Materials and methods. Baseline and follow-up data of a Dutch randomized controlled trial on the implementation of a locally adapted guideline were used. The study involved 30 general practices and 1283 patients. Treatment targets differed between study groups [HbA1c ≤ 8.0% and blood pressure (BP) < 140/85% versus HbA1c ≤ 8.5% and BP < 150/85]. Clinical inertia was defined as the failure to intensify therapy when indicated. A complete medication profile of all participating patients was obtained.

Results. In the intervention and control group, the percentages of patients with poor diabetes or lipid control who did not receive treatment intensification were 45% and 90%, approximately. More control group patients with BP levels above target were confronted with inertia (72.7% versus 63.3%, P < 0.05). In poorly controlled hypertensive patients, inertia was associated with the height of systolic BP at baseline [adjusted odds ratio (OR) 0.98, 95% confidence interval (CI) 0.98–0.99] and the frequency of BP control (adjusted OR 0.89, 95% CI 0.81–0.99). If a practice nurse managed these patients, clinical inertia was less common (adjusted OR 0.12, 95% CI 0.02–0.91). In both study groups, cholesterol decreased significantly more in patients who received proper treatment intensification.

Conclusion. GPs were more inclined to control blood glucose levels than BP or cholesterol levels. Inertia in response to poorly controlled high BP was less common if nurses assisted GPs.

Objective. The purpose of this study was to evaluate the ease of use and in vitro accuracy (sensitivity and specificity) of the five most commonly used RADTs in Europe (OSOM Ultra, Quickvue Dipstick, Streptatest, Clearview Exact Strep A and IMI Test Pack).

Methods. To ensure the RADTs were evaluated objectively, a standardized in vitro method using known concentrations of GABHS was used to remove the inherent biases associated with clinical studies.

Results. The IMI Test Pack was the easiest RADT to use overall. The ability to detect all positive GABHS (sensitivity) varied considerably between kits from 95% [95% confidence interval (CI): 88–98%], for the IMI Test Pack and OSOM, to 62% (95% CI: 51–72%) for Clearview, at the highest GABHS concentration. None of the RADTs gave any false-positive results with commensal flora—they were 100% specific.

Conclusions. The IMI Test Pack is most suitable for use in primary care, as it had high sensitivity, high specificity and was easy to use.

Objective. To estimate the prevalence of selected chronic illnesses based on electronic clinical records in primary care (ECRPC) and to assess its usefulness for epidemiological research, by comparing ECRPC data against those reported by a contemporary health survey.

Methods. Design: Descriptive cross-sectional study. Setting: All primary care medical consultations in the Madrid Regional Public Health System (PHS). Subjects: A total of 23 535 182 ECRPC-registered episodes of illness, generated by PHS patients over 15 years of age seeking medical care during 2005–06. Main outcome measures: Prevalences of chronic diseases estimated on the basis of medically examined cases registered in ECRPC and morbidity as reported by a contemporary health survey covering the same geographic area.

Results. A total of 52.5% of the adult population had some chronic health problem. The highest overall prevalences were hypertension (14.8%), mental disorders (12.0%) and allergy (11.6%). Prevalences were generally highest among women, elderly and the native population. Depending on the specific disease, ECRPC-based prevalences were similar to (e.g. diabetes), higher (e.g. chronic skin problems) or lower (e.g. asthma and dyslipidaemia) than those reported by surveys, with certain age- and sex-related variations.

Conclusions. Prevalences estimated from ECRPC and survey data present variations depending on the disease, age and sex. Both data sources provide complementary information about chronic disease prevalence. ECRPC have the advantage of generating an ongoing standardized register and entailing no additional effort for health professionals.

Methods. Prospective cohort study in general practice of patients presenting with a new UC. Data sources were case record forms, patient questionnaires and electronic medical registries at inclusion, 1, 6 and 12 months. Presence of complaints and diagnoses made over time were documented. Potential risk factors were assessed in mixed-effect logistic and linear regression models.

Results. Sixty-three GPs included 444 patients (73% women; median age 42) with unexplained fatigue (70%), abdominal complaints (14%) and musculoskeletal complaints (16%). At 12 months, 43% of the patients suffered from their initial complaints. Fifty-seven percent of the UCs remained unexplained. UCs had (non-life-threatening) somatic origins in 18% of the patients. QoL was often poor at presentation and tended to remain poor. Being a male [odds ratio (OR) 0.6; 95% confidence interval (CI) 0.4–0.8] and GPs’ being more certain about the absence of serious disease (OR 0.9; 95% CI 0.8–0.9) were the strongest predictors of a diminished probability that the complaints would still be present and unexplained after 12 months. The strongest determinants of complaint persistence [regardless of (un)explicability] were duration of complaints >4 weeks before presentation (OR 2.6; 95% CI 1.6–4.3), musculoskeletal complaint at baseline (OR 2.3; 1.2–4.5), while the passage of time acted positively (OR 0.8 per month; 95% CI 0.78–0.84). Musculoskeletal complaints, compared to fatigue, decreased QoL on the physical domain (4.6 points; 2.6–6.7), while presence of psychosocial factors decreased mental QoL (5.0; 3.1–6.9).

Conclusion. One year after initial presentation, a large proportion of newly presented UCs remained unexplained and unresolved. We identified determinants that GPs might want to consider in the early detection of patients at risk of UC persistence and/or low QoL.

Methods. Single-blinded randomized trial among all GPs in Copenhagen Municipality from 1 November 2006 to 1 May 2007.

Results. A total of 15 of 320 GPs (4.7%) had a web-based logon during the study period. The intervention group had a significantly increased frequency of web-based logons (P = 0.0192) equivalent to a hazard ratio of 8.0 (95% CI: 1.03–66.1; P = 0.047). NNT was calculated to 22.2. We could not detect any significant differences in any of the secondary outcomes.

Conclusions. Three reminder letters added to a nation-wide dissemination increased the probability for a GP logon in the ELP by a Factor 8. However, in total, only a small proportion used the ELP. Thus, further research is needed in order to consider future implementation strategies for Internet-based Continuous Medical Education activities among not primed GPs.

Objective. To examine the practices that surround euthanasia, particularly among vulnerable patients, using qualitative observation-based data.

Methods. A 15-month qualitative, observation-based study of home death and general practice in the greater Amsterdam region of The Netherlands. Study included observation and interviews with a sample of 15 (GPs and 650 of their patients, 192 of whom were living with terminal or life-threatening illness (with and without requests for euthanasia).

Results. Euthanasia practice typically involves extensive deliberations, the majority of which do not end in a euthanasia death. Euthanasia discussions or ‘euthanasia talk’ share at least two consequences: (i) the talk puts the onus on patients to continue discussions towards a euthanasia death and (ii) there is a socio-therapeutic component, which tends to affirm social bonds and social life.

Conclusion. While this qualitative evidence cannot disprove existence of abuse, it suggests that euthanasia practices have evolved in such a way that patients are more likely to talk about euthanasia than to die a euthanasia death.

Objective. Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed.

Methods. The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively.

Results. In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care.

Conclusion. GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.

Objective. To compare parental experiences and opinions regarding the management of AOM in children with AOM in Finland and The Netherlands.

Methods. We sent the questionnaires via public day care in Turku, Finland, and Utrecht, The Netherlands. We asked about family background, child's history of AOM and parental experiences and attitudes about AOM treatment and antimicrobial resistance.

Results. Of 1151 participants, 83% in Finland and 49% in The Netherlands had had at least one episode of AOM. Antibiotics were used more frequently in Finland than in The Netherlands, 99% versus 78%, respectively. More Finnish parents reported to believe that antibiotics are necessary in the treatment of AOM as compared to Dutch parents. Use of analgesics for AOM was similar (80% in Finland and 86% in The Netherlands). One-third of the parents had discussed resistance with their doctor. According to parental experiences, antimicrobial resistance had caused more problems in Finland than in The Netherlands (20% versus 2%). Finally, 88% of parents in Finland and 65% in The Netherlands were worried that bacteria could become resistant to antibiotics.

Conclusions. Treatment practices and parental expectations seem to interact with each other. Therefore, if we aim to change AOM treatment practices, we have to modify both guidelines and parental expectations.

Objectives. To describe demographic, behavioural and clinical characteristics of young women accessing services through FHP in Vitória, Brazil.

Methods. From March to December 2006, women aged 18–29 years were recruited into a population-based, household survey. Responses were analysed to assess previous 6 months utilization of FHP services in this population and characteristics associated with accessing care through this public family practice model.

Results. Of 1200 eligible women identified, 1029 enrolled (85.7%). Median age was 23 (interquartile range 20–26) years, 42.7% were married or cohabitating with a male partner. A majority (72%) accessed FHP services in the preceding 6 months, principally for routine and gynaecological visits. Factors independently associated with seeking FHP included: ever tested for human immunodeficiency virus, using anal sex as contraceptive method and reporting a current vaginal discharge. Prior commercial sex work, previous diagnosis with an sexually transmitted infection or using oral sex as a contraceptive method were associated with less use of FHP services.

Conclusions. A public option for delivery of FHP has attracted wide utilization across a cross-section of young women in Vitoria, Brazil. Greater sensitization to specific practices and needs of this population, especially around reproductive health, could further enhance the services provided by family practitioners.

Objective. We aimed to explore GPs’ experiences with lonely patients. We wanted to gain insight in GPs’ feelings regarding consultations with lonely patients and potential resulting behaviour from these feelings.

Methods. We performed a qualitative study based on semi-structured interviews. We interviewed 20 Dutch GPs. Transcripts were analysed according to a grounded theory-like method in order to bring to surface key concepts and relations between them.

Results. GPs considered loneliness as something subjective, a feeling. They found it relevant to know whether their patients were lonely. However, they had difficulty defining their task and experienced a lack of therapeutic options. Beside feelings of pity and interest, lonely patients could evoke feelings of frustration and powerlessness. These feelings were more pronounced when patients were chronically lonely and could cause GPs to spend less time on these patients or refer them more often. GPs did not constructively use their own emotions during consultation.

Conclusions. When confronted with lonely patients, a helpful distinction could be made between transitory and chronic loneliness. Chronically lonely patients are more likely to evoke negative feelings and behaviour in their GPs. GPs should try to recognize these emotions and make sure they do not harmfully influence consultation.

Objective. To compare US and UK practices on P4P measures prior to program implementation.

Methods. We analysed medical record data collected before QOF implementation from randomly selected patients with diabetes or coronary artery disease (CAD) in 42 UK and 55 US family medicine practices. We compared care processes and intermediate outcomes using hierarchical logistic regression.

Results. While we found gaps in chronic illness care quality across both samples, variation was lower in UK practices. UK patients were more likely to receive recommended care processes for diabetes [odds ratio (OR), 8.94; 95% confidence interval (CI), 4.26–18.74] and CAD (OR, 9.18; 95% CI, 5.22–16.17) but less likely to achieve intermediate diabetes outcome targets (OR, 0.50; 95% CI, 0.39–0.64).

Conclusions. Following National Health Service (NHS) investment in primary care preparedness, but prior to the QOF, UK practices provided more standardized care but did not achieve better intermediate outcomes than a sample of typical US practices. US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts while the NHS should focus on moving from process documentation to better patient outcomes.

Objective. To examine the relation of three levels of HL (i.e. functional, communicative and critical HL) to patient–physician information exchange during a visit.

Methods. Participants were 134 outpatients with type 2 diabetes who were under continuous care by four attending physicians at a university-affiliated hospital. The visit communication was recorded and analysed using the Roter Interaction Analysis System. Patient HL was measured through a self-reported questionnaire using newly developed self-rated scales of functional, communicative and critical HL. Sociodemographic and clinical characteristics and patient's perception of the information exchange were assessed for each patient through self-reported questionnaires and review of electronic medical records.

Results. Patient HL levels were related to the information exchange process during the visit. Among the three HL scales, communicative HL (the capacity to extract information, derive meaning from different forms of communication and apply new information to changing circumstances) was related to patient's perceptions of the information exchange. Further, patient communicative HL had a modifying effect on the relationship between physician's information giving and patient's perception of it, suggesting that physician's communication may be perceived differently depending on the patient's HL.

Conclusion. The exploration of patient HL may provide a better understanding of potential barriers to patient–physician communication and patient's self-management of disease.

Methods. We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO₂ and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO₂, spirometry and clinical data in patients with stable COPD.

Results. Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO₂ ≤92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO₂ in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO₂ values ≤92%. SpO₂ values were associated with Medical Research Council dyspnoea scores (P = 0.019).

Conclusions. FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Methods. This feasibility study used a randomized controlled trial design where participating pharmacies were randomized into two groups (SP or PE, feedback). SP visits were audiotaped and questionnaire data collected from participants post-intervention. Each pharmacy received three covert visits from SPs. Feedback was provided immediately after the first and second visits. Data were collected on information gathering and advice provision. The visits were assessed for minimum standards of practice and appropriateness of outcome.

Results. Twenty-two pharmacists and 34 medicine counter assistants (MCAs) from 20 community pharmacies in Grampian, Scotland, participated. Sixty SP visits were completed (three per pharmacy) and were well received, particularly by the pharmacists. Similar results were shown across both study groups in terms of information gathering and information/advice provision during consultations. Few SP consultations achieved the minimum standard of practice although most resulted in an appropriate outcome.

Conclusions. SP visits with feedback were acceptable to pharmacists as a method of improving the quality of consultations for OTC medicines, irrespective of the person giving feedback (SP or PE). The process by which pharmacists and their staff derived their recommendations, in terms of information gathering, could be improved. A large-scale study is needed to assess the effectiveness and cost-effectiveness of SP visits with feedback.

Objectives. To assess the effect of medical co-morbidity and family history of dementia on cognitive performance in older outpatients of family practitioners.

Methods. Analysis of 535 outpatients from 11 practices aged 65 and older, without a diagnosis of dementia. Information on medical co-morbidities, family history of dementia and cognitive test data were obtained.

Results. Patients were classified into high or low medical co-morbidities (<7 versus >8) and positive or negative family history of dementia. After controlling for age, education, gender and depression, global cognitive test scores, as well as memory, executive function, spatial ability and attention were significantly lower for persons having a high number of medical co-morbidities. Cognitive test scores were not significantly different for persons with or without a family history of dementia. A significant interaction between medical co-morbidities and family history of dementia was observed for the global cognitive score, executive function and spatial ability. Those persons with a high number of medical co-morbidities and positive family history of dementia had the lowest performance. Separate regression analysis assessing individual disease risk factors (e.g. hypertension and diabetes) did not find any relationship between specific medical variables and cognitive test scores for any of the subgroups.

Conclusions. A high number of medical co-morbidities in addition to a reported family history of dementia are particularly detrimental to cognitive performance in elderly non-demented family practice patients.

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.

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. 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. To determine the knowledge and attitudes of patients and primary care practitioners concerning WCM, with particular reference to exploring barriers in a multi-ethnic setting.

Methods. A qualitative study using purposive sampling, semi-structured interviews and thematic analysis was conducted. Nine general practices were selected from Leicestershire, UK. The participants were 10 practitioners (four practice nurses, six general practitioners) and 18 patients (six south Asians).

Results. Two overarching themes were identified from patient and practitioner interviews: understanding of waist size measurement to assess or monitor risk and attitudes related to perceived barriers and facilitators to waist measurement. A few practitioners felt uncomfortable about carrying out WCM and some perceived that patients might feel embarrassed. Practical barriers raised by professionals included lack of time, extra workload and financial implications. In contrast, patients generally raised few barriers to WCM. Being given an explanation appeared to be what was most important to them. No clear differences emerged when comparing views of patients from different ethnic groups or general practitioners and practice nurses.

Conclusions. This study adds to our understanding of views on WCM in a multi-ethnic setting, highlighting factors for consideration if WCM is to be facilitated in routine practice.

Methods. A cross-sectional survey among 488 GPs in the northern part of The Netherlands.

Results. A 44% response was achieved (n = 214) during the last 3 years, 38 (18%) were exposed to suicide, 21 (10%) to help requests without being exposed to suicide and 52 (24%) to both suicide and help requests. Out of 106 requests, 69 (65%) were handled by the GP; 60 (57%) were either directly or additionally referred, principally for mental health care. Suicide exposure and female gender were associated with the doctor's perception that follow-up care following a loss through suicide is useful. The perception that help is useful increased the likelihood of GPs’ referral for evidence-based follow-up care.

Conclusions. GPs support the availability of evidence-based follow-up care for relatives of suicide victims. To modify GPs’ key role in referring relatives for it, GPs should be well informed of its usefulness and to whom.

Objectives. The first aim was to describe some aspects of each of the three perspectives in the triangular meeting between immigrant patients, interpreters and GPs, including their experiences, reflections and interactions during the consultation in primary health care. The second aim was to analyse patients’ satisfaction with the consultation; whether satisfaction is influenced by respect for patients’ culture, personality and wishes; and whether interpreters or GPs experience any ethical conflicts during the consultation.

Methods. Using questionnaires, all three categories were asked about their opinions regarding the communication, their experiences and reflections during the consultation and the patient's satisfaction. The interpreters and GPs were asked about ethical conflicts.

Results. Of the 182 respondents, 52 were patients, 65 GPs and 65 interpreters. A matched group of answers from patients, GPs and interpreters was present in 40 consultations. Eighteen of the patients experienced language difficulties. Twenty-six experienced respect for their culture; 32, respect for their personality; and 33, respect for their wishes. Ethical conflicts were rare. All three categories reported that the majority of patients were satisfied with the consultation.

Conclusions. Professional interpreters are important for both a correct verbal and a cultural interpretation. Patient-centred communication is of key importance to a successful consultation.

Objective. To assess the association between GPs' and patients' assessment of mental health outpatient clinic in Norway and identify important health care predictors for patient and GP satisfaction with the clinics.

Methods. Two cross-sectional national surveys were carried out: survey of GPs in 2006 and patients in 2007 evaluating outpatient clinics at 69 community mental health centres in Norway. A total of 2009 GPs and 9001 outpatients assessed the clinics by means of a postal questionnaire. Main outcome measures were correlations between GP and patient ratings of the outpatient clinics at the clinic level and health care predictors for patient satisfaction and GP satisfaction with the clinics.

Results. Clinic scores for GPs' and patients' assessment of waiting time were moderate to highly correlated (0.65), while clinic scores for GP and patient satisfaction had a lower but significant positive association (0.37). Significant positive correlations between clinic scores for GP and patients ratings were found for 38 of the 48 associations tested. The most important predictors for patient satisfaction with the clinics were interaction with the clinician (beta: 0.23) and being met with politeness and respect at the clinic (beta: 0.19), while the most important predictors for GP satisfaction with the clinics were perceived competence (beta: 0.25), rejection of referrals (beta: –0.17) and waiting time for patients (beta: –0.16).

Conclusions. A consistent positive association between GP and patient ratings at the clinic level was identified. Mental health services aiming at improving GP and patient satisfaction should be sensitive to the fact that the two groups prioritize different health care factors.

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.

Objectives. To provide preliminary evidence of the reliability and validity of a Chinese version of the CARE Measure in a primary care setting in Hong Kong.

Methods. Following translation, back-translation and pilot testing, a Chinese version of the CARE Measure was developed and tested on 253 unselected primary care patients in Hong Kong.

Results. The Chinese-CARE Measure was regarded by patients as being relevant to their consultations, with on average only 5.5% of patients rating the items as not important (range 3.6–10.2% for individual items), suggesting high acceptability and face validity. This was also supported by the relatively low number of ‘not applicable’ responses recorded for the measure (average 8.2%, range 0.4–21.7% for individual items). Internal reliability was high (Cronbach's alpha 0.962) and was reduced by the removal of any of the 10 items, and homogeneity was indicated by high corrected item-total correlations (0.786–0.876). Factor analysis showed a single solution for the Chinese-CARE Measure items with high item loadings (0.821–0.891). Construct validity was further supported by significant hypothesized relationships with other variables (patient enablement and patient satisfaction). Consultation length and continuity of care were independent predictors of Chinese-CARE Measure score in stepwise multiple regression analysis but together explained <10% of variation in CARE score.

Conclusion. These preliminary data support the reliability and validity of the Chinese version of the CARE Measure in primary care in Hong Kong.

Methods. A survey was mailed to 770 randomly selected patients in two academic interprofessional family practices in Hamilton, Canada. Most items were positively worded statements on a five-point scale from strongly agree to strongly disagree. Outcomes were the proportion of respondents agreeing with statements regarding access. For items where ≥25% of respondents did not agree, we examined socio-demographic predictors of disagreement using multiple variable logistic regression.

Results. The response rate was 49.9% (384/770). One-quarter or more of respondents did not agree that they received an explanation if the appointment was delayed at the office, obtain urgent appointments, obtain prescription refills without a visit or that wait times at the office were reasonable. Predictors of not agreeing included younger age, being married or single, more educated, employed and of non-white ethnicity. Less than 10 minutes was the most satisfactory wait time for the appointment to begin; however, the most common wait time reported was 11–20 minutes. One-quarter of respondents had visited the weekend/holiday clinic in the past 12 months; however, use was not associated with perceived ability to obtain an appointment in 1–2 days.

Conclusions. While satisfaction was generally high, some aspects of access could be improved by changes in practice organization or patient education regarding expectations.

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.

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.

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.

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.

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.

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 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. 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.

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.