[RESEARCH] Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys
Objectives To compare mix of patients, scope of practice, and duration of visit in primary care physicians in Australia, New Zealand, and the United States.
Design Comparison of three comparable cross sectional surveys performed in 2001-2. Physicians completed a questionnaire on patients' demographics, diagnoses, and duration of visit.
Setting Primary care practice.
Participants 79 790 office visits in Australia, 10 064 in New Zealand, and 25 838 in the US.
Main outcome measures Diagnostic codes were mapped to the Johns Hopkins expanded diagnostic clusters. Scope of practice was defined as the number of expanded diagnostic clusters accounting for 75% of all managed problems related to morbidity. Exposure to primary care was calculated from duration of visits recorded by the physician, and reports on rates of visits to primary care for each country.
Results In each country, primary care physicians managed an average of 1.4 morbidity related problems per visit. In the US, 46 expanded diagnostic clusters accounted for 75% of problems managed compared with 52 in Australia, and 57 in New Zealand. Correlations in the frequencies of managed health problems between countries were high (0.87-0.97 for pairwise comparisons). Though primary care visits were longer in the US than in New Zealand and Australia, the per capita annual exposure to primary care physicians in the US (29.7 minutes) was about half of that in New Zealand (55.5 minutes) and about a third of that in Australia (83.4 minutes) because of higher rates of visits to primary care in these countries.
Conclusions Despite differences in the supply and financing of primary care across countries, many aspects of the clinical practice of primary care physicians are remarkably similar in Australia, New Zealand, and the US.
UK diabetes care basic, at best
Filed under: Type 1, Type 2, Daily News, Support, Care
British watchdog group The Healthcare Commission just gave diabetes care in the UK a lukewarm review. Its study of the facilities in which British diabetics receive care concludes that care levels overall are basic, at best. Most of the places (73%) surveyed in the study were rated "fair," meaning patients know what medications they are supposed to be on and when they should be taking them. They also know they should be getting annual checkups. Only five percent of facilities were rated "excellent by the Commission.The system is lacking, however, when it comes to anything beyond those most basic of services. Just like here in the US, most British people with diabetes are not receiving help with diabetes management. Studies suggest that regular consultations with a health "coach" on an individual basis could really improve patient outcomes. One reason they are helpful is because they get patients to come up with a care plan tailored for each person, making it more likely he/she will be able to stick with it.
Diabetes UK head of healthcare policy, Bridget Turner, agrees with the Commission's conclusions: "The NHS [National Health Service] has to focus more on...self-care. For people with diabetes, 95% of diabetes management is self-care."
To read more, click here or visit the Healthcare Commission's own web summary of the report.
[RESEARCH] Correlations among measures of quality in HIV care in the United States: cross sectional study
Objective To determine whether a selected set of indicators can represent a single overall quality construct.
Design Cross sectional study of data abstracted during an evaluation of an initiative to improve quality of care for people with HIV.
Setting 69 sites in 30 states.
Data sources Medical records of 9020 patients.
Main outcome measures Adjusted performance rates at site level for eight measures of quality of care specific to HIV and a site level summary performance score (the number of measures for which the site was in the top quarter of the distribution).
Results Of 28 site level correlations between measures, two were greater than 0.40, two were between 0.30 and 0.39, four were between 0.20 and 0.29, and the 20 remaining were all less than 0.20. One site was in the top quarter for seven measures, but no sites were in the top quarter for six or eight of the measures. Across the eight quality measures, sites were in the top quarter no more often than predicted by a chance (binomial) distribution.
Conclusions The quality suggested by one measured indicator cannot necessarily be generalised to unmeasured indicators, even if this might be expected for clinical or other reasons.
[RESEARCH] Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial
Objective To determine whether a combination of a selective serotonin reuptake inhibitor (SSRIs) and cognitive behaviour therapy (CBT) together with clinical care is more effective in the short term than an SSRI and clinical care alone in adolescents with moderate to severe major depression.
Design Pragmatic randomised controlled superiority trial.
Setting 6 outpatient clinics in Manchester and Cambridge.
Participants 208 adolescents, aged 11-17, with moderate to severe major or probable major depression who had not responded to a brief initial intervention. Adolescents with suicidality, depressive psychosis, or conduct disorder were included.
Interventions 103 adolescents received an SSRI and routine care; 105 received an SSRI, routine care, and CBT. The trial lasted 12 weeks, followed by a 16 week maintenance phase.
Main outcome measures Change in score on the Health of the Nation outcome scales for children and adolescents (primary outcome) from baseline with 12 weeks as the primary and 28 weeks as the follow-up end point. Secondary measures were change in scores on the mood and feelings questionnaire, the revised children's depression rating scale, the children's global assessment scale, and the clinical global impression improvement scale.
Results At 12 weeks the treatment effect for the primary outcome was –0.64 (95% confidence interval –2.54 to 1.26, P=0.50). In a longitudinal analysis, there was no difference in effectiveness of treatment for the primary (average treatment effect 0.001, –1.52 to 1.52, P=0.99) or secondary outcome measures. On average there was a decrease in suicidal thoughts and self harm. There was no evidence of a protective effect of cognitive behaviour therapy on suicidal thinking or action. By 28 weeks, 57% were much or very much improved with 20% remaining unimproved.
Conclusions For adolescents with moderate to severe major depression there is no evidence that the combination of CBT plus an SSRI in the presence of routine clinical care contributes to an improved outcome by 28 weeks compared with the provision of routine clinical care plus an SSRI alone.
Trial registration Current Controlled Trials ISRCNT 83809224.
[RESEARCH] Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial
Objective To assess the cost effectiveness of self monitoring of blood glucose alone or with additional training in incorporating the results into self care, in addition to standardised usual care for patients with non-insulin treated type 2 diabetes.
Design Incremental cost utility analysis from a healthcare perspective. Data on resource use from the randomised controlled diabetes glycaemic education and monitoring (DiGEM) trial covered 12 months before baseline and 12 months of trial follow-up. Quality of life was measured at baseline and 12 months using the EuroQol EQ-5D questionnaire.
Setting Primary care in the United Kingdom.
Participants 453 patients with non-insulin treated type 2 diabetes.
Interventions Standardised usual care (control) compared with additional self monitoring of blood glucose alone (less intensive self monitoring) or with training in self interpretation of the results (more intensive self monitoring).
Main outcome measures Quality adjusted life years and healthcare costs (sterling in 2005-6 prices).
Results The average costs of intervention were £89 (113; $179) for standardised usual care, £181 for less intensive self monitoring, and £173 for more intensive self monitoring, showing an additional cost per patient of £92 (95% confidence interval £80 to £103) in the less intensive group and £84 (£73 to £96) in the more intensive group. No other significant cost difference was detected between the groups. An initial negative impact of self monitoring on quality of life occurred, averaging –0.027 (95% confidence interval–0.069 to 0.015) for the less intensive self monitoring group and –0.075 (–0.119 to –0.031) for the more intensive group.
Conclusions Self monitoring of blood glucose with or without additional training in incorporating the results into self care was associated with higher costs and lower quality of life in patients with non-insulin treated type 2 diabetes. In light of this, and no clinically significant differences in other outcomes, self monitoring of blood glucose is unlikely to be cost effective in addition to standardised usual care.
Trial registration Current Controlled Trials ISRCTN47464659.
[RESEARCH] Effectiveness and safety of chest pain assessment to prevent emergency admissions: ESCAPE cluster randomised trial
Objective To determine whether introducing chest pain unit care reduces emergency admissions without increasing reattendances and admissions over the next 30 days.
Design Cluster randomised before and after intervention trial.
Setting 14 diverse acute hospitals in the United Kingdom.
Participants Patients attending the emergency department with acute chest pain during the year before and the year after the intervention started.
Intervention Establishment of chest pain unit care compared with continuation of routine care.
Main outcome measures Proportion of chest pain attendances resulting in admission; reattendances and admissions over the next 30 days; daily emergency medical admissions (all causes); and proportion of emergency department attendances with chest pain.
Results The introduction of chest pain unit care was associated with weak evidence of an increase in the proportion of emergency department attendances with chest pain (16% v 3.5%; P=0.08); no change in the proportion of chest pain attendances resulting in admission (odds ratio 0.998, 95% confidence interval 0.940 to 1.059; P=0.945); small increases in the proportion reattending (odds ratio 1.10, 1.00 to 1.21; P=0.036) or being admitted (1.30, 0.97 to 1.74; P=0.083) over the next 30 days; and evidence of increased daily medical admissions (1.7 per day, 95% confidence interval 0.8 to 2.5; P<0.001). However, this last finding was highly sensitive to changes in the method used to handle missing data.
Conclusion The introduction of chest pain unit care did not reduce the proportion of patients with chest pain admitted and may have been associated with increased emergency department attendances with chest pain.
Trial registration Current Controlled Trials ISRCTN55318418.
[RESEARCH] Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial
Objective To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.
Design Cost utility analysis alongside a randomised controlled trial.
Setting Nine Dutch hospitals.
Participants 283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation.
Interventions Six months of prolonged conservative care compared with early surgery.
Main outcome measures Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient’s costs, and productivity).
Results Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (–0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference 1819 (£1449; $2832), 95% confidence interval 842 to 2790), with a cost utility ratio per QALY of 41 000 (14 000 to 430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (–12, –4029 to 4006).
Conclusions Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of 40 000 or more per QALY, early surgery need not be withheld for economic reasons.
Trial registration Current Controlled Trials ISRCTN 26872154.
[RESEARCH] Population screening for coeliac disease in primary care by district nurses using a rapid antibody test: diagnostic accuracy and feasibility study
Objective To evaluate the feasibility and diagnostic accuracy of screening for coeliac disease by rapid detection of IgA antibodies to tissue transglutaminase performed in primary care.
Design District nurses screened 6 year old children using rapid antibody testing of finger prick blood. They also collected capillary blood samples for laboratory determination of IgA and IgG antibodies to endomysium and IgA antibodies to tissue transglutaminase. Children with positive rapid test results were directly sent for biopsy of the small intestine.
Setting Primary care in J?-Nagykun-Szolnok county, Hungary.
Participants 2690 children (77% of 6 year olds living in the county) and 120 nurses.
Main outcome measures Positivity for antibodies to endomysium or transglutaminase in the laboratory and coeliac disease confirmed at biopsy.
Results 37 children (1.4%, 95% confidence interval 0.9% to 1.8%) had biopsy confirmed coeliac disease. Only five of these children had been diagnosed clinically before screening. Rapid testing had a 78.1% sensitivity (70.0% to 89.3%) and 100% specificity (88.4% to 100%) for a final diagnosis of coeliac disease by biopsy. Sensitivity was 65.1% (50.2% to 77.6%) and specificity was 100% (99.8% to 100%) compared with combined results of IgA and IgG laboratory tests. Trained laboratory workers detected 30 of the 31 newly diagnosed IgA competent patients with the rapid test kit used blindly. Median time to biopsy after a positive rapid test result was significantly shorter (20 days, range 4-148) than after a positive laboratory result (142 days, 70-256; P<0.001). Children with coeliac disease detected at screening were smaller and had worse health status than their peers but they improved on a gluten-free diet.
Conclusions A simple rapid antibody test enabled primary care nurses to detect patients with coeliac disease in the community who were not picked up in clinical care. Extra training is needed to improve sensitivity.
Taking care of women's hearts
Filed under: Heart Centers Online, Research, Women Heart Health
As you may know, The Cardio Blog is being retired today. It's been an honor to write for this blog, and I hope that the information we brought to you was useful and informative. Since this will be my last post for The Cardio Blog, I thought I'd write about a topic that is near and dear to my heart (pun, lamely, intended): women's heart health. We've seen it in the headlines again and again -- women, and often their doctors, don't always prioritize their health, and this seems to be especially an issue when it comes to heart health. But the fact is that heart disease is public enemy number one for women, and we all need to better understand and deal with our risk factors.
So I'll leave you with this post from Her Daily News. In it, they talk about Heart Truth, the National Institute of Health's campaign to bring heart education to women. They also include a checklist of questions to take to your doctor, as well as a list to help you understand your own risk. Do yourself -- and your heart -- a favor today and read through the questions to determine if you need to do more to protect your health.
Thanks for reading The Cardio Blog, and don't forget to come visit us at That's Fit for all of the latest news in health and fitness!
[RESEARCH] Patients' attitudes to the summary care record and HealthSpace: qualitative study
Objective To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care.
Design 103 semistructured individual interviews and seven focus groups.
Setting Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation.
Participants Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants of a drug rehabilitation programme.
Methods Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances.
Results Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person’s level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for "vulnerable groups." Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness.
Conclusion Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The "implied consent" model for creating and accessing a person’s SCR should be revisited, perhaps in favour of "consent to view" at the point of access.