Objective. To outline the process of recruitment, factors impacting on recruitment success and key areas for further research and development.

Methods. Narrative literature review.

Results. This paper argues that three ways of improving recruitment should form the focus of future work: developing a repository of evidence-based techniques and methods which can be introduced by research teams; developing the infrastructure to support recruitment, especially new technologies around the electronic patient record; and increasing public engagement with research, to improve participation by both clinicians and patients.

Conclusion. Recruitment to health research in primary care remains a major hurdle, and key research and development priorities must be addressed.

Objective. To qualitatively examine the attitudes and self-reported behaviour of GPs in relation to guideline adherence for patients with LBP.

Method. A mixed-method design combining a national UK-based survey of GPs and physiotherapists with an embedded qualitative study. This report focuses only on the GP interviews. We explored GPs’ experience of managing LBP patients and the rationale for treatment offered to a patient described in a written vignette. All interviews were digitally recorded, fully transcribed and analysed using the constant comparative method.

Results. GPs encountered difficulties adhering to guideline recommendations for LBP patients. They experienced particular tensions between recommendations to stay active versus the expectation of being prescribed rest. GPs expressed that chronic LBP often poses an intractable problem requiring specialist advice. The perception that guideline recommendations are ‘imposed’ may create resistance, and the evidence base is not always considered believable.

Conclusions. GPs acknowledge guideline recommendations but divergence occurs in implementation. This is due to GPs focussing on the whole person—not just one condition—and the importance of maintaining the doctor–patient relationship, which relies on effective negotiation of mutual perceptions and expectations. Further exploration on how consultation processes can be constructed to effectively combine evidence with patient-centred care is needed.

Objectives. We aimed to use a user-centred design process to develop an animated interface for the UK Prospective Diabetes Study (UKPDS) Risk Engine to illustrate cardiovascular disease (CVD) risk and the potential to reduce this risk. In addition, we sought to use the same approach to develop a brief lifestyle advice intervention.

Methods. Three focus groups were held. Participants were provided with examples of materials used to communicate CVD risk and a leaflet containing a draft brief lifestyle advice intervention and considered their potential to increase motivation-to-change behaviours including diet, physical activity, and smoking in order to reduce CVD risk. Discussions were tape-recorded, transcribed and coded and recurring themes sought.

Results. Sixty-two percent of participants were male, mean age was 66 years (range = 47–76 years) and median age at leaving full-time education was 18 years (range = 15–40 years). Sixteen had type 2 diabetes and none had a prior history of CVD. Recurring themes from focus group discussions included the following: being less numerate is common, CVD risk reduction is important and a clear visual representation aids comprehension.

Conclusion. A simple animated interface of the UKPDS Risk Engine to illustrate CVD risk and the potential for reducing this risk has been developed for use as a motivational tool, along with a brief lifestyle advice intervention. Future work will investigate whether use of this interactive version of the UKPDS Risk Engine and brief lifestyle advice is associated with increased behavioural intentions and changes in health behaviours designed to reduce CVD risk.

Objective. Development of a clinical prediction rule using easily obtainable predictors for major depressive disorder in primary care patients.

Methods. A total of 1046 subjects, aged 18–65 years, were included from seven large general practices in the center of The Netherlands. All subjects were recruited in the general practice waiting room, irrespective of their presenting complaint. Major depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Text Revision edition criteria was assessed with the Composite International Diagnostic Interview. Candidate predictors were gender, age, educational level, being single, number of presented complaints, presence of non-somatic complaints, whether a diagnosis was assigned, consultation rate in past 12 months, presentation of depressive complaints or prescription of antidepressants in past 12 months, number of life events in past 6 months and any history of depression.

Results. The first multivariable logistic regression model including only predictors that require no confronting depression-related questions had a reasonable degree of discrimination (area under the receiver operating characteristic curve or concordance-statistic (c-statistic) = 0.71; 95% Confidence Interval (CI): 0.67–0.76). Addition of three simple though more depression-related predictors, number of life events and history of depression, significantly increased the c-statistic to 0.80 (95% CI: 0.76–0.83). After transforming this second model to an easily to use risk score, the lowest risk category (sum score < 5) showed a 1% risk of depression, which increased to 49% in the highest category (sum score ≥ 30).

Conclusion. A clinical prediction rule allows GPs to identify patients—irrespective of their complaints—in whom diagnostic workup for major depressive disorder is indicated.

Aim. To test the hypothesis that text message communication in primary care research does not lead to lower response rates compared to a paper-based method.

Methods. This randomized controlled trial took place in 26 randomly selected practices in Victoria, Australia. Consecutive patients aged 16–24 years attending general practice appointments were recruited as part of a larger study on patients’ perspectives. Patients owning a mobile phone were randomized to receive a question about satisfaction with the consultation either by text message or on a card completed before leaving the practice. Logistic regression was used to estimate the effect on the response rate of using text message rather than the card method, adjusting for clustering within practices and for differences in baseline characteristics among participants.

Results. In total, 402 of 409 eligible young people agreed to participate and were randomized to either receive a text message (n = 193) or a card enquiry (n = 209). The response rate was 80.2% [95% confidence interval (CI): 73.3–87.1%] with text message and 85.6% (95% CI: 79.6–91.7%) with the card. The adjusted odds of responding (odds ratio: 0.62; 95% CI: 0.30–1.27) were not significantly lower in the group using text messaging compared to the group using the card response method.

Conclusion. These findings offer new perspectives for use of text message communication to gather information from patients in primary care research.

Objective. To explore the patient experience of infertility management from a primary care perspective.

Methods. This was a nested qualitative study with infertile couples in North-East England. In-depth interviews of infertile couples identified in the course of an observational study describing the incidence, prevalence, referral patterns and pregnancy outcomes for infertile couples. A grounded approach was used, with the interviews and analysis proceeding together using the method of constant comparison. Emergent themes and their links gave an overall explanation to the interview data.

Results. We interviewed 22 patients in 13 interviews. Factors that influenced a couple's experience of infertility management were personal and professional relationships, patient autonomy in decision making and access to services.

Conclusions. This study provides insights into the experiences of infertile couples seeking assisted reproduction from their GP. A good experience was linked to a strong personal relationship, a patient-centred professional relationship fostering informed decision making by the couple, GPs using diagnostic resources, interpreting restrictive clinical and social criteria and referring appropriately.

Design. Semi-structured audio-taped telephone interviews with GPs delivering a GP-led follow-up programme for people with cutaneous malignant melanoma.

Subjects. Seventeen GPs currently delivering structured GP-led routine follow-up for people with cutaneous melanoma.

Results. GP-led melanoma follow-up worked well from the perspectives of GPs. The GPs felt that they were well equipped and supported in undertaking the follow-up consultations and recognized that they were freeing up hospital consultant time. They felt that patients appreciated the convenience of GP-led follow-up. The GPs felt that a robust recall system, initial training with regular refreshers and effective consultant backup were vital components of a successful long-term programme.

Conclusions. GP-led melanoma follow-up is feasible and, provided certain concerns can be addressed, GPs are willing to provide it.

Objective. To describe the incidence, prevalence, referral patterns and outcomes of infertile couples, presenting in general practice in UK.

Methods. A population-based retrospective observational outcome study of infertile couples from general practices in Northumberland, Tyne and Wear, UK (population 1 043 513). Outcome data at 1 year were collected on all couples who presented to their GP between the 1st January 2005 and 30th June 2006 with a fertility problem.

Results. Thirty-four per cent of general practices in the study area contributed data (population 404 263). The incidence of infertility was 0.9 couples per 1000 general population. The average age of women was 31 years, and the average time attempting conception was 18 months. Treatment end points for half of all couples were in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Over half of the couples in the study were not eligible for National Health Service (NHS) fertility treatment on social criteria. At 12 months, 27% of all couples in the study achieved a pregnancy spontaneously and a further 9% with treatment.

Conclusions. Infertile women present to their GP later in life compared with 20 years ago, and after a shorter period of infertility. Half of the couples required treatment with IVF or ICSI. Adopting the British Fertility Society recommendation of allowing couples, where one or both partners has a child in a previous relationship, will result in an additional 26% of infertile couples becoming eligible for NHS fertility treatment.

This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE® and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.

Objective. To explore the factors which influence GPs' decision-making process when requested to prescribe specialist drugs.

Methods. A qualitative approach was used to explore the perspectives of a wide range of practice-, primary care trust-, strategic health authority-level staff and other relevant stakeholders in the North-West of England. All semi-structured interviews (n = 47) were analysed comprehensively using the five-stage ‘framework’ approach.

Results. Six diverse factors were identified as having a crucial bearing on how GPs evaluate initial requests and subsequently decide whether or not to prescribe. These include GPs' lack of knowledge and expertise in using specialist drugs, the shared care arrangement, the influence of a locally agreed advisory list, financial and resource considerations, patient convenience and understanding and GPs' specific areas of interest.

Conclusion. This exploration of GPs' decision-making process is needed to support future integrated health care delivery.

Objective. As part of a qualitative investigation into the views of patients, doctors, nurses and administrative staff on the use of telephone consulting in general practice, we set out to explore the impact of the use of this medium on perceptions of confidentiality.

Method. We used focus groups of purposively selected patients, clinicians and administrative staff in urban and rural areas.

Results. Fifteen focus groups comprising 91 individuals were convened. Participants concerns centred on overheard conversations, the receptionist role in triage, difficulty of maintaining confidentiality in small close-knit communities, errors in identification, third party conversations and answering machines. Telephone consulting, depending on the circumstances, could pose a risk or offer a solution to maintaining confidentiality.

Conclusions. Many of the concerns that patients and health care staff have around confidentiality breaches both on the telephone and face to face are amenable to careful management. Although rare, identification error or fraud can be a potentially serious problem and further thought needs to be given to the problem of misidentification on the telephone and the use of passwords considered.

Methods. We recruited two samples: 191 older Primary care patients and 138 Sleep clinic patients. Participants completed the Sleep Symptom Checklist (SSC). This consists of 21 symptoms in four domains: insomnia, sleep disorder, daytime symptoms and psychological distress. All respondents indicated which symptoms had been discussed with their physician in the past year. Primary care subjects were designated as Decliners (completed SSC, refused further evaluation), Dropouts [completed some evaluation steps, but not polysomnography (PSG)] and Completers (completed PSG).

Results. Primary care participants frequently had symptoms but relatively few had discussed them with their doctor. Sleep clinic participants discussed significantly more symptoms with their referring physician than did Primary care Dropouts or Decliners in all categories except psychological distress. Primary care Completers, 88.5% of whom were ultimately diagnosed with sleep apnoea/hypopnoea syndrome and/or periodic limb movement disorder, also discussed their sleep disorder symptoms less frequently than did Sleep clinic patients but tended to give more prominence to symptoms of insomnia and impaired daytime function.

Conclusions. The findings suggest that Primary care patients often have symptoms they do not discuss, even when a primary sleep disorder exists. The brief SSC checklist, developed in our laboratory, has potential to improve the referral rates of older primary care patients who have sleep disorder.

Objective. To describe the nature of MOs to immunize within primary care in New Zealand and their effect on immunization completeness.

Methods. Audit of medical records of ~10 randomly selected children <2 years old from each of 62 primary care practices in Auckland, New Zealand.

Results. The 616 audited children made 10 094 visits to primary care practices. MOs occurred at 97% (60) of practices, in 556 (5.5%) of visits, and 31% of the children had one or more visits that were an MO. Overall, children who had any recorded MO visit were 3.1 times more likely to be incompletely immunized than children who had no recorded MO (95% CI 1.87–5.14). Children with the greater percentage of overall visits that were MOs had up to a 9 times increased likelihood of incomplete immunization compared to those who had no MO visits. Nurse visits have less MOs than doctor (1.5% versus 6%) but are more likely to occur within well-child visits.

Conclusions. MOs are common in primary care practices, occurring in nearly one-third of visiting children. The risk of under-immunization increases with the increasing percentage of visits that are MOs. Overall strategies directed at reducing MOs need to focus on a range of aspects for the practitioner and the practice system.

Objective. The objective is to follow-up a cohort of liver function tested patients to determine their outcome.

Methods. This population-based retrospective cohort study was conducted in Tayside, Scotland, from 1989 to 2003. Subjects were patients with no clinically obvious liver disease at initial liver function testing in primary care. Main outcomes were diagnosed liver disease and mortality. Record linkage of databases ascertained risk factors and outcomes. Measures of performance were calculated and Weibull regression analysis from initial LFT date was performed on all outcomes by level of abnormality.

Results. In total, 95 977 patients had 364 194 incident initial LFTs, with median follow-up 3.7 years. A total of 21.7% had at least one abnormal LFT and 1108 (1.15%) developed liver disease. Elevated transaminase was strongly associated with diagnosed liver disease, hazard ratio (HR) = 4.23 (95% confidence interval 3.55, 5.04) for mild levels and HR = 12.67 (95% CI 9.74, 16.47) for severe levels versus normal. For gamma-glutamyl transferase, these hazards were 2.54 (95% CI 2.17, 2.96) and 13.44 (95% CI 10.71, 16.87), respectively. Low albumin was strongly associated with all-cause mortality, HR = 2.65 (95% CI 2.47, 2.85) for mild levels and HR = 4.99 (95% CI 4.26, 5.84) for severe levels. Sensitivity for predicting events over 5 years was low and specificity high.

Conclusions. All LFTs were predictive markers for liver disease as well as general ill health, although sensitivity was poor. Most patients with abnormal LFTs had no later formal diagnosis of liver disease within the study period. The time taken to develop liver disease in these patients provides opportunity to intervene.

Objectives. To review the existing evidence on the diagnostic value of history taking and physical examination in recognizing COPD in patients suspected of COPD.

Methods. A systematic literature search was performed in electronic medical databases. Studies were included after using defined inclusion and exclusion criteria and judged on their methodological quality by using the Quality Assessment of Diagnostic Accuracy Studies criteria. A formal meta-analysis was not performed because all studied items of history and physical examination were investigated in only in a maximum of three studies.

Results. Six studies were included. The history items dyspnoea, wheezing, previous consultation for wheezing or cough, self-reported COPD, age and smoking and the physical examination items wheezing, forced expiratory time, laryngeal height and prolonged expiration were found to have diagnostic value for COPD. These items were studied in maximally three studies and study population studies were heterogenic. The reference test for COPD in five of the six studies concerned obstructive lung disease in general and not COPD.

Conclusion. There is insufficient evidence to assess the value of history taking and physical examination for diagnosing COPD.

Because of the impressive disruptive character of behavioural disturbances, most caregivers appeal for pharmacological intervention at a given moment, expecting instant suppression of the aberrant behaviour. Beside the antipsychotic drugs, the cholinesterase inhibitors are commonly used in the treatment of agitation, aggression, delusions, etc. Although in meta-analyses on the efficacy of both categories of drugs, only little evidence of their efficacy has been found and an important placebo effect has been reported that >90% of the demented elderly was treated at least once.

The aim of this study was to investigate if pharmacological treatment of behavioural disturbances of the demented can lower the burden and the time spent in the family caregiver irrespective of their effect on the demented himself.

A systematic literature search was performed by means of Medline, Embase, Cochrane DSR, Dare, CCTR and ACP Journal Club.

Based on this review, pharmacological treatment of demented elderly seems to lower caregiver burden (mean difference 0.27) and the time caregivers spent (mean difference 41.65 minutes).

Considering that family caregivers confronted with the troublesome behaviour of their demented relative will apply for pharmacological intervention, future research should particularly focus on the outcome measures of the caregivers’ well-being.

Objective. To explore the medical needs of terminal cancer patients in home care and thus clarify the role and tasks of family physicians in providing palliative home care.

Methods. Seventy-seven terminal cancer patients discharged from a palliative care unit from July 2003 to July 2004 who had received family physician home visits were enrolled. A structured assessment form was applied to each visit.

Results. Under the collaboration by the palliative home care team and family physicians, the average interval from discharge to the first physician visit was 20.3 days and the average interval between physician visits was 37.9 days. The patients had an average of 5.9 active medical problems: the most frequent problem was pain (58.4%), followed by anorexia (42.9%) and constipation (42.9%). Forty-four patients (58.7%) died at home, while 31 patients (41.3%) eventually died in the hospital. Through multiple logistic regression analysis, patients who had never been rehospitalized [odds ratio (OR) = 12.95, 95% confidence interval (CI) = 3.41–49.19], who preferred to die at home (OR = 4.68, 95% CI = 1.21–18.09) and who were most functionally dependent with an Eastern Cooperative Oncology Group scale = 4 (OR = 4.36, 95% CI = 1.02–18.64) were found to be most likely to die at home under this care model.

Conclusion. Through palliative home care with the participation of family physicians, patients’ preference could be a significant determinant of home death. Our finding can be helpful to the establishment of an ethical care model for terminal cancer patients.

Objective. To review the development of diabetes peer support initiatives in New Zealand.

Methods. A systematic review of diabetes peer support publications from New Zealand, supplemented by unpublished records from Diabetes New Zealand (DNZ, the national diabetes patient organization) and the two major regional initiatives in South Auckland and Waikato.

Results. DNZ, which has 40 societies and 71 diabetes support groups, delivers a range of services to members and non-members. The membership is mainly older European New Zealanders with diabetes, with some Maori and associated societies for Pacific and Youth. While demand exists, no quantitative evaluation of health impact by these organizations has been undertaken. Other peer support groups have developed in South Auckland and Northland. Common themes that emerge relate to leadership, organization and balancing the different needs of people with diabetes at different stages (e.g. newly diagnosed versus others) and with different personal needs. In South Auckland and the Waikato, lay educators have been trained to provide 1:1 and group sessions for people with, or at high risk of, diabetes. A range of training, management, funding and organizational barriers existed in the implementation of these lay educator programmes.

Conclusions. Peer-to-peer support and education programmes in diabetes have been considered useful in New Zealand. Knowledge regarding training, management and organization is nearing a level, which would allow formal evaluation of a strategy for both the prevention of diabetes and in supporting people with diabetes.