Trained Practice Nurses Research Articles

Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study.

Implementing the Chronic Care Model (CCM) via involvement of specially trained practice nurses improves cardiovascular risk profiles and perception of care among type 2 diabetes patients in small primary care practices (PCPs) in the short term. Little is known about the long-term effects of this intervention. Cross-sectional survey among the participants of the cluster randomised controlled CARAT trial (30 PCPs, 303 diabetes patients), 3 years after its completion. Proportion of patients still treated according to the CCM, possible reasons for discontinuation, glycosylated haemoglobin (HbA1c), blood pressure, low density lipoprotein cholesterol, and accordance with CCM (assessed by means of PACIC [Patient Assessment of Chronic Illness Care]). Overall, 40.9% of practices (40.7% of patients) continued using the CCM. PCPs originally randomised to the intervention group were significantly more likely to be still using the CCM (11 PCPs / 88 patients vs 11 PCPs / 94 patients, p <0.001). Main reasons for discontinuation were organisational (40.9%) and financial aspects (18.1%), and the general practitioner refusing to transfer treatment responsibility (18.1%). HbA1c and PACIC development over the long term showed significant positive effects in favour of PCPs originally randomised to the intervention group and practices continuing to treat patients according to the CCM. Diabetes care according to the CCM, including the involvement of trained practice nurses, is a reasonable tool to improve care in the long-term. CCM training of the whole team is essential to overcome organisational challenges. Continuous team education, technical decision support, and recognition of the importance of these new structures in healthcare policy might improve the long-term clinical effect of the team approach.

Effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: A pragmatic cluster randomized controlled trial.

PurposeGiven the public health significance of poorly treatable co-morbid major depressive disorders (MDD) among patients with type 2 diabetes mellitus (DM2) and coronary heart disease (CHD), we need to investigate whether strategies to prevent the development of major depression could reduce its burden of disease. We therefore evaluated the effectiveness of a stepped-care program for subthreshold depression in comparison with usual care in patients with DM2 and/or CHD.MethodsA cluster randomized controlled trial, with 27 primary care centers serving as clusters. A total of 236 DM2 and/or CHD patients with subthreshold depression (nine item Patient Health Questionnaire (PHQ-9) score ≥ 6, no current MDD according to DSM-IV criteria) were allocated to the intervention group (N = 96) or usual care group (n = 140). The stepped-care program was delivered by trained practice nurses during one year and consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to the general practitioner. The primary outcome was the 12-month cumulative incidence of MDD as measured with the Mini International Neuropsychiatric Interview (MINI). Secondary outcomes included severity of depression (measured by PHQ-9) at 3, 6, 9 and 12 months.ResultsOf 236 patients (mean age, 67,5 (SD 10) years; 54.7% men), 210 (89%) completed the MINI at 12 months. The cumulative incidence of MDD was 9 of 89 (10.1%) participants in the intervention group and 12 of 121 (9.9%) participants in the usual care group. We found no statistically significant overall effect of the intervention (OR = 1.21; 95% confidence interval (0.12 to 12.41)) and there were no statistically significant differences in the course or severity of depressive symptoms between the two groups.ConclusionsThis study suggest that Step-Dep was not more effective in preventing MDD than usual care in a primary care population with DM2 and/or CHD and subthreshold depression.

Evidence-Based Review and Discussion Points.

Evidence-Based Review and Discussion Points.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery.

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)--a pilot study.

Around one in five children in England is obese when they leave primary school. Thus far, it has not been demonstrated that primary care interventions to manage childhood obesity can achieve significant weight reduction. Training obese children to eat more slowly as an adjunct to other healthy lifestyle behaviour change has been shown to increase weight reduction in a hospital setting. This pilot study aimed to test recruitment strategies, treatment adherence, clinic attendance and participants' experiences of using a device [Mandolean® (previously Mandometer®, Mikrodidakt AB, Lund, Sweden)] to slow down speed of eating as an adjunct to dietary and activity advice in treating obesity in primary school-aged children. A two-arm, parallel, randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. Participants were randomised by the Bristol Randomised Trials Collaboration randomisation service with allocation stratified by hub and minimised by age of the child, gender, and baseline body mass index (BMI) standard deviation score (BMI z-value) of the child, and by BMI of the study parent (obese/not obese). General practices across Bristol, North Somerset and South Gloucestershire primary care trusts. Children (BMI ≥ 95th percentile) aged 5-11 years and their families. Standard care comprised dietary and activity advice by trained practice nurses. Adjunctive Mandolean training (the intervention) educated participants to eat meals more slowly and to rate levels of fullness (satiety). Mandolean is a small computer device attached to a weighing scale that provides visual and oral feedback during meals while generating a visual representation of levels of satiety during the meal. Participants were encouraged to eat their main meal each day from the Mandolean. One parent was also given a Mandolean to use when eating with the child. Outcomes for the pilot were recruitment of 36 families to the trial in the 9-month pilot phase, that meals would be eaten at least five times a week off a Mandolean by 90% of patients randomised to the intervention arm, that 80% of patients in both arms would attend the weight management clinic appointment 3 months post randomisation and that > 60% of children using Mandolean would demonstrate a reduction in speed of eating from baseline within 3 months of randomisation. None of the criteria for progression to the main trial were reached. Despite numerous pathways being available for referral, only 21 (13 to standard care, eight to intervention arm; 58%) of the target 36 families were recruited in the pilot phase. Less than 20% of those randomised to Mandolean used the device at least five times a week. The > 60% target for slowing down of eating speed by 3 months was unmet. Attendance at the weight management clinic in general practice hubs for both arms of the study at 3 months was 44% against a target of 80%. This pilot trial failed to meet its objectives in terms of recruitment, treatment adherence, demonstration of a reduction in speed of eating in sufficient numbers of children, and attendance at follow-up appointments. Despite a high prevalence of childhood obesity in the geographical area and practices signing up for the trial, this study, like many others, demonstrates a failure of families to engage with and respond to primary care weight management interventions. We need to understand why the target population seems inured to the health message that childhood obesity is a significant health-care issue and identify the barriers to seeking help and then acting on positive health behaviour retraining. Only when we have fully understood the general public's perceptions of childhood obesity and have identified ways of engaging target populations can we hope to develop interventions that can work in a primary or community-based setting. Current Controlled Trials ISRCTN90561114. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 47. See the NIHR Journals Library website for further project information.

AB0775 A Model Osteoarthritis Consultation within Primary Care: A Novel Nurse-Led Approach to Promote Self-Management

BackgroundOsteoarthritis (OA) management is not seen as high priority for primary care and health professionals find management of OA challenging. The NICE (2008, 2014) and EULAR recommendations (2013) for OA...

An update to depression case management by practice nurses in primary care: a service evaluation

There is a recognized need to enhance non-pharmaceutical interventions in a way that is more accessible to the primary care population. Collaborative care has been shown to have a positive impact upon depression symptoms and a core element of the collaborative care approach is the case manager. This paper is a service evaluation of a collaborative care intervention that uses primary care nurses as the depression case manager and is a follow-up to the service audit carried out by Ekers and Wilson. The results support the notion that primary care nurses are ideally placed for delivering care to depressed patients; especially in cases were a patient also has a comorbid long-term medical condition. There is a recognized need to enhance non-pharmaceutical interventions for depression in the primary care. This service evaluation of collaborative care for depression by primary care practice nurses is an update of Ekers and Wilson (2008), reporting outcomes 5 years following initial training. From an initial 13 trained practice nurses, three provided anonymized data. Mean post-treatment Patient Health Questionnaire-9 (PHQ9) score was 8 [standard deviation (SD) 6.53, n = 185], indicating a mean positive change in depression symptom level of 8.9 [SD 7.01, 95% confidence interval (CI) 7.89-9.93, P < 0.001]. Subgroup analysis for patients identified with a comorbid long-term conditions (LTC) mean post-treatment PHQ9 score was 9 (SD 7.72, n = 33), indicating a mean positive change in depression symptom level of 8.1 (SD 5.79, 95% CI 6.04-10.41, P < 0.001). Nurses provided feedback on the intervention showing potential areas that would benefit from further detailed qualitative review. It was concluded that primary care practice nurses would be ideally placed to deliver collaborative care to depression patients with comorbid LTCs.

Cost-effectiveness of cardiovascular risk management by practice nurses in primary care

BackgroundCardiovascular disease (CVD) is largely preventable and prevention expenditures are relatively low. The randomised controlled SPRING-trial (SPRING-RCT) shows that cardiovascular risk management by practice nurses in general practice with and without self-monitoring both decreases cardiovascular risk, with no additional effect of self-monitoring. For considering future approaches of cardiovascular risk reduction, cost effectiveness analyses of regular care and additional self-monitoring are performed from a societal perspective on data from the SPRING-RCT.MethodsDirect medical and productivity costs are analysed alongside the SPRING-RCT, studying 179 participants (men aged 50–75 years, women aged 55–75 years), with an elevated cardiovascular risk, in 20 general practices in the Netherlands. Standard cardiovascular treatment according to Dutch guidelines is compared with additional counselling based on self-monitoring at home (pedometer, weighing scale and/ or blood pressure device) both by trained practice nurses. Cost-effectiveness is evaluated for both treatment groups and patient categories (age, sex, education).ResultsCosts are €98 and €187 per percentage decrease in 10-year cardiovascular mortality estimation, for the control and intervention group respectively. In both groups lost productivity causes the majority of the costs. The incremental cost-effectiveness ratio is approximately €1100 (95% CI: -5157 to 6150). Self-monitoring may be cost effective for females and higher educated participants, however confidence intervals are wide.ConclusionsIn this study population, regular treatment is more cost effective than counselling based on self-monitoring, with the majority of costs caused by lost productivity.Trial registrationTrialregister.nl identifier: http://NTR2188

Type 2 diabetes: prevention and cure?

General practice in the UK has been very successful in meeting the challenges raised by increasing prevalence of diabetes. Most diabetes is now managed in general practice and disease registers, evidencebased care, diabetes clinics, and diabetes trained practice nurses are now routine. As a consequence of the obesity epidemic, and the ageing population, diabetes rates are rising, and diabetes can remain undiagnosed for many years. GPs have made progress in recent years in identifying previously undiagnosed cases. Recent population-based reports suggest that only 3% of men and 1% of women over 50 years have undiagnosed diabetes.1 However, many more people are at high risk of developing diabetes (16% of people aged over 60 years have impaired fasting glucose),2 and detecting these people is important because it has been shown that type 2 diabetes can be prevented in a costeffective fashion in people at high risk by weight loss secondary to alteration in diet and exercise.3 There are major problems in translating this research success into everyday practice, chief among these are how to identify people with undiagnosed diabetes or at high risk; and how to intervene once they have been identified. Screening for diabetes is currently not cost-effective,4 although focused case finding has been advocated for some time. The efficiency of looking for diabetes can be greatly improved by initial use of risk scores. Both the Leicester and the Cambridge risk scores can be run on routinely collected data in computerised databases. These scores identify who within the population is at high enough risk to warrant a blood test for diabetes. But …

Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized controlled trial

BackgroundIntensive lifestyle interventions in well-controlled settings are effective in lowering the risk of chronic diseases such as type 2 diabetes (T2DM) and cardiovascular diseases (CVD), but there are still no effective lifestyle interventions for everyday practice. In the Hoorn Prevention Study we aimed to assess the effectiveness of a primary care based lifestyle intervention to reduce the estimated risk of developing T2DM and for CVD mortality, and to motivate changes in lifestyle behaviors.MethodsThe Hoorn Prevention Study is a parallel group randomized controlled trial, implemented in the region of West-Friesland, the Netherlands. 622 adults with ≥10% estimated risk of T2DM and/or CVD mortality were randomly assigned and monitored over a period of 12 months. The intervention group (n=314) received a theory-based lifestyle intervention based on an innovative combination of motivational interviewing and problem solving treatment, provided by trained practice nurses in 12 general practices. The control group (n=308) received existing health brochures. Primary outcomes was the estimated diabetes risk according to the formula of the Atherosclerosis Risk In Communities (ARIC) Study, and the estimated risk for CVD mortality according to the Systematic COronary Risk Evaluation (SCORE) formula. Secondary outcomes included lifestyle behavior (diet, physical activity and smoking). The research assistants, the principal investigator and the general practitioners were blinded to group assignment. Linear and logistic regression analysis was applied to examine the between-group differences in each outcome measure, adjusted for baseline values.Results536 (86.2%) of the 622 participants (age 43.5 years) completed the 6-month follow-up, and 502 (81.2%) completed the 12-month follow-up. The mean baseline T2DM risk was 18.9% (SD 8.2) and the mean CVD mortality risk was 3.8% (SD 3.0). The intervention group participated in a median of 2 sessions. Intention-to-treat analyses showed no significant differences in outcomes between the two groups at 6 or 12-months follow-up.ConclusionsThe lifestyle intervention was not more effective than health brochures in reducing risk scores for T2DM and CVD or improving lifestyle behavior in an at-risk population.Trial registrationCurrent Controlled Trials: ISRCTN59358434

Case-finding of dementia in general practice and effects of subsequent collaborative care; design of a cluster RCT.

BackgroundIn the primary care setting, dementia is often diagnosed relatively late in the disease process. Case finding and proactive collaborative care may have beneficial effects on both patient and informal caregiver by clarifying the cause of cognitive decline and changed behaviour and by enabling support, care planning and access to services.We aim to improve the recognition and diagnosis of individuals with dementia in general practice. In addition to this diagnostic aim, the effects of case finding and subsequent care on the mental health of individuals with dementia and the mental health of their informal carers are explored.Methods and designDesign: cluster randomised controlled trial with process evaluation.Participants: 162 individuals ≥ 65 years, in 15 primary care practices, in whom GPs suspect cognitive impairment, but without a dementia diagnosis.Intervention; case finding and collaborative care: 2 trained practice nurses (PNs) invite all patients with suspected cognitive impairment for a brief functional and cognitive screening. If the cognitive tests are supportive of cognitive impairment, individuals are referred to their GP for further evaluation. If dementia is diagnosed, a comprehensive geriatric assessment takes place to identify other relevant geriatric problems that need to be addressed. Furthermore, the team of GP and PN provide information and support.Control: GPs provide care and diagnosis as usual.Main study parameters: after 12 months both groups are compared on: 1) incident dementia (and MCI) diagnoses and 2) patient and caregiver quality of life (QoL-AD; EQ5D) and mental health (MH5; GHQ 12) and caregiver competence to care (SSCQ). The process evaluation concerns facilitating and impeding factors to the implementation of this intervention. These factors are assessed on the care provider level, the care recipient level and on the organisational level.DiscussionThis study will provide insight into the diagnostic yield and the clinical effects of case finding and collaborative care for individuals with suspected cognitive impairment, compared to usual care. A process evaluation will give insight into the feasibility of this intervention.The first results are expected in the course of 2013.Trial registrationNTR3389

Process Evaluation of a Lifestyle Intervention to Prevent Diabetes and Cardiovascular Diseases in Primary Care

Effective, cost-effective, safe, and feasible interventions to improve lifestyle behavior in at-risk populations are needed in primary care. In the Hoorn Prevention Study, the authors implemented a theory-based lifestyle intervention in which trained practice nurses used an innovative combination of motivational interviewing (MI) and problem-solving treatment (PST). This article presents the intervention's reach, effectiveness in terms of process outcomes, adoption, and implementation. Recruitment strategy and participant flow were documented accurately. The effectiveness in terms of determinants of behavioral change was measured using a validated questionnaire. Questionnaires were also used to assess participant satisfaction and compliance, as well as practice nurses' confidence in providing the intervention. Counseling sessions were tape recorded to assess MI, PST, and general counseling competence. The findings indicate that the recruitment strategy was adequate and resulted in a reasonably extensive reach of the target population. Practice nurses were competent and confident in their provision of MI and PST, and participant satisfaction was high. Nevertheless, the number of sessions attended was low, and almost no effects were seen on determinants of behavioral change. The authors conclude that implementing this type of intervention in primary care is feasible, but more is needed to effectively facilitate changes in determinants of lifestyle behavior in this population.

Do Trained Practice Nurses Apply Motivational Interviewing Techniques in Primary Care Consultations?

BackgroundReducing the prevalence of unhealthy lifestyle behaviour could positively influence health. Motivational interviewing (MI) is used to promote change in unhealthy lifestyle behaviour as part of primary or secondary prevention. Whether MI is actually applied as taught is unknown. Practice nurses’ application of motivational interviewing in real-life primary care consultations was examined. Furthermore, we explored if (and to what extent) practice nurses adjust their motivational interviewing skills to primary versus secondary prevention.MethodsThirteen Dutch practice nurses, from four general practices, trained in motivational interviewing participated, 117 adult patients visiting the practice nurse participated, 117 practice nurse-patient consultations between June and December 2010 were videotaped. Motivational interview skills were rated by two observers using the Behaviour Change Counselling Index (BECCI). Data were analyzed using multilevel regression.ResultsPractice nurses use motivational interviewing techniques to some extent. Substantial variation was found between motivational interviewing items. No significant differences in the use of motivational interviewing between primary and secondary prevention was found.ConclusionsMotivational interviewing skills are not easily applicable in routine practice. Health care providers who want to acquire motivational interview skills should follow booster sessions after the first training. The training could be strengthened by video-feedback and feedback based on participating observation. A possible explanation for the lack of differences between the two types of prevention consultations may be the gain to help patients in primary consultations by preventing complications equals the necessity to help the disease from aggravating in secondary prevention.

The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial

BackgroundMore than half of the patients with type 2 diabetes (T2DM) patients are diagnosed with one or more comorbid disorders. They can participate in several single-disease oriented disease management programs, which may lead to fragmented care because these programs are not well prepared for coordinating care between programs. Comorbid patients are therefore at risk for suboptimal treatment, unsafe care, inefficient use of health care services and unnecessary costs. Case management is a possible model to counteract fragmented care for comorbid patients. It includes evidence-based optimal care, but is tailored to the individual patients' preferences.The objective of this study is to examine the effectiveness of a case management program, in addition to a diabetes management program, on the quality of care for comorbid T2DM patients.Methods/DesignThe study is a randomized controlled trial among patients with T2DM and at least one comorbid chronic disease (N = 230), who already participate in a diabetes management program. Randomization will take place at the level of the patients in general practices. Trained practice nurses (case managers) will apply a case management program in addition to the diabetes management program. The case management intervention is based on the Guided Care model and includes six elements; assessing health care needs, planning care, create access to other care providers and community resources, monitoring, coordinating care and recording of all relevant information. Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers.DiscussionWe expect that the case management program, which includes better structured care based on scientific evidence and adjusted to the patients' needs and priorities, will improve the quality of care coordination from both the patients' and caregivers' perspective and will result in less consumption of health care services.Trial registrationNetherlands Trial Register (NTR): NTR1847

Small but important errors in cardiovascular risk calculation by practice nurses: A cross-sectional study in randomised trial setting

BackgroundPractice nurses play an increasingly important role in the prevention of cardiovascular diseases but we do not have evidence about the accuracy of their cardiovascular risk assessments during real practice consultations. ObjectivesTo examine how nurses perform with regard to absolute 10-year cardiovascular risk assessment in actual practice. DesignCross-sectional study. SettingThis study was nested in the IMPALA study, a clustered randomised controlled trial involving 24 general practices in The Netherlands. Participants24 practice nurses, trained in 10-year cardiovascular risk assessment, calculated the risk of a total of 421 patients without established cardiovascular diseases but eligible for cardiovascular risk assessment. MethodsThe main outcome measure was the accuracy of risk assessments, defined as (1) the difference between the 10-year cardiovascular risk percentage calculated by nurses and an independent assessor, and (2) the agreement between the treatment categories assigned by the nurses (low, moderate or high risk) and those assigned by the independent assessor. ResultsThirty-one (7.4%) of the calculated risk percentages differed by more than our preset limits, 25 (81%) being underestimations. Elderly patients (OR 1.1, 95% CI 1.0–1.1), male patients (vs. female OR 3.1, 95% CI 1.2–7.3), and smoking patients (vs. non-smoking OR 3.8, 95% CI 1.7–8.9) were more likely to have their cardiovascular risk miscalculated. Ten (28%) of the 36 patients who should be assigned to the high-risk treatment category according to the independent calculation, were missed as high-risk patients by the practice nurses. ConclusionsThe overall standard of accuracy of cardiovascular risk assessment by trained practice nurses in actual practice is high. However, a significant number of high-risk patients were misclassified, with the probability that it led to missed opportunities for risk-reducing interventions. As cardiovascular risk assessments are frequently done by nurses in general practice, further specific training should be considered to prevent undertreatment.

Effects of allergen and trigger factor avoidance advice in primary care on asthma control: a randomized‐controlled trial

Allergy contributes significantly to asthma exacerbation, yet avoidance of triggers, in particular allergens, is rarely addressed in detail in regular asthma review in primary care. To determine whether structured, individually tailored allergen and trigger avoidance advice, given as part of a primary care asthma review, improves lung function and asthma control. In a randomized-controlled trial 214 adults with asthma in six general practices were either offered usual care during a primary care asthma review or usual care with additional allergen and trigger identification (by skin prick testing and structured allergy assessment) and avoidance advice according to a standardized protocol by trained practice nurses. Main outcome measures were lung function, asthma control, asthma self-efficacy. Both intervention groups were equivalent in demographic and asthma-related variables at baseline. At 3-6-month follow-up, patients receiving the allergen and trigger avoidance review showed significant improvements in lung function (assessed by blinded research nurses) compared with those receiving usual care. Significantly more patients in the intervention group than in the control group showed improvements in forced expiratory volume in 1 s > or =15%. No significant differences were found in self-report measures of asthma control. Asthma-specific self-efficacy improved in both groups but did not differ between groups. Allergen and trigger identification and avoidance advice, given as part of a structured asthma review delivered in primary care by nurses results in clinically important improvements in lung function but not self-report of asthma control. ISRCTN45684820.

Propofol Sedation in Outpatient Colonoscopy by Trained Practice Nurses Supervised by the Gastroenterologist: a Prospective Evaluation of over 3000 Cases

Propofol has several advantages for sedation in endoscopic procedures. Sedation administered by anaesthesiologists is associated with high costs. In this study the safety of propofol sedation administered by trained practice nurses under the supervision of the gastroenterologist in a cohort of outpatients of an ambulatory practice for gastroenterology in Germany is evaluated. During a period of 21 months all patients referred to colonoscopy were eligible for this prospective observational study. The familiar CRC risk of the individuals, indication, completeness and results of the colonoscopy were registered together with the dose of propofol used. Propofol was administered by intermittent intravenous bolus titration by trained practice nurses under supervision of the gastroenterologist. Oxygen saturation, heart rate and blood pressure were recorded constantly during the procedure and adverse cardiopulmonary events were monitored by the endoscopy team. A respiratory event was defined as an episode of apnoea or laryngospasm requiring assisted ventilation. 23 % of the patients received supplemental oxygen. A total of 3641 colonoscopies were recorded. 33 individuals were sedated with midazolam and were excluded from the evaluation. 3610 individuals were sedated with propofol (119 +/- 39 mg, mean dose +/- S. D.). 40 % of the procedures were performed as combined gastroscopy and colonoscopy. The cecum was reached in 99 % of the colonoscopies. Respiratory events occurred in five patients (0.14 %). Assisted ventilation in all cases was performed by mask ventilation. Bradycardia (HF < 60/min) and arterial hypotension (RR < 90 mmHg) occurred in 0.5 and 0.3 % of the colonoscopies, respectively, but medical intervention was necessary only in 0.2 % for both types of event. Minor events of hypoxaemia were observed in 51 patients (1.4 %), but only 1/3 of these events occurred in patients supplemented with oxygen. Propofol can be administered safely for ambulatory colonoscopy by trained practice nurses, with careful monitoring under supervision of the gastroenterologist.

Cognitive behavioural therapy in addition to antispasmodic therapy for irritable bowel syndrome in primary care: randomised controlled trial

To determine whether cognitive behavioural therapy (CBT) in addition to antispasmodic treatment offers a cost-effective benefit to primary care patients with irritable bowel syndrome (IBS) and to identify predictors of outcome. This was a randomised controlled trial in primary care of the addition of CBT to standard general practice management of IBS, using the antispasmodic agent mebeverine hydrochloride. The study set out to compare the addition of a standardised package of IBS-specific CBT to treatment with mebeverine hydrochloride. Ten general practices, serving a population of around 45,000 patients, located principally in south London, with some patients resident in north London. Patients identified as having IBS by their GPs, aged between 17 and 54 (mean 34) years and predominantly white; 82% were female and half had had IBS for more than 5 years. Practice nurses delivered CBT in a randomised trial of the addition of CBT to mebeverine in patients who had IBS of moderate or greater severity after 2 weeks of GP care and 4 weeks of mebeverine. The Symptom Severity Scale (SSS) was used to identify patients with moderate or severe IBS. Patients who continued to report moderate or severe IBS after 4 weeks of mebeverine at a dose of 270 mg three times a day were randomised to receive six sessions of CBT in addition to mebeverine (72 patients) or mebeverine alone (77 patients). These patients were followed at 3, 6 and 12 months after treatment. As part of the baseline evaluation, blood tests for antiendomysial and antigliadin antibodies were carried out on 141 patients to determine the prevalence of coeliac disease in this population. The principal outcome measure was the SSS. Others included the Hospital Anxiety and Depression Scale, psychopathology, the Work and Social Adjustment Scale (WASA, disability), a modified version of the Illness Perception Questionnaire (illness perceptions), the Beliefs about Medicine Questionnaire (attitudes to medication), the Reported Adherence to Medication Scale (adherence to prescribed medication), the Client Service Receipt Inventory (economic analysis), the Cognitive Scale for Functional Bowel Disorders (illness cognitions) and the Behaviour Scale for IBS (IBS coping behaviour). The addition of CBT produced a significant benefit compared with the mebeverine-only group at 3 months after treatment on all outcome measures, except for the adherence to medication scales. The difference between the groups was 107.8 points on the SSS, 24.5 points on question 4 of the SSS and 6.3 points on the WASA, representing therapeutic gains of approximately 20%, 28% and 40%, respectively. However, there was also evidence that these improvements began to wane, so that at 6 and 12 months follow-up significant therapeutic benefit of the addition of CBT could only be detected on question 4 of the SSS and on the WASA. The behaviour scale for IBS detected significant, positive changes in coping behaviours at up to 6 months after treatment. Three factors predicting a poor outcome were identified: male gender, believing that IBS had serious consequences and belief in an external aetiology, all of which were associated with greater than average disability at follow-up. The addition of CBT to mebeverine did not reduce overall treatment or social costs. The nested study on testing for coeliac disease provides cautious support for the inclusion of antiendomysial and antigliadin antibody testing in the investigation of patients thought to have IBS. Specially trained practice nurses can provide effective CBT to primary care patients with a clinical diagnosis of IBS, which although effective does not reduce service or social costs. Using a variety of measures the beneficial therapeutic effects of the addition of CBT to antispasmodic therapy persist for up to 6 months. Future research might include studies of the long-term follow-up of IBS patients treated with CBT, cost-benefit analyses comparing CBT with other therapeutic approaches to IBS, and evaluating means of training both non-specialist health professionals and GPs to deliver CBT.

Partner notification of chlamydia infection in primary care: randomised controlled trial and analysis of resource use

Objective To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection.Design Randomised controlled trial.Setting 27 general practices...

Assessment of key influences on asthma inhaler device selection in trained asthma practice nurses

The impact of asthma is felt throughout the UK with an average primary care organisation treating 45,000 people for asthma with 439 emergency hospital admissions and eight deaths due to asthma each year (National Asthma Campaign 2001). Optimal asthma management is reliant on individualised patient focused selection of appropriate treatment via a suitable inhaler device. To identify the most important influences on asthma inhaler device selection in a group of asthma trained nurses. Interviews and a focus group were conducted in order to gain information that could be used to develop a questionnaire on which to base a pilot study. Interviews, focus group and pilot study were all held in a semi-rural area of England. Subjects: 3 NRTC asthma nurse experts, eight local asthma trained practice nurses and a non random sample of 18 asthma trained nurses. Practice nurse's identified influences such as patient age, cost to the practice and patient preference as being the most important influences with experts also highlighting the importance of evidence from research and adherence to current national asthma guidelines. The subsequent pilot study showed that ease of use and patient's manual dexterity had the greatest influence on a nurse's choice of device, with adherence to national asthma guidelines and training in asthma management in third and fourth places. Inhaler devices need to be easy to use by the majority of patients to ensure optimal asthma management, while national asthma guidelines also play a prominent role in device selection. Asthma education should include this information in order to promote optimal symptom control.