Usual GP Research Articles

The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain – A systematic review

BackgroundThere is considerable interest in whether best practice management of nonspecific low back pain (NSLBP) should include the targeting of treatment to subgroups of people with identifiable clinical characteristics. However, there are no published systematic reviews of the efficacy of targeted psychosocial interventions. AimThis review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics. MethodBibliographic databases were searched. Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment (treatment effect modification) for the outcomes of pain, activity limitation and psychosocial factors (fear avoidance, catastrophisation, anxiety and depression). Results and conclusionFour studies met the inclusion criteria and collectively investigated nine hypotheses about targeted treatment on 28 subgroup/treatment outcomes. There were only two statistically significant results. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targeted psychosocial interventions.

Patient characteristics associated with GP referral to the Access to Allied Psychological Services Program: A case-control study

GPs have referred patients for psychological treatment under the Better Outcomes in Mental Health Care, Access to Allied Psychological Services (ATAPS) Program since 2003. It is not known how GPs might select patients for referral. We explored which characteristics identified ATAPS patients compared to usual GP patients. The study was conducted in GP Access, a Division of General Practice (Newcastle and Lower Hunter) in NSW, Australia. It was a case-control design with 63 cases (ATAPS patients), and 64 controls (GP patients never referred to ATAPS). Unadjusted and sequentially adjusted logistic regressions were used to identify independent predictors of being an ATAPS case based on official referral guidelines: ICD-10 diagnosis of depression or anxiety and scores on the K-10 (psychological distress) and DASS-21 (psychological symptoms). A multivariable logistic regression was also used to determine the best minimum set of predictor variables. Eight-three per cent of ATAPS cases had anxiety or depression. In unadjusted models, any mood disorder, OR 7.68 (95% CI: 3.47, 17.01), any anxiety disorder, OR 2.88 (95% CI: 1.37, 6.05), higher K-10 score, OR 1.06 (95% CI: 1.04, 1.14) and higher DASS-21 score, OR 1.06 (95% CI: 1.03, 1.09) were associated with being an ATAPS case. Any mood disorder, any anxiety disorder, K-10 score and DASS-21 scores remained significant in most adjusted analyses and all models showed change when adjusted for mental disability and physical disability. Three variables predicted being an ATAPS case in the multivariable regression: greater mental disability, lesser physical disability and greater number of substances misused. Cases had higher levels of mental disability and greater substance misuse, but lower levels of physical disability. This may reflect GP referral decision making and have implications for policy development.

The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction

Cardiovascular disease (CVD) is the leading cause of global mortality. Risk factor management in clinical practice often relies on relative risk modification rather than the more appropriate absolute risk assessment. To determine whether patients receiving more-frequently designated GP visits had increased benefit in terms of their absolute CVD risk assessment, as compared with patients in receipt of their usual GP care. Prospective, open, pragmatic block randomised study in a 1:1 group allocation ratio in three Western Australian general practices. A convenience sample (n = 1200) of patients aged 40-80 years were randomised to 3-monthly GP visits (five in total for the intensive) or usual GP care (two in total for the opportunistic), with 12 months' follow-up. The main outcome was absolute CVD risk scores based on the New Zealand Cardiovascular Risk Calculator. Others outcome measures were weight, height, waist circumference, blood pressure, and fasting blood lipids and glucose. There were 600 patients per group at baseline. At 12 months' analysis there were 543 in the intensive group and 569 in the opportunistic group. Mean (standard deviation [SD]) absolute CVD risk reduced significantly between baseline and 12 months in the intensive group (6.28% [5.11] to 6.10% [4.94]) but not in the opportunistic group (6.27% [5.10] to 6.24% [5.38]). There was a significant reduction between baseline and 12 months in mean (SD) total cholesterol (5.28 mmol/l [0.94] to 5.08 mmol/l [0.96]); low-density lipoprotein cholesterol (3.08 mmol/l [0.87] to 2.95 mmol/l [0.89]); triglyceride (1.45 mmol/l [0.86] to 1.36 mmol/l [0.84]); and in mean (SD) waist circumference in men (98.74 cm [10.70] to 97.13 cm [10.20]) and females (90.64 cm [14.62] to 88.96 cm [14.00]) in the intensive group. A targeted approach using absolute risk calculators can be used in primary care to modify global CVD risk assessment.

One-Year Effectiveness of a 3-Week Balneotherapy Program for the Treatment of Overweight or Obesity

Objective. To assess the one-year effectiveness on weight loss of a 3-week balneotherapy program (BT). Method. A Zelen double consent randomised controlled trial to compare one-year BMI loss between a 3-week BT program versus usual care (UC) for overweight or obese patients (BMI: 27–35 kg/m2), associated or not with a dietary motivational interview (DMI) during the follow-up, using a 2 × 2 factorial design. Main analysis was a per protocol analysis comparing patients attending BT to patients managed by UC, matched on sex, overweight or obese status, DMI randomisation and a propensity score to attend BT or to be managed by UC. Results. From the 257 patients who completed the follow-up, 70 patients of each group could be matched. Mean BMI loss was 1.91 kg/m2 [95%CI: 1.46; 2.35] for the BT patients and 0.20 kg/m2 [−0.24; 0.64] for the UC patients (P < 0.001), corresponding to a significant BT benefit of 1.71 kg/m2 [1.08; 2.33]. There was no significant effect of DMI and no interaction with BT or UC. No adverse reaction was observed for patients attending BT. Conclusion. A 3-week BT program provided a significant one-year benefit over the usual GP dietary advice for overweight and obese patients.

Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review

Complementary medicine and alternative approaches to chronic and intractable health conditions are increasingly being used, and require critical evaluation. The aim of this review was to systematically evaluate available evidence for the effectiveness and safety of instruction in the Alexander Technique in health-related conditions. PUBMED, EMBASE, PSYCHINFO, ISI Web-of-Knowledge, AMED, CINHAL-plus, Cochrane library and Evidence-based Medicine Reviews were searched to July 2011. Inclusion criteria were prospective studies evaluating Alexander Technique instruction (individual lessons or group delivery) as an intervention for any medical indication/health-related condition. Studies were categorised and data extracted on study population, randomisation method, nature of intervention and control, practitioner characteristics, validity and reliability of outcome measures, completeness of follow-up and statistical analyses. Of 271 publications identified, 18 were selected: three randomised, controlled trials (RCTs), two controlled non-randomised studies, eight non-controlled studies, four qualitative analyses and one health economic analysis. One well-designed, well-conducted RCT demonstrated that, compared with usual GP care, Alexander Technique lessons led to significant long-term reductions in back pain and incapacity caused by chronic back pain. The results were broadly supported by a smaller, earlier RCT in chronic back pain. The third RCT, a small, well-designed, well-conducted study in individuals with Parkinson's disease, showed a sustained increased ability to carry out everyday activities following Alexander lessons, compared with usual care. The 15 non-RCT studies are also reviewed. Strong evidence exists for the effectiveness of Alexander Technique lessons for chronic back pain and moderate evidence in Parkinson's-associated disability. Preliminary evidence suggests that Alexander Technique lessons may lead to improvements in balance skills in the elderly, in general chronic pain, posture, respiratory function and stuttering, but there is insufficient evidence to support recommendations in these areas.

Inequality in provider continuity for children by Australian general practitioners

BackgroundThere is little published on provider continuity in Australian general practice and none on its effect on inequality of care for children.MethodQuestionnaire administered to parents of the ACT Kindergarten Health Screen asking the name of their child's usual GP and practice address between 2001 and 2008.ResultsParents of 30,789 children named 433 GPs and 141 practices. In each year, an average of 77% of parents could name both the GP and the practice, an average of 11% of parents could name only the practice, and an average of 12% of parents could name neither. In each year, 25% of parents could not name a usual GP for children of Aboriginal or Torres Straight Islander descent, or children born outside of Australia, compared to 10% of all other children (p = < 0.0001). The frequency of GPs displaying continuity of care varied over time with 19% of GPs being present in the ACT in only one year and 39% of GPs being present in every year over the eight years of study. GPs displayed two different forms of transience either by working in more than one practice in each year (5% of GPs), or by not being present in the ACT region from one year to the next (15% of GPs). Fewer parents nominated transient GPs as their child's GP compared to choosing GPs who displayed continuity (p < 0.001).ConclusionsMany GPs (39%) were reported to provide continuity of care for in the ACT region and some GPs (20%) displayed transient care. Indigenous children or children born outside of Australia had less equity of access to a nominated GP than all other children. Such inequity might disappear if voluntary registration of children was adopted in Australian general practice.

Protocol-based nurse management of type 2 diabetes did not differ from usual GP care for HbA1clevels

Source Citation Houweling ST, Kleefstra N, van Hateren KJ, et al. Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial. J Clin N...

Novel Use of Intra-arterial Doppler in the Assessment of Pulmonary Artery Flow Velocities—Observations Before and After Therapy for Pulmonary Arterial Hypertension

Background: Intra-arterial Doppler is a novel technique which enables accurate assessment of blood flow haemodynamics. We evaluated the feasibility of using intra-arterial Doppler for insights into the pulmonary artery flow velocity profile in patients with pulmonary arterial hypertension (PAH), and determined the changes in the flow velocity profile following pulmonary vasodilator therapy. Methods: Intra-arterial Doppler was performed in the pulmonary arteries of seven subjects with PAH before and after six months of Bosentan therapy. The following Doppler derived parameters weremeasured: acceleration time (AcT), systolic ejection time (ET), ratio of acceleration time to systolic ejection time (AcT/ET), systolic velocity time integral (sVTI), diastolic velocity time integral (dVTI) and total velocity time integral (tVTI). Relationships between Doppler parameters and clinical response to Bosentan therapy were analysed. Results: At baseline, all PAH patients displayed a standardised pharmacological treatment and computer assisted, intensified follow-up and treatment titration). Methods: VIPER-BP is a multicentre, open-label, randomisedcontrolled trial inGPclinics throughoutAustralia comparing usual GP management with an intensive BP management strategy using three forms of valsartanbased therapy. The primary endpoint is individualised BP control at six months. Results: During recruitment 2334 patients initially screened. Of these, 2131 (91%) commenced a 28 day valsartan 80mg “run-in” phase. Subsequently, 310 patients achieved their individualBP target (15%)whilst 81patients (5.2%) were rescue randomised. Overall, 1555 patients were randomised to usual care (n= 519) or the VIPER-BP Intervention (n= 1036): comprising 948men (62%) and 607 women (aged 59± 12 vs. 60± 12 years, respectively) and 1004 patients (65%) previously treated for hypertension. Individual BP targets (systolic/diastolic BP) were as follows; 125/75mmHg (18%withproteinuria), 130/80mmHg (55% with diabetes or CVD) and 140/90mmHg (27%). Mean BP at randomisation was 149± 17/88± 11mmHg with similar BP profiles for men and women, respectively (149± 16/88± 11 versus 149± 17/87± 10mmHg). Conclusion:With study completion in August 2011, the VIPER-BP Study will provide invaluable insights into the most effective means to optimise BP levels (on an individualised basis) in the primary care setting.

Nurse-delivered, home-based pragmatic rehabilitation has a short-term effect on improving fatigue in people with chronic fatigue syndrome compared with usual GP care, but effects were not sustained at 1 year

Nurse-delivered, home-based pragmatic rehabilitation has a short-term effect on improving fatigue in people with chronic fatigue syndrome compared with usual GP care, but effects were not sustained at 1 year

One-year follow-up results of unsupported online computerized cognitive behavioural therapy for depression in primary care: A randomized trial

Objective To report the one-year follow-up results of computerized cognitive behavioural therapy (CCBT), offered online without professional support, for depression compared with usual GP care and a combination of both treatments. To explore potential relapse prevention effects of CCBT. Methods 303 depressed patients were randomly allocated to (a) unsupported online CCBT (b) treatment as usual (TAU), or (c) CCBT and TAU combined. We had a 12-month follow-up period. Primary outcome measure was the Beck Depression Inventory II. Self-reported health care use was also measured. Key findings At 12 months, no statistically significant differences between the three interventions are found in the intention-to-treat population for depressive severity, reliable improvement, remission, and relapse. In the first quarter, differences in health care consumption between the three interventions are significant (i.e. less GP contacts, less antidepressant medication, and less specialist mental health care in the CCBT group), but these differences disappear over time. Conclusions Unsupported online CCBT is not superior to TAU by a GP for depression. With equal effects, CCBT alone leads to less health care consumption than TAU and CCBT&TAU. Overall effects are modest in all interventions, which can be explained by the finding that the use of health care services decreases despite the lack of substantial improvements.

Acupuncture for irritable bowel syndrome: A protocol for a pragmatic randomised controlled trial

BackgroundThere is insufficient evidence on the effectiveness of acupuncture for irritable bowel syndrome (IBS) for conclusions to be drawn. Given the current interest in acupuncture by patients, it is in the public interest to establish more rigorous evidence. Building on the positive findings from a pilot study, in this paper we present the protocol for a fully-powered trial designed to establish whether or not acupuncture is effective and cost-effective.Methods/DesignIn this pragmatic randomised controlled trial we will randomise patients recruited directly from GP databases to either 10 sessions of acupuncture plus usual GP care or to usual GP care alone. The primary clinical outcome will be the IBS Symptom Severity Score (SSS) (maximum score 500) at three months, and at 12 month assessing whether there is an overall benefit. We estimate the sample size required to detect a minimum clinical difference at 90% power and 5% significance to be 188 patients. To allow for loss to follow up we will recruit 220 patients drawn from an estimated primary care population of 140 000. Analysis will be by intention-to-treat, and multiple imputation is to be used for missing data.In a nested qualitative study using in-depth interviews, we will explore how patients, acupuncturists, and GPs explain and subsequently understand acupuncture to work. We will use purposive sampling to identify patients and flexible topic guides for the interviews. The data analysis will lead to a thematic description of how patients and practitioners explain how acupuncture works, and whether or not the explanations influence treatment outcome and/or referrals.We will undertake a cost-effectiveness analysis at 12 months by comparing resource use in the two groups with any treatment benefit. We will use the EQ-5D to measure health-related quality of life and convert into quality adjusted life years (QALYs). We will generate cost effectiveness acceptability curves (CEACs) exploring the probability that acupuncture will produce an acceptable cost per QALY at different cost-effectiveness thresholds.DiscussionThe trial has received NHS ethics approval and recruited 233 patients between November 2008 and June 2009. Results are expected in 2011.Trial RegistrationCurrent Controlled Trials ISRCTN08827905

Patients’ Attitudes to General Practice Registrars: A Review of the Literature

With the population ageing, it is imperative for training practices to provide general practice registrars (GPRs) with sound experience in managing the health problems of older persons, especially chronic conditions. However, it is reported that a significant proportion of these patients will be resistant to consulting registrars, with concerns regarding disruption of continuity of care being a significant factor. The challenge for training practices is to identify approaches to engage registrars in the management of older patients whilst maintaining patient satisfaction. This paper presents a review of the literature on patient attitudes to GPRs to better understand the nature and magnitude of the challenge, and to identify important research gaps. Major electronic medical literature databases were searched for relevant articles using search terms including general practice, registrar, doctor-patient relationship, patient attitudes and elderly, for the period from January 1980 to March 2009. The studies were analysed by methodology, content and theme. A total of 15 studies were identified that directly addressed patients' attitudes to GPRs. Whilst there appeared to be an overall high acceptance of registrars by patients, increasing patient age was associated with more negative attitudes towards registrars, reduced trust and decreased satisfaction with communication. Presentations for chronic or emotional problems were associated with reduced willingness to consult registrars. Patients generally appreciated an ongoing involvement with their usual GP. These findings have implications for training practices and research directions. Demonstrating continuity of care through shared chronic disease management between supervisors and registrars is a possible model that meets registrars' training and patients' continuity needs. There is a need for quality research on the type and magnitude of problems affecting GPR encounters with older patients and, based on results from these studies, to create and assess models of registrar training involving older patients, that meet patients' needs for continuity of care.

Graduate mental health worker case management of depression in UK primary care: a pilot study

This randomised controlled trial examined GMHWs’ case management of depressed primary care patients. The authors contacted 1,073 patients aged between 18 and 65 who had moderate to severe depression and had failed to respond to an eight-week period of antidepressant treatment. Of these, 78 were eligible and 62 consented to participate. They were randomised to either their usual treatment from their GP or their usual GP treatment and case management from GMHWs. All patients received a prescription for an alternative antidepressant within a week of their baseline assessment.

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: Design of a randomised trial

BackgroundMajor depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care.Methods/DesignIn a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18–65) will be recruited in the general population by means of a large-scale Internet-based screening (N = 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life.DiscussionAlthough computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed.Trial registrationThe study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).

Acupuncture for Irritable Bowel Syndrome – An Exploratory Randomised Controlled Trial

The evidence on the effectiveness of acupuncture for irritable bowel syndrome (IBS) is inconclusive. However, many patients with IBS are self referring for acupuncture, therefore it is of interest to know whether acupuncture is effective or not. The aim of this study was to establish variability in the primary outcome measure to enable a sample size to be calculated for a full scale trial, and to explore feasibility and design criteria. A pragmatic randomised controlled trial compared 10 sessions of acupuncture plus usual GP care with usual GP care alone. Thirty patients were recruited from four GP databases in Birmingham, UK, and randomised one-to-two to acupuncture or usual care alone. The primary outcome was the IBS Symptom Severity Score (SSS) at three months (maximum score 500). Analysis was by intention-to-treat, and multiple imputation was used for missing data. From the databases, 189 patients with IBS were identified, of whom 30 were eligible and consented to randomisation. At three months, a statistically and clinically significant difference between groups of 138 points (SD 90) in favour of acupuncture was observed on the IBS SSS (95% CI: 66 to 210; P=0.001) using multiple imputation. For a full scale trial, we estimate that a sample size of 108 patients per arm is required, based on a minimum clinically significant change of 50 points, drawn from a primary care population of 140 000. We established the feasibility of a full scale trial, successfully recruiting patients and calculating the sample size required. The results of our pilot analysis suggest that more definitive research into acupuncture for IBS is merited. A pragmatic trial design will not be able to distinguish between acupuncture specific effects and placebo effects; however, it is the design of choice to determine cost effectiveness.

Graduate mental health worker case management of depression in UK primary care: a pilot study

Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. Three primary care practices in the North East of England. Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.

A randomised controlled study of reflexology for the management of chronic low back pain

The use of complementary and alternative medicine (CAM) for the management of chronic low back pain (CLBP) continues to rise. However, questions regarding the efficacy of many CAM therapies for CLBP remain unresolved. The present study investigated the effectiveness of reflexology for CLBP. A pragmatic randomised controlled trial was conducted. N = 243 patients were randomised to one of three groups: reflexology, relaxation, or non-intervention (usual care). All completed a questionnaire booklet before and after the treatment phase, and at six months follow up. This measured their general health status, pain, functioning, coping strategies and mood. After adjusting for pre-treatment scores repeated measures ANCOVA found no significant differences between the groups pre and post treatment on the primary outcome measures of pain and functioning. There was a main effect of pain reduction, irrespective of group. Trends in the data illustrated the pain reduction was greatest in the reflexology group. Thus, the current study does not indicate that adding reflexology to usual GP care for the management of CLBP is any more effective than usual GP care alone.

Cost-effectiveness of an activating intervention by social workers for patients with minor mental disorders on sick leave: a randomized controlled trial

Sickness absence often occurs in patients with emotional distress or minor mental disorders. In several European countries, these patients are over-represented among those receiving illness benefits, and interventions are needed. The aim of this study was to evaluate the cost-effectiveness of an intervention conducted by social workers, designed to reduce sick leave duration in patients absent from work owing to emotional distress or minor mental disorders. In this Randomized Controlled Trial, patients were recruited by GPs. The intervention group (N = 98) received an activating, structured treatment by social workers, the control group (N = 96) received routine GP care. Sick leave duration, clinical symptoms, and medical consumption (consumption of medical staffs' time as well as consumption of drugs) were measured at baseline and 3, 6, and 18 months later. Neither for sick leave duration nor for clinical improvement over time were significant differences found between the groups. Also the associated costs were not significantly lower in the intervention group. Compared with usual GP care, the activating social work intervention was not superior in reducing sick leave duration, improving clinical symptoms, and decreasing medical consumption. It was also not cost-effective compared with GP routine care in the treatment of minor mental disorders. Therefore, further implementation of the intervention is not justified. Potentially, programmes aimed at reducing sick leave duration in patients with minor mental disorders carried out closer to the workplace (e.g. by occupational physicians) are more successful than programmes in primary care.

Acupuncture for chronic neck pain: a pilot for a randomised controlled trial

BackgroundAcupuncture is increasingly being used for many conditions including chronic neck pain. However the evidence remains inconclusive, indicating the need for further well-designed research. The aim of this study was to conduct a pilot randomised controlled parallel arm trial, to establish key features required for the design and implementation of a large-scale trial on acupuncture for chronic neck pain.MethodsPatients whose GPs had diagnosed neck pain were recruited from one general practice, and randomised to receive usual GP care only, or acupuncture (up to 10 treatments over 3 months) as an adjunctive treatment to usual GP care. The primary outcome measure was the Northwick Park Neck Pain Questionnaire (NPQ) at 3 months. The primary analysis was to determine the sample size for the full scale study.ResultsOf the 227 patients with neck pain identified from the GP database, 28 (12.3%) consenting patients were eligible to participate in the pilot and 24 (10.5%) were recruited to the trial. Ten patients were randomised to acupuncture, receiving an average of eight treatments from one of four acupuncturists, and 14 were randomised to usual GP care alone. The sample size for the full scale trial was calculated from a clinically meaningful difference of 5% on the NPQ and, from this pilot, an adjusted standard deviation of 15.3%. Assuming 90% power at the 5% significance level, a sample size of 229 would be required in each arm in a large-scale trial when allowing for a loss to follow-up rate of 14%. In order to achieve this sample, one would need to identify patients from databases of GP practices with a total population of 230,000 patients, or approximately 15 GP practices roughly equal in size to the one involved in this study (i.e. 15,694 patients).ConclusionThis pilot study has allowed a number of recommendations to be made to facilitate the design of a large-scale trial, which in turn will help to clarify the existing evidence base on acupuncture for neck pain.

Preferences of patients for emergency services available during usual GP surgery hours: a discrete choice experiment

A study was undertaken to investigate patients' strength of preferences for attributes or characteristics associated with delivery of emergency primary care services available during usual GP surgery hours and to investigate the trade-offs between attributes. A discrete choice experiment was used to quantify patients' strength of preferences for several key attributes of usual-hours emergency primary care. The attributes were chosen to reflect the findings of previous research, current policy initiatives and discussions with local key stakeholders. A self-complete questionnaire was administered to NHS Direct callers and adult attenders at Accident and Emergency, GP services and the NHS Walk-in Centre in the locality. Regression analysis was used to estimate the relative importance to patients of the different attributes. An overall response of 71% (n=432) was achieved. All but one of the attributes was a statistically significant predictor of preference. The attribute 'being kept informed about waiting time' was the most important. This was followed by 'quality of the consultation', 'having a consultation with a nurse', 'having a consultation with a doctor' and 'contacting the service in person'. Respondents were prepared to wait an extra 68 min to have a consultation with a doctor, but an extra 2 h 9 min for information about expected waiting time. There were no measurable preference differences between patients surveyed at different NHS entry points. Respondents younger than 45 years held strong preferences with respect to how they wanted to make contact with the system, whereas older respondents appeared not to hold strong preferences, seemingly indifferent between the alternatives. There was weak evidence which showed the younger group more strongly preferred accessing services via an integrated telephone system than making contact in person. This study showed that local solutions for reforming emergency primary care during hours when the GP surgery is open should take account of the strength of patient preferences. The discrete choice method was acceptable, and the results directly informed the development of a local service framework for such care.