Practices In Grampian Research Articles

Using the theory of planned behaviour as a process evaluation tool in randomised trials of knowledge translation strategies: A case study from UK primary care

BackgroundRandomised trials of knowledge translation strategies for professional behaviour change can provide robust estimates of effectiveness, but offer little insight into the causal mechanisms by which any change is produced. To illustrate the applicability of causal methods within randomised trials, we undertook a theory-based process evaluation study within an implementation trial to explore whether the cognitions of primary care doctors' predicted their test requesting behaviours and, secondly, whether the trial results were mediated by the theoretical constructs.MethodsThe process evaluation comprised a cross-sectional questionnaire survey of a random 50% sample of the randomised groups of primary care practices in Grampian (NHS Grampian), UK, who took part in a trial of the effect of enhanced feedback and brief educational reminders on test requesting behaviour. The process evaluation was based upon the Theory of Planned Behaviour and focussed on three of the test requesting behaviours that were targeted in the trial -- ferritin, follicle stimulating hormone (FSH), and Helicobacter Pylori serology (HPS).ResultsThe questionnaire was completed by 131 primary care doctors (56%) from 42 (98%) of the sampled practices. Behavioural intention, attitude, and subjective norm were highly correlated for all the tests. There was no evidence that perceived behavioural control was correlated with any of the other measures. Simple linear regression analysis of the rate of test requests on minimum behavioural intentions had R2 of 11.1%, 12.5%, and 0.1% for ferritin, FSH, and HPS requesting, respectively. Mediational analysis showed that the trial results for ferritin and FSH were partially mediated (between 23% and 78% mediation) through intentions. The HPS trial result was not mediated through intention.ConclusionsThis study demonstrated that a theory-based process evaluation can provide useful information on causal mechanisms that aid not only interpretation of the trial but also inform future evaluations and intervention development.

Public knowledge, attitudes and behaviour regarding antibiotics: does five years make a difference?

Abstract Objective To compare patient knowledge, attitudes and behaviour regarding antibiotic use between 2000 and 2005. Method Postal survey to 400 patients in March-April 2005. Setting Two general medical practices in Grampian, UK. Key findings There was a 64% response rate; 90% had experience of antibiotic use and 96% were happy to take antibiotics when necessary; 75% felt we should be more careful about how we use antibiotics. Compared to 2000, fewer patients indicated that most infections clear up by themselves without the need for antibiotics (48% versus 59%, P = 0.031). Fewer of those who experienced at least one respiratory tract infection (RTI) in the review period had consulted a doctor (2005, 14% versus 2000, 23%), and fewer consultations resulted in an antibiotic being prescribed (55% versus 75%). Fewer patients now agreed that telephone helplines for advice on RTIs are a good idea (42% versus 54%, P = 0.009), while more felt that people should make more use of their local pharmacist for advice on treatments for RTI and that they, themselves, would consult a pharmacist. On advice (from doctors, pharmacists or advertisements) on the management of RTI, fewer patients now cited: drink fluids (48% versus 68%, P = 0.023); rest (35% versus 54%, P = 0.012); take paracetamol (35% versus 50% P = 0.028); while more cited: self-medicate (non-paracetamol) (32% versus 15%, P = 0.004); let infection run its course (11% versus 5%, P = 0.027). Conclusions Antibiotic use remains a concern for many patients; however, almost all would take antibiotics when necessary. Fewer patients now consult a doctor about a RTI, and fewer consultations lead to an antibiotic being prescribed. Patients are increasingly positive about pharmacist advice but less keen on telephone helplines. A further local health education initiative should be considered to remind patients of strategies for the self-management of RTI.

Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting

Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially. To assess whether GPs prescribe antidepressants appropriately. Observational study of adults (aged >/=16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP. Four practices in Grampian, Scotland. Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed. A total of 237 (26%) participants had HADS scores indicating 'possible' (15%) or 'probable' (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for 'possible' versus 'no' depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for 'probable' versus 'possible' depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for 'possible' versus 'no' depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for 'probable' versus 'possible' was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with 'probable' depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression. There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.

Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care

The 2004 National Institute for Health and Clinical Excellence (NICE) guidelines highlight the importance of assessing severity of depression in primary care. To assess the psychometric properties of the Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for measuring depression severity in primary care. Psychometric assessment. Thirty-two general practices in Grampian, Scotland. Consecutive patients referred to a primary care mental health worker completed the PHQ-9 and HADS at baseline (n = 1063) and at the end of treatment (n = 544). Data were analysed to assess reliability, robustness of factor structure, convergent/discriminant validity, convergence of severity banding, and responsiveness to change. Both scales demonstrated high internal consistency at baseline and end of treatment (PHQ-9 alpha = 0.83 and 0.92; HADS-D alpha = 0.84 and 0.89). One factor emerged each for the PHQ-9 (explaining 42% of variance) and HADS-D (explaining 52% of variance). Both scales converged more with each other than with the HADS anxiety (HADS-A) subscale at baseline (P<0.001) and at end of treatment (P = 0.01). Responsiveness to change was similar: effect size for PHQ-9 = 0.99 and for the HADS-D = 1. The HADS-D and PHQ-9 differed significantly in categorising severity of depression, with the PHQ-9 categorising a greater proportion of patients with moderate/severe depression (P<0.001). The HADS-D and PHQ-9 demonstrated reliability, convergent/discriminant validity, and responsiveness to change. However, they differed considerably in how they catergorised severity. Given that treatment decisions are made on the basis of severity, further work is needed to assess the validity of the scales' severity cut-off bands.

Practice development plans to improve the primary care management of acute asthma: randomised controlled trial.

BackgroundOur professional development plan aimed to improve the primary care management of acute asthma, which is known to be suboptimal.MethodsWe invited 59 general practices in Grampian, Scotland to participate. Consenting practices were randomised to early and delayed intervention groups. Practices undertook audits of their management of all acute attacks (excluding children under 5 years) occurring in the 3 months preceding baseline, 6-months and 12-months study time-points. The educational programme [including feedback of audit results, attendance at a multidisciplinary interactive workshop, and formulation of development plan by practice teams] was delivered to the early group at baseline and to the delayed group at 6 months. Primary outcome measure was recording of peak flow compared to best/predicted at 6 months. Analyses are presented both with, and without adjustment for clustering.Results23 consenting practices were randomised: 11 to early intervention. Baseline practice demography was similar. Six early intervention practices withdraw before completing the baseline audit. There was no significant improvement in our primary outcome measure (the proportion with peak flow compared to best/predicted) at either the 6 or 12 month time points after adjustment for baseline and practice effects. However, the between group difference in the adjusted combined assessment score, whilst non-significant at 6 months (Early: 2.48 (SE 0.43) vs. Delayed 2.26 (SE 0.33) p = 0.69) reached significance at 12 m (Early:3.60 (SE 0.35) vs. Delayed 2.30 (SE 0.28) p = 0.02).ConclusionWe demonstrated no significant benefit at the a priori 6-month assessment point, though improvement in the objective assessment of attacks was shown after 12 months. Our practice development programme, incorporating audit, feedback and a workshop, successfully engaged the healthcare team of participating practices, though future randomised trials of educational interventions need to recognise that effecting change in primary care practices takes time. Monitoring of the assessment of acute attacks proved to be a feasible and responsive indicator of quality care.

A cost-utility analysis of multivitamin and multimineral supplements in men and women aged 65 years and over

As people age there is a progressive dysregulation of the immune system that may lead to an increased risk of infections, which may precipitate hospital admission in people with chronic heart or respiratory diseases. Mineral and vitamin supplementation in older people could therefore influence infections in older people. However, the evidence from the available randomised controlled trials (RCTs) is mixed. The aim of the study was to assess the relative efficiency of multivitamin and multimineral supplementation compared with no supplementation. Cost-utility analysis alongside an RCT. Participants aged 65 years or over from six general practices in Grampian, Scotland, were studied. They were randomised to one tablet daily of either a multivitamin and multimineral supplement or matching placebo. Exclusion criteria were use of mineral, vitamin or fish oil supplements in the previous 3 months (1 month for water soluble vitamins), vitamin B12 injection in the last 3 months. Nine hundred and ten participants were recruited (454 placebo and 456 supplementation). Use of health service resources and costs were similar between the two groups. The supplementation arm was more costly although this was not statistically significant ( pound15 per person, 95% CI-3.75 to 34.95). After adjusting for minimisation and baseline EQ-5D scores supplementation was associated with fewer QALYs per person (-0.018, 95% CI-0.04 to 0.002). It was highly unlikely that supplementation would be considered cost effective. The evidence from this study suggests that it is highly unlikely that supplementation could be considered cost effective.

Who are your public? A survey comparing the views of a population-based sample with those of a community-based public forum in Scotland

This paper describes a questionnaire survey, carried out in the NHS Grampian area of NE Scotland. It compares responses from 84 members of a community-based public forum (39 of whom were sent questionnaires) and a random sample of 10,000 adults registered with general practices in Grampian (2,449 of whom were sent questionnaires). differences in demographic profiles and opinions about different feedback mechanisms (patient representative, telephone helpline and NHS feedback website) and their likely effectiveness in three different scenarios. 46% of community forum members consented to take part compared to 24% of the population sample. Younger people and residents in more deprived areas were under-represented in both groups. Community forum members were older (only one under 40 years of age), more likely to be retired and not in employment. Internet access was similar in both groups. Opinions about different systems of feeding back views to the NHS varied but community forum members were more likely to be positive in their opinions about the value of different feedback mechanisms and less likely to think they were 'a waste of NHS money'. Responses to three scenarios revealed similar opinions, but on some issues, there were key differences in the responses from the two groups. Community forum members were more likely to consider writing a letter as a means of getting something done about a problem and were more likely to talk to their GP if experiencing a problem than respondents in the main group. In general their responses were more positive towards the NHS. There is a need to ensure a broad basis for membership of public forums and/or proactively seek the views of groups that are under-represented if public forums are to be used to represent the views of the wider population and inform decision making in the NHS.

The 'number needed to sample' in primary care research. Comparison of two primary care sampling frames for chronic back pain

Sampling for primary care research must strike a balance between efficiency and external validity. For most conditions, even a large population sample will yield a small number of cases, yet other sampling techniques risk problems with extrapolation of findings. To compare the efficiency and external validity of two sampling methods for both an intervention study and epidemiological research in primary care--a convenience sample and a general population sample--comparing the response and follow-up rates, the demographic and clinical characteristics of each sample, and calculating the 'number needed to sample' (NNS) for a hypothetical randomized controlled trial. In 1996, we selected two random samples of adults from 29 general practices in Grampian, for an epidemiological study of chronic pain. One sample of 4175 was identified by an electronic questionnaire that listed patients receiving regular analgesic prescriptions--the 'repeat prescription sample'. The other sample of 5036 was identified from all patients on practice lists--the 'general population sample'. Questionnaires, including demographic, pain and general health measures, were sent to all. A similar follow-up questionnaire was sent in 2000 to all those agreeing to participate in further research. We identified a potential group of subjects for a hypothetical trial in primary care based on a recently published trial (those aged 25-64, with severe chronic back pain, willing to participate in further research). The repeat prescription sample produced better response rates than the general sample overall (86% compared with 82%, P < 0.001), from both genders and from the oldest and youngest age groups. The NNS using convenience sampling was 10 for each member of the final potential trial sample, compared with 55 using general population sampling. There were important differences between the samples in age, marital and employment status, social class and educational level. However, among the potential trial sample, there were no demographic differences. Those from the repeat prescription sample had poorer indices than the general population sample in all pain and health measures. The repeat prescription sampling method was approximately five times more efficient than the general population method. However demographic and clinical differences in the repeat prescription sample might hamper extrapolation of findings to the general population, particularly in an epidemiological study, and demonstrate that simple comparison with age and gender of the target population is insufficient.

Monitoring mortality in general practice in Grampian, Scotland.

Information on the distribution of mortality and morbidity in general practice is scarce, and not easily accessible either by health authorities or individual general practices. Although the assessment of population mortality is a standard public health measure, colleagues in public health, information sciences and general practice rarely undertake such activity related to general practice populations. Mortality information can be used for various purposes. Examples are providing background data for clinical audits or alerting practitioners to quality issues in the healthcare industry or even suggesting environmental hazards. We measured the experience of mortality in all generally practices in Grampian in the years 1991 to 1999. All practices were notified of their actual and expected mortality over this period of time and asked for comment. Only three general practices had excess mortality experience in both the periods 1991 to 1995 and 1996 to 1999. Only a minority of practices commented on the results. It appears that a high presence of nursing homes in a practice might skew the results; this phenomenon will be central to further inquiry. Future methodology for recording death in general practice should take account of this, as well as providing an account of the qualitative aspects of patients' need for a dignified satisfactory death.

Public knowledge, attitudes and behaviour regarding antibiotics

Objective: To assess public knowledge, attitudes and behaviour regarding antibiotics to provide information for a local health education policy.Design: Postal survey to 605 patients registered with two general medical practices in Grampian, NorthEast Scotland (351 respondents, 59.3%) in February/ March 2000. Questionnaire topics covered attitudes, knowledge and behaviour towards antibiotic use.Results: 326 (93%) bad experience of antibiotic use and 319 (81%) were happy to take antibiotics when necessary. 158 (45%) were concerned about antibiotic resistance. Few would expect antibiotics to treat a slight cold or heavy cold, but around half would expect antibiotics for very sore throats and influenza. 262 (75%) indicated they would ask a pharmacist for advice about the treatment of RTI. Most respondents experienced at least one episode of RTI during the review period. 280 (80%) provided details of their most recent episode; most self-treated, 57 consulted a doctor of whom 43 (75%) were prescribed antibiotics.Conclusions: Antibiotic resistance is a matter of concern for the public. Mixed opinions about the use of antibiotics for common respiratory tract infection were heard. Encouragingly the majority of people suffering an RTI during the review period treated themselves with paracetamol-based products for symptom relief. Those who consulted a doctor were in the minority but were likely to be prescribed antibiotics. Future local health education initiatives should target antibiotic use for sore throats as well as colds and flu.

Patient reporting of potential adverse drug reactions: a methodological study.

To develop a systematic generic method of enabling patients to report symptoms which they believe to be due to a particular prescribed drug. A piloted body system-based questionnaire was distributed to patients registered with 79 medical practices in Grampian prescribed one of nine recently marketed 'black triangle' drugs. These comprised four antidepressants, three antiepileptics and two analgesics. This requested respondents to identify any symptoms experienced over the previous year which they thought could be due to the 'black triangle' drug they had used. A sample of medical records was examined to compare symptoms recorded with those reported by patients. A classification system was developed for the study to enable the assessment of symptoms reported for their potential relationship to patients' drug therapy. All symptoms reported were classified, taking into account information provided by patients on their concomitant drugs and diseases. A specialist pharmacist independently re-classified a sample of the symptoms to validate the process. A 36.3% response rate was obtained (837/2307) with 742 respondents (88.6%) reporting at least one symptom. The median per patient was 6.0 (range 0--71), with almost half (406, 48.5%) reporting fewer than five symptoms. Most symptoms (71.0%) were classified as being probably or possibly related to the drugs studied. Agreement between researcher and specialist on the classification of 75.3% of 716 symptoms was obtained (Kappa=0.563). Responses from patients prescribed antidepressant drugs were more likely to include symptoms potentially caused by these drugs (74.5% of all symptoms reported) than those from patients prescribed analgesics (67.4%) or antiepileptics (65.1%, chi2 = 23.858, d.f. = 2, P < 0.001). Patients reporting large numbers of symptoms were more likely to report some which were classed as unlikely to be an ADR or unattributable (chi2 = 80.587, d.f. = 3, P < 0.001). Of the 742 reporting symptoms in questionnaires, 402 (54.2%) claimed to have reported some or all of these to their doctor. Only 162 (22.6%) of 716 patient-reported symptoms were documented in the primary care medical records of 103 patients prescribed tramadol or venlafaxine. Respondents were clearly willing to report symptoms, the majority of which were classed as possibly/probably related to the drugs studied. The results suggest that patients do not report all symptoms they suspect to be ADRs to their GP and that GPs do not record all symptoms which may be reported to them. The method could help to identify problems which patients perceive as being related to their drug therapy and contribute to increased ADR reporting.

Prevalence of hip fracture risk factors in women aged 70 years and over.

We estimated the prevalence of common risk factors for hip fracture and the numbers needed to treat (NNT) to prevent a hip fracture in various high-risk population groups, using a postal risk factor survey of women aged 70 years and above from General Practices in Grampian and Yorkshire. Recorded risk factors included prior fracture of any type; low body weight; smoking; and family history of fracture. The prevalence rates of hip fracture risk factors were 34%, 7% and 11% for previous fracture, maternal hip fracture and smoking, respectively for the Grampian practices (low body weight being defined as falling in the lowest quartile) and 34%, 7% and 7% for a single practice in the York area. Applying previously published estimates of risk, NNT analysis produced a value of about 300 for women with no risk factors, whilst for women with three risk factors it was between 32 and 71, depending on which risk factors were present and assuming intervention reduced fracture rates by 30% or 50%. Groups of women at high risk of hip fracture can easily be identified in primary care and offered treatment, with realistic prospects of hip fracture prevention.

Patient centred assessment of quality of life for patients with four common conditions.

OBJECTIVES: To assess the reliability, validity, and responsiveness of a new quality of life measure, the patient generated index (PGI) of quality of life, in patients with four common clinical...

Audit of prehospital thrombolysis by general practitioners in peripheral practices in Grampian

BackgroundIn the Grampian region early anistreplase trial (GREAT), domiciliary thrombolysis by general practitioners was associated with a halving of one year mortality compared with hospital administration. However, after completion of...

Adult asthma review in general practice: nurses' perception of their role.

Asthma clinics have become widespread in general practice with nurses now playing an important role in asthma review. However, little is known about training of nurses carrying out reviews and how this affects the nurse role in patient management. We aimed to discover the level of asthma training of practice nurses carrying out review of adult asthma patients in one Health Authority and to see if this has any effect on their perception of their role. All 187 practice nurses in Grampian were sent a postal questionnaire investigating how asthma review is organized in general practice, their role in review and the asthma training they had received. Personal interviews were carried out with 17 nurses, exploring in more depth the topics covered in the questionnaire. A total of 167 nurses from 92% of the practices in Grampian responded, of whom 61% carried out asthma reviews. Among nurses carrying out reviews 71% did so on their own. 49% of nurses had or were training for advanced asthma qualification. Nurses without an asthma qualification were significantly more likely to feel that their training was not sufficient for their asthma related tasks (54% versus 11%, P = 0.0002). Nurses without advanced asthma qualifications were less likely to provide or review a self-management plan (29% versus 49%, P = 0.01), to review patient PEF recording (38% versus 65%, P < 0.01), to discuss patient worries (75% versus 94%, P < 0.05) or to make the initial diagnosis of asthma (24% versus 76%, P < 0.005). Nurses were unlikely to view their role as fully responsible unless they had an asthma qualification (13% versus 49%, P < 0.001). Nurses without advanced asthma qualifications do not feel fully confident in responsibility for patient management. Nurses without training are more likely to only carry out routine monitoring at reviews while nurses with asthma training are more likely to actively develop patient self-management skills. This suggests that nurses should be supported to obtain asthma qualifications if they are to give the best possible care to asthma patients.

Bronchial reactivity and dietary antioxidants.

BACKGROUND: It has been postulated that dietary antioxidants may influence the expression of allergic diseases and asthma. To test this hypothesis a case-control study was performed, nested in a cross...