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Moyez Jiwa

Publications and source records attributed to Moyez Jiwa.

At least 19 recordsLinked to original sources
PubMed2006

Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice.

BACKGROUND: Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion. However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral. METHODS: A cluster randomised factorial trial. 44 general practices in North Trent, UK. Practices were offered either an electronic interactive referral pro forma, an educational outreach visit by a local colorectal surgeon, both or neither. The main outcome measure was the proportion of cases with severe diverticular disease, cancer or precancerous lesions and inflammatory bowel disease in those referred by each group. A secondary outcome was a referral letter quality score. Semi-structured interviews were conducted to identify key themes relating to the use of the software RESULTS: From 150 invitations, 44 practices were recruited with a total list size of 265,707. There were 716 consecutive referrals recorded over a six-month period, for which a diagnosis was available for 514. In the combined software arms 14% (37/261) had significant pathology, compared with 19% (49/253) in the non-software arms, relative risk 0.73 (95% CI: 0.46 to 1.15). In the combined educational outreach arms 15% (38/258) had significant pathology compared with 19% (48/256) in the non-educational arms, relative risk 0.79 (95% CI: 0.50 to 1.24). Pro forma practices documented better assessment of patients at referral. CONCLUSION: There was a lack of evidence that either intervention increased the proportion of patients with organic pathology among those referred. The interactive software did improve the amount of information relayed in referral letters although we were unable to confirm if this made a significant difference to patients or their health care providers. The potential value of either intervention may have been diminished by their limited uptake within the context of a cluster randomised clinical trial. A number of lessons were learned in this trial of novel innovations.

Colonic Diseases↗
PubMed2006

Breast cancer follow-up: could primary care be the right venue?

AIMS: To identify the elements of a follow-up protocol for treated breast cancer patients in primary care with reference to key stakeholders in one region of the UK. METHODS: Stage 1: a survey of 100 consecutive hospital records relating to patients treated for primary breast cancer. The most common problems managed at follow-up and the type and frequency of resources used were identified. Stage 2: focus groups with stakeholders identifying potential barriers to follow-up of breast cancer patients in primary care after successful therapy. Stage 3: a nominal group outlined the elements of a follow-up protocol in primary care. RESULTS: The most frequently recorded problems in 702 patient years of follow-up were anxiety, unrelated medical problems and joint pain. Anxiety and depression tend to present relatively soon and are often enduring whereas concomitant medical problems also present later. Health care professionals considered patients difficult to manage because symptoms of recurrence require investigation for absolute reassurance of the symptomatic patient. However, investigations other than mammograms were seldom necessary. CONCLUSIONS: A multidisciplinary panel identified attention to the psychosocial sequelea of breast cancer as a vital aspect of follow-up. Patients and their partners are preoccupied with a fear of recurrence. This may manifest in a variety of guises including mental health problems. These can be addressed in primary care especially with the support of counsellors, with teamwork and agreed protocols for referral back to specialists when indicated.

Breast Neoplasms↗
PubMed2006

Refugee health.

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Australia↗
PubMed2006

GI malignancies.

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Diagnostic Errors↗
PubMed2005

Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities.

BACKGROUND: Colorectal cancer can present in a variety of ways, and with any of several symptoms. Different referral routes from primary to secondary care cater for these different presentations. The route that has received most investment in the UK National Health Service is the 2-week clinic, but the proportions of patients taking this and other routes to diagnosis are largely unknown. METHODS: We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified. RESULTS: Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short. CONCLUSION: Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources-the 2-week clinic-is used by a minority of patients.

Adult↗
PubMed2005

Meeting the educational needs of people at risk of diabetes-related amputation: a vignette study with patients and professionals.

OBJECTIVE: To investigate how patients and professionals view the role of advice in diabetes foot care, in order to inform educational practice. DESIGN: A qualitative study based upon one-to-one interviews using a vignette technique with patients and professionals. SETTING AND PARTICIPANTS: Interviews with 15 patients with diabetes-related foot complications attending diabetes foot clinics, and 15 health professionals across two hospital sites and two primary care trusts. RESULTS: There were similarities between issues raised by patients and professionals, with differences in emphasis. An important factor was patient understanding and acceptance of the implications of diabetes from diagnosis. Many patients reported a lack of early understanding that may reflect inadequate provision or acceptance of advice. Development of positive relationships with health professionals was important for patients and encouraged shared understanding. Use of the vignette technique highlighted the gap between patient knowledge and action, with patients and professionals emphasizing their own responsibilities in relation to reduction of risk through education and action. Responses suggest that early positive interactions with appropriately trained professionals are needed to help patients assimilate advice into everyday routines. CONCLUSIONS: For effective preventive care, patients need to understand how diabetes impacts on their health. Foot care education should begin early, be patient-centred and delivered with empathy by professionals whom the patients trust. The findings reflect patient and professional expectations in educational practice, and therefore have relevance for other chronic conditions for which much education and advice is related to self-care.

Adult↗
PubMed2005

Do older patients feel able to cope with illness following telephone consultations? A multi-practice survey in the UK.

BACKGROUND: Worldwide, patients are offered a telephone consultation as a first point of access to a health care professional. Whilst older patients form a significant proportion of callers, this group has expressed reservation about consultations that preclude a physical examination. OBJECTIVE: This study compares how two groups of patients (< 70 years, > or = 70 years) perceive their ability to cope with illness following a telephone consultation. METHODS: Nine hundred and fifty-six patients from deprived inner city areas receiving telephone consultations with a General Practitioner (GP)/Family doctor or nurse at five practices in South Yorkshire, UK were surveyed within 24 h of the consultation. A 49% response rate was achieved; the mean age of respondents in the respective groups was 78.5 years and 48 years. The questionnaire included the Patient Enablement Instrument (PEI), a self-reported measure of patients' ability to cope with illness measure of patients' ability to cope with illness and supplementary questions on access to GPs in the practice. RESULTS: There was a low response rate from younger patients and males in particular. Ethnic minority groups were hardly represented among the respondents. How ever, scores on the PEI following telephone consultations were no different between older and younger respondents (Mann-Whitney U test, p = 0.56). Regression analysis with PEI scores as the dependent variable and fitting age and differences in responses to the questionnaire as explanatory variables yielded an R(2) of 0.02 suggesting that 'age' per se was a poor predictor of 'enablement'. CONCLUSIONS: These data support an inclusive policy in the provision of telephone access to health care professionals in primary care. We conclude that older patients are not disadvantaged by consulting a primary care professional by telephone.

Adaptation, Psychological↗
PubMed2004

Less haste more speed: factors that prolong the interval from presentation to diagnosis in some cancers.

BACKGROUND: In the UK, the GP is the gatekeeper to specialist services in addition to many other roles. Recently, the GP is also expected to select cases that warrant 'urgent' as opposed to 'routine' specialist investigation. Failure to refer on the appropriate timetable may have implications for timely diagnosis. OBJECTIVE: Our aim was to explore the circumstances in which the diagnosis of cancer is delayed with reference to the primary care records and by a structured investigation of clinical records in one practice. METHODS: The study was set in an urban group practice serving a mixed population of deprived and affluent communities. List size was 10 440 patients, with five whole time equivalent partners and three practice nurses. The appointment system was fully computerized and there were no personal lists. Records for all cases with specified common cancers diagnosed since 1990 and still registered in the practice were reviewed. The interval from presentation to referral, referral to diagnosis and presentation to diagnosis was compared for a series of factors including 'urgent' referral. The clinical team currently working in the practice conducted a structured review of the case records for the most delayed cases. RESULTS: Fifty-four cases were listed in the practice. A series of factors were identified as having a bearing on delayed diagnosis, including a reticence on the part of patients to seek to expedite specialist appointments, failures of communication, and patients presenting multiple problems in short general practice consultations. The action plan agreed by the clinical team includes improving the quality of communication with secondary care, follow-up of patients who have been referred for radiological or ultrasound investigation and reviewing patients who fail to attend specialist clinics. CONCLUSIONS: The data imply that delays sometimes result from avoidable errors before and after referral and especially by the patient entering secondary care on the wrong pathway. Improving the patients' experience in health care requires the provider to take a global view of the service. Primary care is not merely a filter but influences and is influenced by policies in other parts of the health care system.

Family Practice↗
PubMed2004

Surveying general practitioners: a new avenue.

BACKGROUND: The validity of opinions expressed in questionnaire surveys diminishes with lower response rates. Recent research suggests that general practitioners (GPs) are more likely to respond to questionnaire surveys if they are motivated to do so because the subject of the survey is perceived as relevant to the practitioner at the time of the survey, and there is an opportunity to respond without encroaching on existing obligations or interests. AIM: To compare the results of a questionnaire survey administered by two routes: a postal survey with reminders and after an educational meeting with no reminders. METHODS: A validated questionnaire with 19 questions using a Likert scale seeking views about the ideal contents of a referral letter to colorectal surgeons was administered to GPs attending a monthly educational meeting in one locality in the UK and by post to a different group in a second locality. The response rate and demographic characteristics of the GPs were compared for respondents, non-respondents, attenders and non-attenders to the educational meeting. The mean responses to the questions on the Likert scale were used to produce a schedule to score the contents of referral letters. The schedules produced by the two methods (postal/educational meeting) were used to score 551 referral letters at one district general hospital. Mean scores calculated using the two schedules derived by the postal and educational routes were compared. Cases diagnosed with 'significant organic pathology' as defined in a previous study were identified. The predictive value of the scores in identifying these cases was compared. RESULTS: 88% (138/157) of GPs in the locality attended the educational meeting and were invited to participate in the survey. Non-attenders were more likely to be assistants, locums or part-time practitioners. Overall 71% (98) of the GPs responded to the survey. There were no significant demographic differences between the respondents and non-respondents to the survey. Response rates to the survey conducted by the two routes were similar. Referral letter 'quality' scores derived via the two alternative routes were equally valuable in predicting which patients had significant organic pathology. CONCLUSIONS: Responses to questionnaire surveys are equally valid when administered via an educational meeting or by post. The value of the educational meeting approach was the relative ease of administering the questionnaire and the rapid turn around of replies. However this method may exclude the views of part-time practitioners who were more likely to fail to attend. These practitioners may need to be targeted by alternative routes in questionnaire surveys.

Attitude of Health Personnel↗
PubMed2004

Satisfying the patient in primary care: a postal survey following a recent consultation.

BACKGROUND: Factors over and above the skills of the health care professional appear to impact on how well patients can cope with an illness following a consultation in general practice. These other factors appear to relate to the organisation and fabric of the doctor's practice. This study reports a systematic analysis of responses to a questionnaire survey of patients following a telephone consultation in a general practice setting. This study aims to explore how views on specific aspects of a general practice service contrast among patients. METHODS: A structured anonymised postal questionnaire was sent to 916 patients within 24 h of a telephone consultation with a doctor or nurse in five general practices in North Trent, UK. No reminders were sent. Included on the questionnaire were free-text questions that invited opinions on areas for improvement for the patients' registered practice. These were analysed qualitatively using content analysis by two independent researchers. RESULTS: The overall response rate was 52% although responses from young men were under-represented in the survey. One in three responders expressed a need for improvements in the appointments, more access and less delay before practice. Five themes and a number of sub-themes were identified. Patients wanted more appointments. Other themes included a desire for better communication, more patient friendly policies and facilities. Analysis suggests that it would be very difficult to satisfy the contrasting and divergent needs of all patients. CONCLUSIONS: Communication with patients in general practice is influenced by the fabric, policies and reception staff in the practice as much as by the skills and resources of the care provider. Seeking patients' opinions about the practice within the context of a recent telephone consultation unearthed conflicting desires that cannot be satisfied given existing resources in the National Health Service (NHS). Patients favour a speedy, convenient and above all, tailored service. This may be impossible to deliver universally. Attention to the non-doctor aspects of the service may enhance the ability of practitioners to enable patients to cope with illness. The data suggest that patients are not universally satisfied with the service provided and that it would be naive to attempt to please them all.

Female↗
PubMed2004

Referral letters to colorectal surgeons: the impact of peer-mediated feedback.

BACKGROUND: General practitioners (GPs) select few patients for specialist investigation. Having selected a patient, the GP writes a referral letter which serves primarily to convey concerns about the patient and offer background information. Referral letters to specialists sometimes provide an inadequate amount of information. The content of referral letters to colorectal surgeons can now be scored based on the views of GPs about the ideal content of referral letters. AIM: To determine if written feedback about the contents of GP referral letters mediated by local peers was acceptable to GPs and how this feedback influenced the content and variety of their referrals. DESIGN: A non-randomised control trial. SETTING: GPs in North Nottinghamshire. METHOD: In a controlled trial, 26 GPs were offered written feedback about the documented contents of their colorectal referral letters over 1 year. The feedback was designed and mediated by two nominated local GPs. The contents of referral letters were measured in the year before and 6 months after feedback. GPs were asked about the style of the feedback. The contents of referral letters and the proportion of patients with organic pathology were compared for the feedback GPs and other local GPs who could be identified as having used the same hospital for their referrals in the period before and after feedback. RESULTS: All GPs declared the method of feedback to be acceptable but raised concerns about their own performance, and some were upset by the experience. None withdrew from the project. There was a difference of 7.1 points (95% confidence interval = 1.9 to 12.2) in the content scores between the feedback group and the controls after adjusting for baseline differences between the groups. Of the GPs who referred to the same hospital before and after feedback, the feedback GPs referred more patients with organic pathology than other local colleagues. CONCLUSIONS: GPs welcome feedback about the details appearing on their referral letters, although peer comparisons may not always lead to changes in practice. However, in some cases feedback improves the content of GP referral letters and may also impact on the type of patients referred for investigation by specialists.

Attitude of Health Personnel↗
PubMed2004

Referral of suspected colorectal cancer: have guidelines made a difference?

In the United Kingdom, patients with colorectal symptoms referred on the fast-track pathway into secondary care are offered investigation of their symptoms within 2 weeks. Audits demonstrate that a minority of patients with colorectal cancer are referred under this arrangement. We assessed referral letters to hospitals in one district in the period before and after the introduction of the 2-week wait initiative. The guidelines appear to have made little difference to the proportion of cases selected for referral on the urgent pathway. However, cancers in the earliest stages present with fewer clinical features than advanced disease and a combination of signs and symptoms are more likely to arouse suspicion in the referring agent.

Aged↗
PubMed2004

Advanced access.

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Aged↗