Designing trials of interventions to change professional practice in primary care: lessons from an exploratory study of two change strategies.
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Clinical Trials as Topic↗
Biomedical subjects
I Nazareth
Publications and source records attributed to I Nazareth.
Psychiatric dysfunction and dizziness.
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Dizziness↗
Beta-blockers in heart failure.
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Adrenergic beta-Antagonists↗
A randomized trial of Evidence-based OutReach (EBOR): rationale and design.
There is increasing interest in evaluating the methods used to implement the findings from medical research. This paper describes the Evidence-based OutReach (EBOR) trial, which is the first large randomized study in the United Kingdom that will evaluate the effectiveness and efficiency of educational outreach visits by trained pharmacists who are delivering messages derived from four evidence-based clinical practice guidelines. General practices form the unit of allocation and analysis. The study design addresses important factors that may influence the effectiveness of the intervention, such as the pharmacist who delivers the messages, the health authority in which practices are located, and the size of a practice.
Family Practice↗
Medical education in the community--the UNITRA experience.
The creation of the independent black state of Transkei, under the apartheid regime, resulted in inadequate allocation of resources to the region. These inequalities were translated into health care. Despite these limitations, over the last five years an innovative community-based educational programme involving medical students, nurses and health educators is evolving at the relatively new medical school in this region. This programme, however, has not been free of difficulties. There is an urgent need to address these issues using a combination of administrative, educational and research approaches. This would provide a strong basis for the further development of this educational programme that could serve as a unique South African example of medical education in the community.
Black or African American↗
Outcome of symptoms of dizziness in a general practice community sample.
BACKGROUND: Dizziness is commonly experienced in the community, but little is known about the long-term progression of the condition. OBJECTIVE: We aimed to assess over 18 months the outcome of symptoms of dizziness in a sample of patients identified from London general practices. METHOD: We followed up at 18 months a cohort of patients who reported symptoms of dizziness with or without anxiety, panic reactions or avoidance of situations that provoked the symptoms. The subjects completed a structured questionnaire both at baseline and at 18 months. RESULTS: At 18 months, 24% (95% CI = 23.5-34.8%) were more handicapped and 20% (95% CI = 15.2-25.2%) had recurrent dizziness, while 20% (95% CI = 14.9-24.8%) had improved. Patients with significant dizziness were more likely to consult their GP (OR = 14.4, 95% CI = 7.0-29.1) and were more likely to receive treatment (OR = 7.8, 95% CI = 3.2-22.4) or be referred to hospital (OR = 8.4, 95% CI = 3.2-22.4). The independent predictors of handicapping dizziness at 18 months were a history of fainting (OR = 2.4, 95% CI = 1.2-4.7), vertigo (OR = 2.6, 95% CI = 1.3-5.0) and avoidance of a situation that provoke dizziness (OR = 4.8, 95% CI = 2.5-9.0). CONCLUSION: Four per cent of all patients registered with a GP suffer persistent symptoms of dizziness and at least 3% are severely incapacitated by their symptoms. The presence of vertigo, fainting and avoidance in a person with dizziness is predictive of chronic handicapping dizziness. Further research is required on the progressions of symptoms of dizziness in a sample of GP attenders and those in the community.
Adolescent↗
Evaluation of general practice computer templates. Lessons from a pilot randomised controlled trial.
We conducted a pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London. Uptake of the guidelines by general practitioners and practice nurses was assessed using qualitative (semi-structured interviews designed to assess the users' views) and quantitative (change in use of the template during the study period) outcome measures. The practice nurses used the templates frequently but general practitioners rarely used them. Several reasons were offered for non-use of the templates, such as the length of the template and non-involvement in the care of asthma or diabetes. Despite this, however, health professionals were favourably disposed to the use of templates for general clinical care. Pilot investigations of computerised templates are best achieved by observational or quasi-experimental methods rather than a randomised controlled trial. The use of both qualitative and quantitative methods in this study allowed exploration of the barriers to use of computers.
Asthma↗
Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community.
Since the majority of people with dizziness in the community are never referred for specialist testing and treatment, the purpose of this study was to investigate whether it was desirable and feasible to provide vestibular rehabilitation for this patient population. Demand for therapy was assessed by a survey of 9198 working age people randomly sampled from six general practices. One in 10 respondents reported current, handicapping dizziness, but fewer than 2% of those with dizziness severe enough to merit treatment proved suitable and willing to attend hospital for testing and rehabilitation. Nevertheless, vestibular rehabilitation was clearly beneficial for the 16 patients who completed the therapy programme, as their scores on measures of symptoms, disability, handicap and postural stability improved significantly post-therapy to near-normal levels. We conclude that there is a need for provision of vestibular rehabilitation in primary care for patients with dizziness in the community.
Adolescent↗
Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation.
OBJECTIVES: To determine neurootological and psychiatric abnormalities associated with complaints of dizziness in an epidemiological community sample of people of working age, and the extent of comorbidity between neuro-otological and psychiatric dysfunction. METHOD: A survey of 3884 people randomly selected from six general practice lists identified 262 people with significant dizziness, from which a subsample of 15 men and 22 women were recruited for testing. Dizzy subjects were evaluated by blind neuro-otological testing, computerised dynamic posturography, a computerised psychiatric assessment, neuro-otological and general medical examination, and diagnosis. An age matched control group of 18 men and 22 women underwent the same evaluation. RESULTS: Tests of auditory, vestibular, and oculo-motor function did not discriminate between dizzy subjects and controls, but dizzy subjects had significantly worse balance on posturographic testing, more diagnoses of medical disorder, and a higher prevalence of psychiatric morbidity. CONCLUSIONS: The findings suggest that dizziness in the community is typically characterised by mild physical disorder accompanied by some psychiatric disturbance. As the combination of minor physical and psychiatric disorder is known to be unusually persistent and handicapping, treatment programmes must be provided for this prevalent syndrome, perhaps by a partnership between primary care and neuro-otological and psychiatric hospital outpatient clinics with experience and expertise in the diagnosis and management of dizziness and psychiatric disturbance.
Adolescent↗
Prevalence and presentation of dizziness in a general practice community sample of working age people.
BACKGROUND: Dizziness is known to be a common, handicapping condition in the elderly, and a strong association between dizziness and anxiety disorders has been observed in hospital samples. However, little is known about the prevalence of dizziness among people of working age in the community and its implications for psychosocial functioning and general practice consultation and treatment. AIM: To determine the prevalence of dizziness, giddiness, vertigo, and unsteadiness, and associations with disability and handicap, symptoms of panic and agoraphobia, and general practice consultation and treatment. METHOD: Postal questionnaires were completed by 2064 people aged 18-64 years randomly sampled from the patient lists of four London practices. Validated survey items were used to assess symptoms, panic and agoraphobia, levels of occupational disability and handicap, and general practice consultation and treatment. RESULTS: More than one in five responders (n = 480) had experienced dizziness during the past month; nearly half of these (n = 225) reported some degree of handicap and 30% had been dizzy for more than five years. Almost half (n = 221) of those with dizziness also reported anxiety and/or avoidance behaviour. Multiple physical and psychological symptoms were associated with higher levels of handicap. Only one in four of the 225 dizzy responders reporting some degree of handicap had received any form of treatment. CONCLUSION: Dizziness is a common, chronic, and often untreated symptom in people aged 18-65 years, associated with extensive handicap and psychological morbidity.
Adult↗
A controlled evaluation of small-group education of general practitioners in the management of drug users.
We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.
Education, Medical, Continuing↗
A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires.
BACKGROUND: A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study. METHODS: Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated. RESULTS: Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone. CONCLUSION: Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires.
Adult↗
Monitoring psychosis in general practice: a controlled trial.
BACKGROUND: This trial evaluated the feasibility, acceptability and effectiveness of a structured approach to the management of schizophrenia in general practice. METHOD: All patients with non-affective psychosis (mainly schizophrenia) in four inner-city general practices were recruited. A check-list and a set of outcome measures were used by the general practitioner and the practice nurses. Information on attendances at the general practice and psychiatric out-patient departments was also collected. RESULTS: Two practices took part in the intervention and two served as control practices. Sixty-seven patients with non-affective psychosis were identified. Thirty-three (81%) of the 41 patients in the two intervention practices attended the initial assessment by the doctor and nurse, but only 13 (32%) attended the first review assessment. The attendance for the second review, after six months, was six out of 15 (40%) in one practice, but rose to 16 out of 18 (89%) in the other practice. Significant improvements were recorded in the intervention group on the Global Assessment Scale (GAS) and the Behaviour, Speech and Other Syndromes (BSO) subscore of the Present State Examination (PSE). The absolute risk reduction and relative risk reduction as a result of the intervention, as measured by the GAS scores, was 29% (95% CI 4% to 54%) and 36% (95% CI 5% to 66%), respectively, and in the case of the BSO subscores of the PSE, this was 23% (95% CI-1.8% to 47.2%) and 28% (95% CI-2.2% to 57%), respectively. For one patient to show an improvement in GAS and BSO scores 3.5 patients (95% CI 1.85 to 25) and 4.3 patients (95% CI-55 to 2.1), respectively, would need to receive the intervention. There was a significant increase in consultation rates for patients in the intervention practices. CONCLUSIONS: Health surveillance of patients with non-affective psychosis is possible in general practice.
Adult↗
Community care of patients with schizophrenia: the role of the primary health care team.
Schizophrenia is a severe, chronic mental disorder that usually begins in early adulthood. Recurrent relapse leading to long-term psychological and social disability means that patients may require intensive community support. Despite a recent fall in the overall numbers of patients consulting their general practitioner with mental disorders, presentations by those suffering from severe mental disorders have risen. This review encompasses the role of general practitioner in the management of schizophrenia, considering in turn drug and psychological therapies, family interventions, innovations in care, the effects of community care developments, and the liasion between primary health care and mental health professionals. There is a need for further research in the area of family-practice-based interventions involving general practitioners and the practice team.
Community Mental Health Services↗
Characteristics of drug misusers and their perceptions of general practitioner care.
BACKGROUND: Little is known about drug misusers' views of the care they receive from general practitioners. AIM: This study set out to determine drug users' views about primary health care and their relationship with their general practitioners. METHOD: A semi-structured interview was conducted with 180 drug users who were consecutive attenders at five treatment services in north east London--a general practice with a special interest in treating drug users, a private drug clinic, a community drug team, a drug dependence unit and a street agency for drug users. RESULTS: The majority of the 145 London-based drug users attending the four treatment centres other than the general practice with a special interest were registered with a general practitioner (88%). Forty-two per cent of users sought out a general practitioner prepared to treat them, rather than register with a local or the family doctor. Most drug users reported that their general practitioners were aware of their drug problems (88%) but half of the general practitioners were not prescribing replacement drugs with almost 20% of the users not receiving prescriptions claiming that this was due to lack of knowledge or trust on the part of the doctor. Sixty per cent of the drug users attending the four centres perceived that their general practitioners held negative or neutral views about them. However, 34 of the 35 drug users interviewed in the specialist general practice believed their doctors had a positive view of drug users. CONCLUSION: Most drug users were registered with general practitioners but the relationship between doctor and patient was not always easy or productive. There is a need to clarify the role of general practitioners in this field and provide them with better educational opportunities.
Adolescent↗
Drug users' views on general practitioners.
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Adult↗
Withdrawal of triazolam's product licence: effect on patients 18 months later.
The product licences for triazolam in Britain were suspended in October 1991. We aimed to determine whether the sudden withdrawal of a benzodiazepine from the market constitutes a major impetus for patients to reduce or stop their benzodiazepine consumption. Patients in 10 London general practices who were prescribed triazolam in the 12 months prior to the withdrawal of its licence were interviewed. Data from written and computerized general practice records were also studied. One hundred and forty-seven patients were identified, of whom 107 (73%) were interviewed; 38 were chronic users; 68 patients had a history of serious physical illness while 33 had a history of psychiatric problems; 45% of chronic and 66% of intermittent triazolam users had stopped receiving prescriptions for benzodiazepines from 6 months after the withdrawal of triazolam's licence up to 18 months later. Only 12 (11%) recalled suffering significant withdrawal effects. We conclude that official action to curb prescribing of a benzodiazepine acts as an important stimulus for patients to reduce or stop their use of all psychotropic medication without increasing psychological morbidity or leading to unacceptable side effects.
Adult↗
Care of schizophrenia in general practice: the general practitioner and the patient.
BACKGROUND: The transfer of patients with chronic schizophrenia from large mental hospitals into the community has had an impact on the role of the general practitioner in the effective delivery of primary care services to these patients. AIM: A study was undertaken to assess the care available in general practice for patients with schizophrenia, the attitudes of general practitioners and patients to the care provided and the factors influencing patients' use of services. METHOD: Eighty three patients with a diagnosis of schizophrenia and 26 doctors in 13 London practices registered on the VAMP research bank took part in a series of structured and semi-structured interviews. This was followed by a systematic examination of the patients' case notes. RESULTS: Only 14 patients (17%) had no active symptoms according to the present state examination interview and 52 (63%) were currently taking antipsychotic medication. Fifty three patients were in contact with a psychiatrist. Approximately one quarter of patients were visited by a community psychiatric nurse; in 18 of these 19 cases, the main reason for contact was reported to be for administration of medication by depot injection. In all but one case, patients seeing a community psychiatric nurse were also being seen by a psychiatrist. Sixteen doctors reported having had a consultation in the previous month with a patient's relative, friend or member of hostel staff. There were considerable differences between patients and their doctors in their attitudes to the use of services. Of the 26 general practitioners, 23 were enthusiastic about the possibility of introducing shared care records. Of the 54 patients in contact with a mental health professional, only 18 favoured the use of shared care records. Most of the doctors (19, 73%) reported they would welcome a psychiatric liaison service in their practice; 40% of 53 patients said they would not. Patients receiving antipsychotic drugs and patients registered with inner city practices attended their general practitioners more frequently than those not taking antipsychotic medication and those registered with suburban practices. Use of antipsychotic medication (adjusted odds ratio (OR) 8.2, 95% confidence interval (CI) 2.2 to 30.7, P < 0.01), male sex (OR 5.8, 95% CI 1.5 to 22.1, P < 0.01) and active symptoms on the present state examination (OR 4.1, 95% CI 1.0 to 17.5, P = 0.06) were all predictive of current contact with mental health professionals. CONCLUSION: Family doctors were closely involved with the care of patients with schizophrenia and their relatives and were eager for increased liaison with secondary care services. Although patients were more resistant than doctors to management innovations this may reflect lack of familiarity with changes in community services. Greater input is needed by mental health professionals, particularly community psychiatric nurses, and some consideration of the burden of care in inner city practices is necessary in health service planning.
Adult↗