Biomedical subjects
N Stott
Publications and source records attributed to N Stott.
Communicating risk reductions. Researchers should present results with both relative and absolute risks.
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Efficient literature searching in diffuse topics: lessons from a systematic review of research on communicating risk to patients in primary care.
Using the example of communication about risk in a primary care setting, this paper puts forward a method of developing and evaluating a detailed search strategy for locating the literature for a systematic review of a 'diffuse' subject. The aim of this paper is to show how to develop a search strategy that maximizes both recall and precision while keeping search outputs manageable. Six different databases were used, namely Medline, Embase, PsychLIT, CancerLIT, Cinahl and Social Science Citation Index (SSCI). The searches were augmented by hand-searching, contacting authors, citation searching and reference lists from included papers. Other databases were searched but yielded no extra references for this subject matter. Of the 99 papers included, 80 were indexed on Medline. The Medline search strategy identified 54 of them and the remaining 26 were located on other databases. The 19 further unique references were found using the other databases and methods of retrieval. A combination of several databases must be used to maximize recall and to increase the precision of searches on individual databases, thus improving the overall efficiency of the search.
In-house referral: a primary care alternative to immediate secondary care referral?
BACKGROUND: Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit. In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral. OBJECTIVE: To describe whether in-house referral is practical and acceptable to patients, and the health outcomes for patients. METHODS: Practices were randomized into an intervention or a control group. In intervention practices, patients with certain conditions who were about to be referred to secondary care were referred in-house. If the second clinician agreed referral was appropriate the patient was referred on to secondary care. In control practices patients were referred in the usual fashion. Patient satisfaction and health status was measured at the time of referral, 6 months and one year. RESULTS: Eight intervention and seven control practices took part. For the 177 patients referred in-house, 109 (61%) were judged to need referral on to secondary care. For patient satisfaction, the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital. For health status, the only difference found was that at the time of referral, patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the 'Physical function' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral. CONCLUSION: In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care.
Attitudes to the use of health outcome questionnaires.
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The patient-centredness of consultations and outcome in primary care.
BACKGROUND: There is general support for general practitioners (GPs) using patient-centred styles. However, there is limited British evidence of beneficial outcomes for patients from such styles. AIM: To explore whether, for patients presenting for new episodes of care, the GP's consulting style, specifically the patient-centredness of the consultation, is related to five generic outcomes. METHOD: General practitioners in South Wales were recruited, and one surgery consulting session was audiotape recorded for each participating clinician. Questionnaires were given to consenting patients before their consultations, immediately afterwards, and, by post, at two weeks to measure the following outcomes: doctor-patient agreement (on the nature of the problem and management), patient satisfaction, resolution of symptoms, resolution of concerns, and functional health status. From the patients consulting for a new episode of care and completing all three questionnaires, one patient was selected at random for each GP and the audiotape of their consultation rated for patient-centredness. Statistical analysis employed correlation coefficients and t-tests, followed by multiple regression and logistic regression to control for potential confounders. RESULTS: In total, 143 patients consulting 143 GPs were studied. The patient-centred score was positively and statistically significantly associated with patient satisfaction (Pearson correlation = 0.28; P = 0.002). No other associations were found with the other outcomes measured. CONCLUSION: The study presents evidence that patient-centred styles of consulting produce benefits in terms of increased patient satisfaction for patients consulting for new episodes of care in Britain.
Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats.
OBJECTIVES: To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help. DESIGN: Qualitative study with semi-structured interviews. SETTING: General practices in South Wales. SUBJECTS: 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection. MAIN OUTCOME MEASURES: Subjects' experience of management of the illness, patients' expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing. RESULTS: Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing "against the evidence" uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief. CONCLUSIONS: This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors' prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.
Reducing antibiotics for respiratory tract symptoms in primary care: consolidating 'why' and considering 'how'.
We summarize recently published evidence showing that antibiotic treatment offers little or no benefit to most patients presenting with sore throats, acute otitis media, maxillary sinusitis, and acute bronchitis. Despite this research, the prescription of antibiotics for respiratory tract conditions is rising in Britain. This wastes money, encourages people to consult for self-limiting conditions, and causes bacteria to become resistant to antimicrobials. Ways of changing present practice are underresearched. Enhanced consulting skills, guidelines and monitoring strategies, patient education, and anti-inflammatory drugs for recurrent and chronic sufferers all hold promise.
Helping smokers make decisions: the enhancement of brief intervention for general medical practice.
Primary care clinicians are often encouraged by government agencies to intervene systematically with all smokers. Pressure of time and pessimism about their own efficacy and patients' capacity to change are some of the reasons why clinicians do not feel it is appropriate to always advise every patient about unhealthy behaviours. Developments in patient centred approaches to the consultation and progress in the addictions field suggest that new consulting methods could be constructed which are more satisfying than giving brief advice to change. The aim of this study was to develop a structured, teachable and acceptable intervention for clinicians to help patients consider their smoking during general medical consultations. Patient centred strategies derived from the stages of change model and motivational interviewing and its adaptations were explored in experimental consultations with 20 volunteer smokers. Feedback from them and from general practice registrars trained in the use of the method informed its development. Acceptability to clinicians was assessed by semi structured telephone interviews with 24 general practice registrars who participated in a randomised controlled trial assessing the effectiveness of the method. Anonymous, written questionnaires were also completed by 20 of the registrars who recruited ten or more patients into the trial. The method is described. Key components are: establishing rapport, assessing motivation and confidence, and then depending on the response, asking standard scaling questions, asking about pros and cons of smoking, non-judgmental information sharing, brainstorming solutions and negotiating attainable goals and follow-up. The clinicians used the method with a total of 270 smokers, taking an average of 9.69 min with each patient. Evaluation reveals that it is acceptable to the group of general practice registrars. Longer consultation time was seen as the main drawback. We conclude that acceptable methods for opportunistic health promotion can be developed by taking into account patient centred approaches to the consultation, developments from the addictions field and the practical problems faced by clinicians. The process can be further enhanced by considering feedback from those who are likely to receive and use the interventions.
Measuring general practice-based primary care: generic outcomes. Welsh Primary Care Outcomes Group.
Increasing attention is being paid to the measurement of outcomes in primary care. However, many of the methods proposed are measures based on readily collectable data or standardized population measures of health status. These may interest population scientists but are unlikely to satisfy most primary-care clinicians. The reason for this dissonance is that the population measures do not reflect the complex and personal nature of primary care. Quality measures are needed that have validity to clinicians and patients. An alternative classification is proposed which is based more formally on the functions of primary care. This would appear to provide a framework which is more likely to be valued by those who provide primary care. The need for further research and testing of some outcome measures is identified.
Communicating risk. Use of standard terms is unlikely to result in standard communication.
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The practitioner, the patient and resistance to change: recent ideas on compliance.
Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients' lives. This article focuses on how clinicians' consulting methods can affect patients' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients' intrinsic motivation to make their own decisions. This approach also promotes clinicians' acceptance of patients' decisions, even if these decisions run counter to current medical wisdom.
A comparison of methods for measuring patient satisfaction with consultations in primary care.
BACKGROUND: Attention needs to be paid to comparing and standardizing methods for measuring patient satisfaction with consultations in primary care. OBJECTIVES: To compare the Medical Interview Satisfaction Scale (MISS) and the Consultation Satisfaction Questionnaire (CSQ) in terms of acceptability, distribution of responses, reliability and gather evidence of validity. In addition, to compare the scores of patients completing the questionnaires immediately after the consultation in the general practitioners' surgeries with those completing the questionnaires later at home. METHODS: The two questionnaires were bound as a single instrument with order determined at random. This was given to patients immediately after their consultations in eight practices in South Glamorgan. RESULTS: One hundred and ninety-eight of 316 (63%) patients completed and returned questionnaires. The distributions of patient satisfaction scores for the two questionnaires were very similar. For the MISS: mean 76.6% (SD 11.4); for the CSQ mean 7.2% (SD 12.6). Correlations between sub-scales ranged from 0.58-0.84 for the MISS and from 0.40-0.79 for the CSQ. The correlation between the overall scales was 0.82. Levels of reliability for the scales and sub-scales were fair to good ranging from 0.78-0.96 for the MISS and from 0.73-0.94 for the CSQ. CONCLUSIONS: The study does not identify one scale as being superior in psychometric terms, however by demonstrating consistency of responses it provides support for the scales as measures of patient satisfaction for use in primary care. The level of inter-correlation suggests that the sub-scales may not be clearly independent of each other and suggests that total scores may be preferred. Lower levels of satisfaction are expressed if patients complete questionnaires at home rather than in general practitioners' surgeries.
The incidence and causes of rectal bleeding.
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Glycated haemoglobin and metabolic control of diabetes mellitus: external versus locally established clinical targets for primary care.
OBJECTIVES: To examine current targets for glycated haemoglobin as a marker for metabolic control in diabetes mellitus in relation to datasets from several areas, and to consider whether target setting could be improved. DESIGN: Data collected from enhanced care records of general practices for a representative community based sample of people with diabetes. SETTING AND SUBJECTS: 3022 people with diabetes on the lists of 37 general practices (total list size 222,550) in South Glamorgan in 1992; samples of glycated haemoglobin had been processed at two laboratories with different methodologies and reference ranges. MAIN OUTCOME MEASURES: Last glycated haemoglobin level measured in subjects for 1992 and published data from other studies considered in relation to existing goals and standards for the metabolic control of diabetes. RESULTS: An ascertainment rate for people with diabetes of 1.36% was obtained. The rate of data capture for haemoglobin A1 was 75.7%, and the mean level for study samples was 10.5% at one laboratory and 10.0% at the other (similar values to those of comparable studies). These mean levels of haemoglobin A1 in representative populations of people with diabetes are poor or very poor according to published standards, including those of the British Diabetic Association. These findings are set in the context of the psychology of goal setting and performance in complex clinical situations. CONCLUSION: Targets for clinical care that are set in the absence of normative data and local feasibility assessments should be treated with caution. Targets are more likely to enhance health care if target setters recognise the importance of psychological aspects of goal setting and motivation.
Day surgery: the impact on general practice-based primary care.
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Screening for cardiovascular risk in general practice.
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Measuring functional health status in primary care using the COOP-WONCA charts: acceptability, range of scores, construct validity, reliability and sensitivity to change.
BACKGROUND: The COOP-WONCA charts comprise six scales designed to measure functional health status in primary care. AIM: A study was undertaken to describe the acceptability, distribution of chart scores, construct validity, test-retest reliability and sensitivity to change when these charts were used in the United Kingdom. METHOD: For acceptability, distribution of scores and construct validity, data were obtained from 100 consecutive consulting patients aged 16 years and over and 100 non-consulting age-sex matched individuals from one general practice. In order to examine reliability and sensitivity to change, both groups were followed up two weeks later. RESULTS: Regarding acceptability, four patients refused to complete the charts during the initial recruitment of the consulters; 74 out of 100 non-consulters returned the first postal questionnaire. The follow-up questionnaire was returned by 68 out of 100 consulters and 57 out of 74 non-consulters. Overall distributions of scores demonstrated reasonable variation. Regarding construct validity, differences between the consulters and non-consulters were all in the anticipated direction and reached statistical significance for three of the six charts. For reliability, the proportion of non-consulters whose scores were unchanged ranged from 56% to 73%. For those whose scores changed, the differences were small and evenly balanced. For sensitivity to change, the proportion of consulters whose scores altered ranged from 45% to 59% with mean changes all indicating improvements in health. There were larger changes for patients consulting about acute problems than for those with chronic problems. CONCLUSION: It appears that the charts were acceptable, with reasonable distributions of scores and evidence of construct validity. Moderate levels of reliability and sensitivity to change were demonstrated. This study suggests that the COOP-WONCA charts are suitable for measuring functional health status in primary care in the UK.