Objectives. We explored GPs' experiences of managing patients with chronic pain from a South Asian community in Leicester.

Methods. Qualitative semi-structured interviews were conducted with GPs from practices in two primary care trusts within Leicester. Eighteen GPs (11 males and 7 females) were interviewed in this study.

Results. Several emerging themes were identified from the data including consulting behaviour, presentation of pain, GPs personal challenges, psychosomatic interpretations and communication. Overall, GPs find that managing South Asian patients with chronic pain can be challenging as a consequence of the way in which patients present with pain. Difficulties for GPs were created not only by language differences but also by cultural differences, which were not seen in second or third generation South Asians. GPs felt that self-management was difficult to address, and compliance with medication difficult to determine. In such consultations, GPs perceived that patients were more likely to present with psychosomatic symptoms.

Conclusions. Cultural influences play an important role in the consultation process where patients' behaviour is often bound in their cultural view of health care. Patients' presentation of their condition makes diagnosis difficult but can also lead to miscommunication. Whether South Asian people are more likely to present mental health problems as chronic pain is not clear and warrants further investigation.

Objective. To validate this framework in clinical practice.

Methods. We used an action research approach, helping five diverse general practices in the South of Scotland to implement the care framework. The process and outcomes were evaluated using in-depth interviews (18 patients and their family carers and 49 health professionals), participant observation and an ongoing dialogue between the practices, the research team and the original user groups.

Results. Practices implemented the framework in a variety of ways. In general, they used their own customized cancer register to improve communication within the practice and began to offer proactive care from a diagnosis of cancer, not just when the disease became advanced. Local innovations included an intranet-based register, information sheets and regular multidisciplinary meetings. Patients, family carers and professionals suggested that the framework had helped achieve continuity of care, teamwork, proactive care and improved support and information for patients and carers.

Conclusions. Proactive personalized care can be improved in primary care for patients with cancer and their family carers through flexible adoption of a framework to embrace key characteristics of good care, as perceived by patients and carers, throughout the illness. Practices can achieve this by choosing approaches suited to their setting, experiences, structure and resources.

Aim. This study investigates how often ICS are prescribed without a proper indication and how big the diagnostic problem is caused by inappropriate prescription and use of ICS.

Methods. All patients referred to a primary care diagnostic centre during 6 months who used ICS without a clear indication were included. Their GPs were questioned about the reasons for prescribing ICS. If still no diagnosis could be assessed, GPs were advised to stop ICS and renew spirometry after a steroid-free period of at least 3 months. After 1 year, the use of ICS was evaluated and the diagnoses were reassessed.

Results. Of all referred patients (2271), 1171 used ICS, 505 (30%) without a clear indication. After 1 year, final results showed that 11% of all patients originally using ICS had no indication to use ICS and had successfully ceased using this mediation. For 15%, the reasons for using ICS remained unclear.

Conclusions. Overtreatment with ICS in primary care seems to be considerable, which falsely labels patients as asthmatic and which generates unnecessary costs and possible side effects. The awareness of GPs of the need for proper diagnostic testing before prescribing ICS needs to be improved. Overtreatment with ICS in primary care patients can be diminished by systematically supporting the GP in the diagnostic procedures and decision making.

Methods. A study of the content of electronic medical records (EMRs) in pre- and post-disaster periods linked to an enquiry using self-reported questionnaires administered 3 weeks and 18 months post-disaster. The disaster (explosion of a firework depot in Enschede, The Netherlands) caused 23 deaths, about 1000 people injured and 1200 people who had to relocate. Sample included survivors (N = 922) who participated in two surveys and whose data could be linked to EMRs of GPs. A comparison of reported morbidity in ‘infrequent’ (a maximum of three times in men and four times in women in the first two post-disaster years) and ‘more frequent attenders’ (frequency determined post-disaster) in general practice examined in relation to health status (measured by diagnoses in EMRs, symptom checklist and quality of life instrument) was the main outcome measure.

Results. Infrequent attenders reported approximately three times as few contacts as more frequent attenders in the pre-disaster year (P < 0.001). Multivariate logistic regression analyses revealed that infrequent attenders were likely to be younger, less depressed, have better subjective health and physical functioning and exhibited more hostile behaviour (measured by questionnaire). Infrequent attenders were less often personally bereaved by the disaster, but more often relocated, and had a lower prevalence of psychological problems pre- and post-disaster although this increased stronger (by 10-fold).

Conclusions. Both groups showed the same type of psychological problems post-disaster, but differed in the frequency of contacting the GP.

Objective. To evaluate the impact on readiness to change of an educational intervention on management of depressive disorders based on a modified version of the Prochaska model in comparison with a standard programme of continuing medical education (CME).

Methods: This is a randomized controlled trial within primary care practices in southern Tehran, Iran. The participants included 192 general physicians working in primary care (GPs) were recruited after random selection and randomized to intervention (96) and control (96). Intervention consisted of interactive, learner-centred educational methods in large and small group settings depending on the GPs' stages of readiness to change. Change in stage of readiness to change measured by the modified version of the Prochaska questionnaire was the main outcome measure.

Results. The final number of participants was 78 (81%) in the intervention arm and 81 (84%) in the control arm. Significantly (P < 0.01), more GPs (57/96 = 59% versus 12/96 = 12%) in the intervention group changed to higher stages of readiness to change. The intervention effect was 46% points (P < 0.001) and 50% points (P < 0.001) in the large and small group setting, respectively.

Conclusions. Educational formats that suit different stages of learning can support primary care doctors to reach higher stages of behavioural change in the topic of depressive disorders. Our findings have practical implications for conducting CME programmes in Iran and are possibly also applicable in other parts of the world.

Objective. To elucidate doctors' motives for non-participation in, and subjective barriers to, general practice research.

Methods. German GPs that had opted out of a quality assessment project involving electronic patient records (EPRs) were mailed a questionnaire regarding their attitudes towards general practice research and their specific objections to the current project. A sub-sample of doctors was interviewed. Their statements were coded and classified with regard to the reasons given for non-participation and possible motivating factors.

Results. The survey response rate was 37% (96/263); 21 GPs completed an additional qualitative interview. Nearly all respondents (88/96) considered general practice research to be important, but 58% had not previously participated in research projects and 56% would not do so in the future. Nearly half (47/96) were opposed to having data extracted from their EPRs. The qualitative analysis revealed deep concerns related to the collection of EPRs (e.g. potential misuse of data, being subject to control or resulting computer problems). Some GPs expressed concerns about recruiting their own patients for the study. Some doctors complained of not being sufficiently recognized as a partner or not having a voice in the research process.

Conclusion. Doctors' negative attitudes, concerns and ambivalent feelings should be addressed in recruitment strategies, especially when the analysis of EPRs or direct patient contact is required. Some doctors do not participate in research out of principle and will be very difficult to convince.

Aims and methods. The aim of the paper is to make a proposal for the future development of the discipline in CEE countries. The proposal is based on reports on an invitational conference that was organized for the key representatives of family medicine from CEE countries. For the purpose of this paper, additional information about the situation was gathered from literature reviews, country visits and personal interviews.

Results. Information shows that although family medicine has been formally recognized and introduced in university curricula, there is a very big difference in its academic position. Postgraduate training has been established in all CEE countries, according to the European Directive. Quality measures such as the development and implementation of guidelines and the re-certification procedure have also been formally introduced, but its quality varies. The key areas of concern are atomization of practices, unsatisfactory payment systems, lack of academic infrastructure and unsatisfactory continuous professional development. On the other hand, examples of good practice exist and need to be promoted.

Conclusion. There is a need for continuous exchange of expertise within the countries. The paper will serve as a discussion paper for the next meeting of experts from CEE countries.

Objectives. To investigate the impact of the RRW on participants' skills, confidence, interest in research and research activity.

Methods. Cross-sectional postal survey in 2006 of five groups of registrars who participated in the annual workshop in 2002–2006 (response rate: 64%; 77 of 121). Outcome measures included research experience and skills prior to and after the workshop; impact of the workshop on capacity, confidence, attitude and interest in research; and research involvement as measured by publications and grant funding.

Results. Self-reported research skills increased over time for the whole group (two-way analysis of variance: P = 0.047), most significantly for registrars with little or no research experience (P < 0.001) and research project participants (P = 0.003). The impact of the workshop on capacity, confidence and interest in research was rated highly (mean 3.5–4.0 ± 0.1 on a five-point scale). Two-thirds of the survey respondents had been research active, 34% presented their findings at conferences, 25% published in peer-reviewed journals and 31% received research funding. Eighty-four per cent of respondents indicated a high interest in undertaking research in the future. All survey respondents recommended the workshop to other registrars.

Conclusions. The RRW provides a useful model for effective research training for interested general practice trainees. Such training has the potential to increase knowledge of research methods, which might augment future research activity in general practice.

Representation of audible and visual data into written form is an interpretive process which is therefore the first step in analysing data. Different levels of detail and different representations of data will be required for projects with differing aims and methodological approaches. This article is a guide to practical and theoretical considerations for researchers new to qualitative data analysis. Data examples are given to illustrate decisions to be made when transcribing or assigning the task to others.

Objective. To test the rule's safety and efficiency in clinically relevant subgroups; i.e. across three age groups, in men and women, and in patients with and without a history of DVT, separately.

Methods. We retrospectively analysed data of 2086 primary care patients suspected of DVT, in whom all rule items and the result of the reference (‘gold’) standard (compression ultrasonography) were collected.

Results. The rule's efficiency decreased with age from 38.1% in the relatively young (<50 years) compared to 9.8% in patients aged ≥70 years. The percentage of DVT among the very low risk patients was <1.5% in all subgroups. The low efficiency in the elderly could be improved without compromising the safety by increasing the D-dimer threshold.

Conclusion. The rule can safely exclude DVT in primary care patients suspected of DVT, irrespective of age, gender and history of DVT.

Methods. Anonymous questionnaire study concerning the ‘three most serious errors in your career as a GP’. The participating doctors were given an operational definition of ‘serious error’. They applied a special recall technique, using patient-induced associations to bring to mind former ‘serious errors’. The recall method and the semi-structured 25-item questionnaire used were developed and piloted by the authors. The items were analysed quantitatively and by qualitative content analysis.

Setting. General practices in the North Rhine region in Germany: 32 GPs anonymously reported about 75 ‘most serious errors’.

Results. In more than half of the cases analysed, other people contributed considerably to the GPs’ serious errors. Most of the errors were discovered and disclosed to the patient by doctors: either by the GPs themselves, or by colleagues. A lot of GPs suffered loss of reputation and loss of patients. However, the number of patients staying with their GP clearly exceeded the number leaving their GP, depending on who else contributed to the error, who discovered it and who disclosed it to the patient.

Conclusions. The majority of patients still trusted their GP after a serious error, especially if the GP was not the only one who contributed to the error and if the GP played an active role in the discovery and disclosure or the error.

Objective. The objectives were to assess situations within the immunization event with discordance between health provider and caregiver and evaluate strategies used to empowering parents while obtaining the desired clinical outcome.

Methods. This was a qualitative study nested within a larger study of immunization rates in 124 randomly selected primary care practices. Interactions between immunizing practice nurses, caregivers and children were videotaped and transcribed and underwent conversation analysis. Six purposively sampled primary care practices in Auckland, New Zealand, served as the setting. The participants were eight practice nurses immunizing 10 children and their parents. Normative pattern of interactions and ‘deviant cases’ involving discordance between nurse and parent.

Results. A total of 168 minutes of video-recorded conversation from 10 immunization sessions provided strong ‘typical’ pattern and equally striking ‘deviant cases’. Parents mostly treated nurses as ‘experts’ and accepted asymmetry of knowledge over medical matters. Nurses demonstrated skilful strategies in delineating their area of medical expertise from areas in which patients are expert—their knowledge of themselves and their children.

Conclusion. While patient centredness and empowering patients are contemporary goals of primary health care delivery, these attributes are not precisely defined. Patients may wish to be informed, but many trust their health professionals to direct their decision making. Although health professionals may impart as much knowledge as they can, asymmetry of knowledge remains. However, patients hold expertise beyond their clinical situation in the social and economic world in which they live.

Aim: To explore patients' views of sickness certification within general practice consultations, and how these could be improved.

Methods: A qualitative study was carried out with 12 general practices in South Wales; interview study of 19 patients who had recently received a sick note from a GP.

Results: Patients rarely attended just for a sick note, more often wanting advice or an opportunity to ask questions. Patients valued continuity of care, a good doctor–patient relationship, adequate consultation time and discussion about their illness, social situation and work-related issues when consulting with their GP for a sick note. Many patients felt doctors did not have enough time or knowledge of the patient to the able to address this issue adequately and this increased feelings of anxiety. Patients did not feel that being questioned by their GP or discussing return to work threatened the doctor–patient relationship.

Conclusions: GPs who simply give out sick notes without question or discussion are not necessarily giving the patient what they want. More time should be spent discussing work and illness-related issues. Policy makers should recognize that continuity of care a good doctor–patient relationship and adequate consultation time are important to patients and any initiatives aimed at GPs to improve return to work rates should take these into consideration.

Objectives. To quantify the impact of the latest GMS contract, which incorporates additional payments for quality outcomes, on prescribing patterns in GP practices.

Methods. This retrospective observational study of prescribing compared the defined daily doses (DDDs) for drugs mentioned or implied within the Quality and Outcomes Framework (QOF) of the latest GMS contract (QOF drugs) to the DDDs for all other drugs listed within the first 10 chapters on the British National Formulary (non-QOF drugs) for four financial years; two before and two after the introduction of the latest GMS contract. These measures were calculated for 92 GP practices of 100 in the Lothian region of Scotland, and the rate of change of prescribing was calculated from regression slopes within the log-scale interrupted time series analyses.

Results. The prescribing of QOF drugs increased significantly faster than the non-QOF drugs both before and after the introduction of the latest GMS contract but the rate of increase for the QOF drugs slowed significantly after April 2005 unlike prescribing of non-QOF drugs.

Conclusions. The prescribing of relevant drugs increased before the introduction of the 2004 GMS contract; the increase continued in the first 2 years of the new contract but at a significantly lower level.

Objective. To determine whether the recording of CHD-related health indicators and prescribing of medicines have increased following the introduction of the nGMS contract and whether differences in the treatment of patients of differing age, gender and deprivation have been affected.

Methods. A serial cross-sectional study carried out with 310 general practices in Scotland. The subjects were patients with CHD as identified by their GP. Main outcome measures were the recording of CHD-related health indicators and prescribing of medicines at pre- and post-contract time points (covariates: gender, age, co-morbidity, deprivation and practice size).

Results. The recording of CHD-related quality indicators and prescribing increased dramatically (mean absolute increase of 17.1%) after the introduction of the nGMS contract. Post-contract, disparities between patient subgroups, continued for certain components of care. Women were less likely to be recorded than men in 9 of 11 components of care, with older patients (7 of 11 components of care) and the most deprived (4 of 11 components of care) also less likely to have a record than the youngest and least deprived, respectively.

Conclusion. The introduction of the new contract was associated with a dramatic rise in the recording of CHD-related quality indicators. However, not all the population benefited equally for certain aspects of care.

Objective. To evaluate whether a comprehensive preventive intervention program using outreach facilitators improves preventive care delivery.

Design. Match-paired, cluster-randomized controlled trial.

Setting. Fee-for-service primary care practices in Eastern Ontario, Canada, at a time of physician shortage.

Participants. Volunteer sample of 54 primary care practices.

Main outcome measures. Mean difference between trial arms in practices’ delivery of preventive manoeuvres, measured by preventive performance indices estimated from chart reviews and patient survey data.

Results. No difference was detected between the trial’s arms for the primary outcome’s overall prevention index [2.0%; 95% confidence interval (CI) –3.2 to 7.3; P = 0.44]. A small significant difference between the arms was detected for the secondary outcome’s overall prevention index (2.8%; 95% CI 0.7–4.8; P = 0.01).

Conclusion. In contrast to similar facilitation trials, this outreach facilitation program did not produce improvements in the delivery of preventive care. This lack of effect may be due to differences in the intervention and context, or the practice’s limited capacity to change. Our intervention simultaneously facilitated a high number of manoeuvres, blinded facilitators and physicians to the targeted tests and had a relatively short intervention period and large number of practices assigned per facilitator. Changes in the primary care service model in Ontario at the time of the trial could have also washed out the intervention effect.

Objective. To determine the association between patient race and patient expectations of their primary care physician.

Methods. The design was a cross-sectional study. Setting and participants were sample of 709 primary care patients from four clinic sites at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Health System. The measures were an expectations instrument asking patients to rate the necessity of the physician performing 13 activities during the index visit, self-reported race, demographics, the Rapid Estimate of Adult Literacy in Medicine, the Charlson Comorbidity Index and SF-12.

Results. After adjusting for age, sex, education, clinic site, comorbidity, health literacy and health status, African Americans were more likely to report it was absolutely necessary for the physician to refer them to a specialist [AOR 1.55 (95% confidence interval, CI, 1.09–2.21), P = 0.01], order tests [AOR 1.59 (95% CI 1.11–2.27), P = 0.01] and conduct each of the six physical exam components.

Conclusions. African American race is associated with greater expectations of the primary care physicians. More research is needed to confirm the differential expectations by race and determine the reasons for the differential expectations.

Objective. To compare research active and non-active practices in terms of practice demographics, disease prevalence and quality scores from the Quality and Outcomes Framework.

Design. Cross-sectional survey using publicly available data.

Setting. A total of 973 general practices from the West Midlands, UK.

Main outcome measures. Practice population characteristics, research status, disease prevalence, clinical and non-clinical quality scores.

Results. Of 973 practices, 298 (31%) were defined as research active. Research active practices had younger populations (% over 65: 15.2% versus 16.2%, z = 3.95, P < 0.0001) compared to non-research active practices, were larger [median list size 6123 (interquartile range, IQR, 3642–9691) versus 4059 (IQR 2675–7060) z = 6.96, P < 0.0001] and more likely to be in deprived areas [median Townsend quintile 5 (IQR 3–5) versus 4 (IQR 3–5), z = 3.23, P = 0.001]. Disease prevalence was similar in both research active and non-active practices but the former attained higher median quality scores for both clinical [research active 534/550 (IQR 508–546) versus non-research active 525/550 (IQR 483–542) z = 4.00, P < 0.0001] and non-clinical [310/320 (IQR 283–319) versus 296/320 (IQR 265–314), z = 5.76, P < 0.0001] areas.

Conclusion. General practices which participate in research are larger and located in more deprived areas than non-research active practices but disease prevalence is similar and research practices attain only modestly higher quality points. Research in research active practices is likely to be generalizable to the wider primary care community.

Objective. Assess metabolic control, body mass index (BMI) and treatment in relationship to diabetes duration to study these mechanisms.

Methods. Cross-sectional study of 7875 patients with T2DM in primary care in The Netherlands. Clinical data and laboratory results were obtained for the 2005 annual visit. Patients were grouped according to diabetes duration in 2-year intervals. Each step in the traditional treatment sequence was considered as a sign of progression of β-cell failure.

Results. Complete data regarding duration and treatment were available for 6850 patients (87%). After the initial years following diagnosis, treatment with diet alone decreases and oral hypoglycaemic agents (OHA) are prescribed to an increasing percentage of patients. Treatment with OHA diminishes after approximately 10 years following diagnosis and treatment with insulin increases until approximately two-thirds of patients with diabetes duration of more than 20 years are being treated with insulin. BMI does not increase with longer disease duration.

Conclusion. The concept of β-cell failure as the primary determinant of the chronic progression of T2DM is supported by these results, whereas a deterioration of obesity-related insulin sensitivity as indicator is not supported.

Objectives. To test the hypothesis that, in women who present to primary care with menorrhagia, excessive menstrual loss in regular cycles is the most common clinical presentation, and to determine the frequency with which symptoms known to be associated with gynaecological malignancy occur.

Methods. A postal survey of all women aged 18–54 years was used to identify symptoms of vaginal bleeding in an urban general practice with 10 000 registered patients. Follow-up surveys were carried out at 6 and 12 months. Consultation data from general practice held records were gathered from baseline to 18 months. Women who consulted with increased vaginal bleeding during the 18-month study period were separately analysed according to their self-reported symptoms in the questionnaire completed in the 6 months prior to the consultation.

Results. At baseline, of the 736 women in the community identified with menorrhagia, 46% had at least one symptom of irregular vaginal bleeding. In the subgroup of 138 women with menorrhagia who consulted primary care with increased vaginal bleeding, the proportion with at least one symptom of irregular vaginal bleeding was 73%.

Conclusion. In women with heavy menstrual bleeding, excessive menstrual loss in regular cycles is not the most common clinical presentation in primary care. Guidelines on menorrhagia should acknowledge the variety of symptoms that women with heavy menstrual bleeding present to primary care.

Objective. To compare GPs' pharmacological treatment patterns for anxiety in patients with and without co-morbidity.

Methods. Data were extracted from computerized medical records of 77 general practices participating in the Dutch National Information Network of General Practice (LINH). We used diagnosis and prescription data of patients, aged 18–65 years, with a newly diagnosed anxiety disorder (n = 4604). A mixed model technique was used to determine if there was a difference in the pharmacological treatment of anxiety with and without co-morbidity.

Results. During the year after diagnosing anxiety, anxious patients who also suffered from chronic somatic morbidity or social problems were prescribed more benzodiazepines (effect size [ES] = 0.44, 95% confidence interval [CI] = 0.16–0.72 and ES = 0.67, 95% CI = 0.22–1.25, respectively) but no more antidepressants than patients with anxiety only. Compared to patients with a single diagnosis of anxiety, anxious patients who suffered simultaneously from other psychiatric conditions received twice as many antidepressant prescriptions (ES = 2.07, 95% CI = 1.89–2.56) as well as twice as many benzodiazepine prescriptions (ES = 1.98, 95% CI = 1.84–2.60) during the year after diagnosing anxiety. For all subgroups, the prescription rate of benzodiazepines remained high throughout the year after diagnosing anxiety.

Conclusion. Our results indicate that psychiatric co-morbidity in anxious patients leads to higher prescription levels of both antidepressants and benzodiazepines. Chronic somatic co-morbidity and co-morbid social problems also lead to higher prescription levels of benzodiazepines, but does not seem to influence GPs' prescribing of antidepressants. The prescription pattern of benzodiazepines was inconsistent with guideline recommendations.

Objective. To quantify the relationships between patient and practice factors and blood pressure in patients with type 2 diabetes.

Methods. A cross-sectional study was carried out in 42 general practices in Nottingham. Participants were 1534 people with type 2 diabetes. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by questionnaire. The outcome measures were systolic and diastolic blood pressure.

Results. In all, 46% of participants had well-controlled blood pressure (≤145/85 mmHg) and 68% were on anti-hypertensive treatment. Systolic and diastolic blood pressure were significantly higher in males overall, in those with a body mass index ≥25 kg/m², and increased with alcohol consumption. Systolic blood pressure increased whereas diastolic blood pressure decreased with increasing age and duration of diabetes. Current smokers and ex-smokers had a significantly lower diastolic blood pressure than those who had never smoked. Patients from practices where blood pressure targets were negotiated with most patients had significantly lower mean systolic and diastolic blood pressure than those where targets were negotiated with few patients.

Conclusions. A number of patient characteristics are associated with blood pressure. Negotiating individual goals for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore the process of negotiating targets.

Objective. To evaluate the efficiency of population-based screening for Type 2 diabetes.

Methods. From 2002 to 2004, we performed a four-step screening procedure [questionnaire, random glucose measurement, fasting glucose measurement and oral glucose tolerance test (OGTT)] and a three-step procedure (without random glucose measurement) in 79 general practices in the southwestern region of the Netherlands.

Results. A total of 56 978 non-diabetic subjects, aged 50–70 years, were asked to complete the questionnaire. Those with a score above threshold underwent further glucose testing. Eventually, 586 participants (1.0%) were diagnosed with Type 2 diabetes (in four-step procedure 285 subjects and in three-step procedure 301). Impaired glucose regulation was assessed in 1011 participants (1.8%). Dropout rate in the screening programme among participants who should undergo an OGTT was 23.4%. The risk score was higher if glucose metabolism was more disturbed.

Conclusion. In the Netherlands, the yield of population-based screening is low. The dropout among high-risk individuals was high. Given the decreasing prevalence of undiagnosed diabetes and the possibility of opportunistic screening on a continuous basis, opportunistic screening for diabetes might be more appropriate than population-based screening. Further research on this topic is needed.

Objective. To build an explanatory model of PCC concerning users’ psychosocial factors.

Methods. We undertook a multicentre, prospective cohort study of a random sample of 1141 persons assigned to 113 GPs, belonging to 11 urban health centres in four Spanish cities (Seville, Malaga, Jaen and Granada), of whom 955 (84%) were interviewed in their homes. They were followed up for 1 year and then contacted again. After the second interview, 70 (7.3%) patients were excluded; accordingly, we measured the number of PCC of 885 valid patients using their medical charts.

Results. A multilevel analysis was developed. The null model with three levels showed that 93.29% of the variability was explained by the patients, 1.56% by the GPs and 5.15% by the health centres. We selected a two-level model (patients and health centres) with random effects. The variables used in the multilevel analysis explained 48% of PCC, 36% at the patient level and 12% at the health centre level. Poor mental health (GHQ-28, partial correlation coefficient = 0.28) and family dysfunction (Family APGAR index, partial correlation coefficient = 0.26) were the most predictive variables, whereas social support (Duke-UNC-11, partial correlation coefficient = –0.14) lost significance in the multivariate analysis. Chronic illness seemed less relevant in our study, and only two predisposing factors were included in the equation: age and satisfaction with their doctor.

Conclusions. Mental health and family function were the most important psychosocial factors predicting PCC. More comprehensive identification of psychosocial factors may enhance our understanding of PCC.

Aim. To explore patient experiences of and beliefs about their long-standing SSRI use and understand the barriers and facilitators to discontinuation.

Design. Face-to-face semi-structured qualitative interview study.

Setting. One group general practice in Southampton, UK.

Findings. Three overarching themes were identified: (i) patient uncertainty about the benefits of, and continued need for, SSRI medication; (ii) barriers to stopping, including fear of withdrawal symptoms and fear of relapse; and (iii) the importance of the GP's role in facilitating cessation. Uncertainty and fear about withdrawal symptoms and what patients would be like without their medication were key barriers to stopping, even among patients who felt no discernible benefit from taking SSRIs. Patients indicated a need to share the decision to stop with their GP. However, the majority of patients interviewed had received repeat prescriptions of SSRIs without being reviewed by the GP.

Conclusions. Patients prescribed SSRI medication need to be reassured that, as with starting medication, thinking about or actually stopping medication is a task that will not be managed in isolation, but with the support of their GP.

Objectives. To elicit the perceptions of people with learning disabilities, carers and care workers regarding risk factors associated with cardiac disease.

Methods. A qualitative approach was adopted incorporating semi-structured interviews based on vignettes. Twenty people with mild learning disabilities, 10 carers and 10 care workers were recruited. Data were analysed using Miles and Huberman's five-fold process.

Results. In total, 29 women and 11 men were interviewed. A range of health risks was identified with different patterns across groups. There were common concerns around diet. Approximately 50% of participants also had worries regarding ‘excessive computer usage’, often related to physical inactivity, and a similar proportion identified social isolation as a risk. The importance of safeguarding personal autonomy was stressed in all three groups.

Conclusion. We demonstrated the feasibility of engaging with people with mild learning disabilities regarding health improvement. Participants recognized not only risks but also the subtle interplay of different factors, reflecting a grasp of the complexity of health promotion. Approaches within primary care to health improvement need to acknowledge this level of awareness.

Objectives. This study aimed to explore views and experiences of incontinence and perceptions of care among South Asian Indian women in Leicester, UK.

Methods. A qualitative focus group study involving four focus groups, each of six women, was undertaken. Focus groups were conducted in the participants’ chosen language and facilitated by a bilingual moderator. Groups were tape-recorded, transcribed and analysed in a systematic and iterative way based on the constant comparative method.

Results. Women commonly normalized symptoms of urinary incontinence, attributing them to the ageing process or consequences of childbirth. Help-seeking behaviour was hindered not only by feelings of embarrassment in discussing sensitive problems, especially with male health professionals, but also the perceived embarrassment felt by doctors. Women reported a lack of available information in culturally sensitive media. Talk-based media were more highly valued than text-based media. Generational differences in help-seeking behaviour were apparent.

Conclusions. This exploratory study provides valuable understanding of the continence needs of South Asian Indian women. Common needs were identified, as were important generational differences. Suggestions offered by women for the existing service improvement seemed relatively modest in terms of resources required.

Methods. We conducted a pragmatic randomized controlled trial (n = 149) of a decision aid in women attending their primary care practitioners with menorrhagia. Alongside the trial, a qualitative study was conducted with interviews with a sample of women who had received the intervention (n = 18). Hypotheses generated by the qualitative study were used to inform subsequent quantitative subgroup analyses.

Results. The results from both studies showed that the decision aid was broadly beneficial. The qualitative study found that women with less formal education reported greater levels of benefit from the intervention. However, quantitative analyses of formal education as a moderator of treatment effect found that the intervention provided the greatest benefit in women with greater formal education. The findings of the qualitative and quantitative studies thus demonstrated a significant inter-method discrepancy. Possible reasons for this discrepancy are discussed.

Conclusions. Mixed methods can illuminate different aspects of an intervention or provide greater insight into particular issues. Health service researchers need to be aware that the qualitative and quantitative results may be discrepant, and methods need to be developed to deal with such discrepancies. However, exploring seemingly discrepant results can lead to greater insight and the development of new hypotheses and avenues of research.

Objective. We evaluated (i) if risk factors in one or more of five predefined domains were detected in a primary care-based HRA and (ii) how often these findings had an impact on the further management of patients.

Methods. We performed a prospective observational study in a rural community in Austria and included persons (age ≥ 70 years) living at home. We applied the standardized assessment for elderly people in primary care (STEP) instrument and evaluated risk factors for status decline assessing five domains (cognitive function, depression, urinary incontinence, hearing impairment and mobility/falls).

Results. Two hundred and sixty-four persons participated and the HRA revealed a wide range of risk factors for health status decline [from 4.5% (12/264) in the depression domain up to 31% (81/264) for mobility/falls and 41% (107/264) in the cognitive domain]. The findings had an impact on the further management in four domains: hearing impairment (100% of findings with impact), mobility/falls (93%), depression (83%) and urinary incontinence (65%). In contrast, abnormal cognitive findings lead to action only in every fifth participant (18%; 19/107).

Conclusion. In contrast to other domains, family physicians are hesitant to act upon abnormal findings of cognitive testing. Additional knowledge is needed to clarify the value of abnormal cognitive findings for management of patients and support of their carers.

Methods. This study was undertaken in Maccabi Health care Services a preferred provider health care organization. This is a multistage study using both qualitative and quantitative methods. A semi-structured interview using 14 key questions identified the reasons for resistance to treatment among 64 people with diabetes. A questionnaire was built based on these themes and then validated with a further 123 people with diabetes. A further validation was undertaken comparing our questionnaire with that of Kavookjian.

Results. This resulted in a four theme, 40-item questionnaire which can be administered in about 10 minutes. Resistance patterns and their intensity were different in each patient. This resistance questionnaire identifies the core reasons for non-compliance: lack of faith or dissatisfaction with the treatment or with the medical team, emotional reasons, specific problems or constraints and factors connected to despair and failure.

Conclusions. We present a tool 'The Resistance to Treatment Questionnaire' which may be used by medical personnel to identify the barriers to treatment for each individual and in turn improve patient compliance to treatment.

Objective. To explore the predictors of GPs to decide on the presence and absence of dementia as well as the predictors of diagnostic confidence of GPs.

Design. An observational study was set up among 107 patients of 64 GPs. The GPs were instructed to use the Dutch national dementia guideline on consecutive patients newly suspected of dementia and to register their assessment on a detailed form. The predictors of the presence and absence of dementia according to the GPs and their diagnostic confidence were explored by logistic regression analyses.

Main outcome measures. Dependent variables: (i) presence and absence of dementia according to GPs and (ii) diagnostic confidence.

Independent variables: clinical (cognitive, behavioural, somatic, functional), applications of recommendations, patient related and GP related.

Results. Dementia was diagnosed in 67% of the suspected patients. The presence of dementia according to the GPs was positively associated with observed impairment of the higher cognitive functions, absence of depression and female gender of patients. The GPs expressed diagnostic confidence in 58% of the cases. This was positively associated with application of recommendations, ADL dependency, longer duration, informant availability, restless behaviour and a patient's female gender. Use of the Mini Mental Status Examination was not associated with confidence.

Conclusions. GPs seem to base the diagnosis of dementia on rational grounds. Application of the dementia guideline's recommendations may contribute to more diagnostic confidence.

In primary care, the history is the most important diagnostic tool. However, there are only few studies exploring diagnostic criteria that GPs actually use in their daily practice.

Objective. To identify GPs' diagnostic criteria for diagnosing CHD in patients with chest pain.

Methods. In a semi-structured interview, 23 GPs were asked to describe their individual diagnostic criteria in two of their patients with chest pain they had prospectively identified. Interview data were taped, transcribed and analysed qualitatively.

Results. Histories of 39 patients were described, of which 17 patients were thought to have CHD and/or an indication for an emergency hospital admission. GPs mentioned the person-specific discrepancy, that is differences in behaviour or a different appearance of a patient in comparison to previous consultations, as an important diagnostic criterion. Known risk factors for CHD and past illness behaviour also influenced the GPs' diagnoses.

Conclusion. Apart from classical textbook criteria, GPs make use of their prior knowledge of individual patients in a specific way. Discrepancies between previous and actual consultations alert the GPs for serious diseases. At the primary care level, medical practitioners use criteria that differ from secondary or tertiary care.

Methods: Prospective cohort studies of 458 symptomatic patients (derivation cohort) and 535 patients (validation cohort) in 26 general practices in Tayside and Fife, Scotland. All patients underwent a structured clinical examination and ECG and the ‘reference standard’ investigation of echocardiography to establish the presence of LVSD.

Results: Four elements from the clinical history and examination were all independently associated with LVSD—male sex [adjusted odds ratio (OR) 2.5; 95% CI 1.1, 5.0], presence of orthopnoea (OR 5.4; 1.9, 13.8) history of myocardial infarction (OR 5.6; 2.3, 13.6) and elevated jugular venous pulsations (OR 15.1; 4.6, 49.3). Addition of ECG (OR 20.6; 2.7, 158.6) provides important diagnostic information in terms of probability of LVSD. A CPR based on the presence or absence of these five elements will generate probabilities ranging from 1% to 97% for LVSD when applied to an individual patient. In the validation cohort, the model under-predicted the probability of LVSD, particularly at lower levels of expected risk, reflecting differences in the risk-factor profiles of the derivation and validation cohorts.

Conclusions: The derived CPR provides quantitative estimates of post-test probability for LVSD. This rule requires further validation in other populations and settings because of the difficulties encountered in the validation cohort.

Methods. A consecutive cohort of 127 patients presenting with palpitations and/or light-headedness to 41 GPs in the Netherlands underwent physical examination, patient history and standard electrocardiogram. The GPs' estimation of the probability of patients having an arrhythmia was compared with the diagnostic result of 30 days of continuous event recording (CER). We assessed discriminating factors that can assist a GP in diagnosing an arrhythmia.

Results. No correlation was found between the GPs' assessment of risk and actual diagnoses. GPs were more likely to predict an arrhythmia in patients who suffer from hypertension (P = 0.049) or patients with a history of cardiovascular disease (P = 0.006). Vasovagal symptoms [odds ratio (OR) = 2.91, 95% confidence interval (CI) 1.1–7.6] and bradycardia (OR = 4.2, 95% CI 1.3–14.0) were significantly more common in patients with a CER diagnosis of arrhythmia.

Conclusion. Prediction of arrhythmias by GPs based on history taking and physical examination alone is not accurate. These parameters are insufficient to decide which patients need further diagnostic evaluation. A diagnostic facility with low threshold for GPs is essential for an adequate diagnostic process in patients with palpitations and light-headedness.