pedometer and consultation evaluation--UP)--a pedometer-based walking intervention with and without practice nurse support in primary care patients aged 45-75 years: study protocol for a randomised controlled trial.

BackgroundMost adults do not achieve the 150 minutes weekly of at least moderate intensity activity recommended for health. Adults’ most common physical activity (PA) is walking, light intensity if strolling, moderate if brisker. Pedometers can increase walking; however, most trials have been short-term, have combined pedometer and support effects, and have not reported PA intensity. This trial will investigate whether pedometers, with or without nurse support, can help less active 45–75 year olds to increase their PA over 12 months.Methods/designDesign: Primary care-based 3-arm randomized controlled trial with 12-month follow-up and health economic and qualitative evaluations.Participants: Less active 45–75 year olds (n = 993) will be recruited by post from six South West London general practices, maximum of two per household and households randomised into three groups. Step-count and time spent at different PA intensities will be assessed for 7 days at baseline, 3 and 12 months by accelerometer. Questionnaires and anthropometric assessments will be completed.Intervention: The pedometer-alone group will be posted a pedometer (Yamax Digi-Walker SW-200), handbook and diary detailing a 12-week pedometer-based walking programme, using targets from their baseline assessment. The pedometer-plus-support group will additionally receive three practice nurse PA consultations. The handbook, diary and consultations include behaviour change techniques (e.g., self-monitoring, goal-setting, relapse prevention planning). The control group will receive usual care.Outcomes: Changes in average daily step-count (primary outcome), time spent sedentary and in at least moderate intensity PA weekly at 12 months, measured by accelerometry. Other outcomes include change in body mass index, body fat, self-reported PA, quality of life, mood and adverse events. Cost-effectiveness will be assessed by the incremental cost of the intervention to the National Health Service and incremental cost per change in step-count and per quality adjusted life year. Qualitative evaluations will explore reasons for trial non-participation and the interventions’ acceptability.DiscussionThe PACE-UP trial will determine the effectiveness and cost-effectiveness of a pedometer-based walking intervention delivered by post or practice nurse to less active primary care patients aged 45–75 years old. Approaches to minimise bias and challenges anticipated in delivery will be discussed.Trial registrationISRCTN98538934

Promoting health and wellbeing for older people in primary care: a feasibility study

BackgroundThere is a need for research into effective approaches to promote health and wellbeing for older people in primary care, particularly using technologies. These interventions may, however, generate inequalities in access. We aimed to assess the implementation in UK primary care of the multidimensional risk appraisal in older people (MRAO). The objectives were to (1) assess feasibility and costs of embedding the MRAO system; (2) identify sociodemographic characteristics of older people who choose to take part in a health promotion intervention; (3) identify factors helping or hindering older people and professionals from using recommendations to promote health and wellbeing; and (4) assess the utility of the MRAO to promote working across health, local government, and voluntary sectors. MethodsWe completed a mixed-methods feasibility study in five general practices in London and Hertfordshire. A random sample of people aged at least 65 years were included. People living in nursing or care homes and those with severe dementia or terminal illness were excluded. The MRAO intervention was a software system that analysed responses to a multidimensional questionnaire covering health, lifestyle, and social and environmental domains and generated tailored advice about health services, behaviour change, and local resources. Participants and practices received copies of the report and followed up those with new or complex problems. Four locality cross-sector working groups considered commissioning and service recommendations from local profiles of needs generated. We undertook quantitative and qualitative assessments. Quantitative analyses consisted of feasibility (uptake, attrition, process), wellbeing, needs or health risks, lifestyle, quality of life, service use, and costs at baseline and 6 months of follow-up. Qualitative analyses consisted of thematic analysis of four cross-sector working group meetings and in-depth qualitative interviews with 22 working group participants and 30 older people. Ethics approval was granted by the London-East REC (11/LO/1814). Written informed consent was obtained before enrolment. Findings527 of 1550 (34·0%) people responded and 454 of 527 (86·1%) returned completed questionnaires. There were differences across sites, with 283 of 770 (36·8%) returned in Hertfordshire and 171 of 780 (21·9%) in London. Median age of participants was 73·2 years (IQR 68·9–78·9), 240 (52·9%) were women, 378 (83·3%) were white British, 400 (88·1%) lived in owner-occupied accommodation, 271 (59·7%) had no post-16 education, and 122 (26·9%) received only the state pension. Compared with local UK Census 2011 data, participants were younger, more were owner occupiers, and fewer were from ethnic minority groups than expected. A range of needs were identified at baseline, including pain (300 of 454 [66·1%]), low physical activity levels (211 [46·5%]), deteriorating mobility (change in last 12 months in walking in 131 [28·9%] or climbing stairs in 170 [37·4%]), falls (117 [25·8%]), urinary incontinence (111 [24·4%]), vision (116 [25·6%]), hearing (106 [23·3%]), depression (71 [15·6%]), impaired memory (44 [9·7%]), social isolation (46 [10·1%]), and loneliness (31 [6·8%]). Recent life events were common (182 [40·1%]). Baseline self-rated health was good or excellent in 312 (68·7%) and wellbeing was slightly above median age-specific population norms (median score Warwick–Edinburgh mental wellbeing scale 55·0, IQR 49·0–61·0). Preliminary analysis of 52 in-depth interviews and four working groups suggests the process was feasible to implement and of value to practices in identifying previously unknown needs. Multidisciplinary working groups seemed to find it difficult to interpret and act on findings. We will present findings on costs, behaviour changes, health service utilisation, wellbeing and quality of life at follow-up, and qualitative data on context, mechanisms, and effect. InterpretationBaseline findings suggest the MRAO system is feasible to implement in primary care. Practices can use it to identify individual needs and inform commissioning. However, participation rates are low, particularly for older age (at least 85 years), lower socioeconomic status, and ethnic minority groups. FundingMedical Research Council LLHW G1001822/1.