Objective. To test whether type 2 diabetes patients with elevated depression scores are more often physically inactive.

Methods. Demographic features, clinical factors, level of physical inactivity and depressive symptoms were assessed in 2646 primary care patients with type 2 diabetes. Sequential multiple logistic regression analyses [odds ratio, 95% confidence interval (CI)] were performed to test the association between depressive symptoms and physical inactivity.

Results. About 48% of the respondents were physically inactive. Elevated depressive symptoms were found in 14% of the respondents. After adjustment for potential confounders, the odds for being physically inactive were almost doubled in depressed patients with type 2 diabetes 1.74 (95% CI 1.32–2.31).

Conclusions. Presence of depressive symptoms almost doubles the likelihood of physical inactivity in patients with type 2 diabetes. Longitudinal studies are needed to investigate whether physical inactivity forms the link between depression and poor disease outcomes.

Objective. Our aim was to establish and compare incidence and referral rates for foot problems in children in 1987 and 2001.

Methods. A comparison was made of two large consecutive surveys in Dutch general practice performed in 1987 (86 577 children aged 0–17 years) and 2001 (87 952 children aged 0–17 years), which were carried out by The Netherlands Institute for Health Services Research. Both surveys included a representative sample of the Dutch population. Incidence and referral rates were calculated and, data were stratified for age group and gender.

Results. Compared to 1987, in 2001 the overall incidence rate of foot problems presented to the family physician (FP) decreased substantially from 80.0 [95% confidence interval (CI) 77.0–84.7] to 17.4 (95% CI 16.5–18.3) per 1000 person-years (P < 0.0001). The incidence rate of flat feet decreased from 4.9 (95% CI 4.0–5.9) per 1000 person-years in 1987 to 3.4 (95% CI 3.0–3.8) per 1000 person-years in 2001 (P = 0.001). The distribution of referrals to other primary health care professionals and medical specialists has almost reversed in favour of primary health care professionals.

Conclusion. Total incidence rate of musculoskeletal foot problems seen by the FP has decreased substantially, between 1987 and 2001.

Methods. We used an observational prevalence study in primary care from one Staffordshire practice in 2005–2006. Egton Medical Information Systems Ltd computer database was searched for patients with two Modification of Diet in Renal Disease eGFRs separated by 3 months, HB levels and medications.

Results. From a list size of 1830 patients, 362 had two eGFRs <60; of those, 308 had a HB available. In all, 29 (9.4%) patients had NICE renal anaemia, with over-representation of diabetic patients, 13 (16%) against 16 (7%) without diabetes (P < 0.02). We found that diabetic patients were also over-represented at HB 11.0 to <12.5 g/dl, 26 (32%) with diabetes and 39 (17.6%) without (P < 0.001). Mean HB was significantly lower for the diabetic group (n = 81, 26%), 12.8 g/dl (95% Confidence Intervals (CI) 12.4–13.1) against non-diabetic group (n = 227, 74%), 13.4 g/dl (95% CI 13.2–13.6), P < 0.01. Predictors of HB on multivariate regression analysis were female gender, eGFR and diabetes (all P < 0.001).

Conclusions. Diabetic patients were more likely to have NICE defined renal anaemia in this primary care population with CKD stages 3–5. This is similar to observations in secondary care settings. We observed over-representation of diabetic patients above NICE definition at HB 11.0 to <12.5 g/dl.

Objective. To assess the effectiveness of a multiple intervention in primary care at a large scale.

Methods. A controlled before and after study in 2006 and 2007 was designed. Participants were from general practices within a geographically defined area in the middle region of The Netherlands. Participants were GPs in 141 practices in 25 peer review groups. A control group of GP practices from the same region, matched for type of practice and mean volume of antibiotic prescribing. The multiple intervention consisted of the following elements: (i) group education meeting and communication training; (ii) monitoring and feedback on prescribing behaviour; (iii) group education for GPs and pharmacists assistants and (iv) patient education material. The main outcome measures are as follows: (i) number of antibiotic prescriptions per 1000 patients per GP and (ii) number of second-choice antibiotics, obtained from claims data from the regional health insurance company. The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses.

Results. At baseline, the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group (184 versus 176). In 2007, the number of prescriptions had increased to 232 and 227, respectively, and not differed between intervention and control group.

Conclusions. The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates. The failure might be attributed to a less tight monitoring of intervention and audit. Inserting practical tools in the intervention might be more successful and should be studied.

Aim. To identify subgroups of patients with depression who could be the focus of effectiveness trials.

Methods. Qualitative research using in-depth interviews in UK primary care. In-depth interviews with 30 participants from three stakeholder groups: 10 acupuncture patients and 10 acupuncturists—to examine the reasons why acupuncture is used for depression and 10 physicians—to elicit who would be acceptable to refer into a trial of acupuncture for depression. Interviews were transcribed and analysed using a Framework approach.

Results. The data have highlighted that the acceptability of particular treatments for depression is influenced by the individuals' illness career within their social context. In addition, the plausibility and associated acceptability of depression treatments are also closely tied to an individuals' explanatory model of their condition. Seven patient subgroups were identified who could potentially find acupuncture of particular interest and on which effectiveness trials could be focused.

Conclusions. We have identified the main reasons why people seek acupuncture for depression and the circumstances in which physicians would be willing to refer for depression were it to prove effective. We have also set out a number of potential patient subgroups who may be particularly interested participating in a randomized controlled trail of acupuncture for depression.

Objective. To explore and categorize the health concerns of adolescent girls sending unsolicited emails to a teenage girls’ magazine.

Method. We conducted a content analysis of 1000 systematic randomly selected unsolicited emails submitted to the health column of an Australian adolescent girls’ magazine over a 6-month period.

Results. Three main foci of concern were identified: Context of Concern, Health Issue of Concern and Advice Sought for Concern. Within Health Issue of Concern, there were five categories: body (47.5%), sex (31.9%), relationship (14.7%), mind (4.7%) and violence and/or safety (1.2%). Concerns within the body and sex categories ranged enormously, but frequently expressed intimate descriptions of anatomy, feelings, sexual practices and relationships. Many concerns occurred in the context of adolescents’ relationships with others. The proportion of concerns about physical or psychological symptoms or health issues commonly associated with the adolescent age group (such as health risk behaviours, mental health, pregnancy and sexually transmitted infections) was relatively small.

Conclusions. GPs and other health professionals might engage more readily with adolescent patients with a deeper understanding of the concerns that adolescents have about their bodies, relationships and overall health. Seemingly ‘trivial’ issues, such as normal puberty, could be used as discussion triggers in health consultations to help alleviate anxiety and build rapport.

Objective. This study investigates how pharmaceutical sales representative visits influenced physicians’ company-specific drug preferences and prevalence of steroid prescribing.

Methods. Observational cohort study in Funen County, Denmark, including 165 general practices visited 832 times by pharmaceutical representatives and 54 080 patients treated with asthma drugs. Visits were conducted from 2001 to 2003. Our main outcome measures were (i) company-specific drug preferences measured as the proportion of dispensings of the promoted drug among all dispensings of fixed combinations of inhaled corticosteroid and long-acting β₂-agonists and (ii) the proportion of patients receiving repeated β₂-agonist dispensings who were treated with inhaled steroids.

Results. The first visit had a statistically significant effect on the GPs’ drug preference in favour of the marketed drug [odds ratio (OR), 2.39; 95% confidence interval (CI), 1.72–3.32]. The effect on drug preference increased further after the second visit (OR, 1.51; 95% CI, 1.19–1.93), while there was no significant change after the third visit (OR, 1.06; 95% CI, 0.94–1.20). Pharmaceutical sales representative visits did not influence the overall treatment pattern with inhaled steroids (OR, 1.01; 95% CI, 0.97–1.06).

Conclusions. Pharmaceutical sales representative visits markedly increased the market share of the promoted drug, but only the two first visits had significant impact. Visits had no significant impact on GPs’ overall prescribing of inhaled steroids.

Objectives. The aim was to explore the views of GPs and patients in London and Melbourne about primary care system features which support or hinder best care for mild-to-moderate depression. The study differentiated between policy and reality ‘on the ground’.

Methods. Two round Delphi technique methodology with four panels: GPs and patients in London and GPs and patients in Melbourne, to elicit views on the extent to which system features were reflected in policy, reflected in reality and were of value for best care.

Results. Four themes were generated: system and financing, responsibility and continuity, consultations and primary care team. Patient-centred care, having sufficient time during a consultation, and the GP–patient relationship extending over time were rated highly by all panels. Panellists differentiated between policy and reality on a number of features.

Conclusions. The Australian system does not guarantee continuity of care with practitioner or practice but patients took steps to see the same doctor for depression. There was a difference in the way London and Melbourne panels responded to finance-related statements. There was a tendency for panellists to value aspects of their own system and to fail to see possibilities of other systems.

Objective. To assess cancer survivors’ perceived need for physical and psychosocial rehabilitation, whether these needs have been presented to and discussed with their GP.

Methods. A survey among a cohort of cancer survivors approximately 15 months after diagnosis. The questionnaire consisted of an ad hoc questionnaire on rehabilitation needs and the two validated questionnaires, the SF-12 and the Research and Treatment of Cancer quality of life questionnaire, the QLQ C-30 version 3.

Results. Among 534 eligible patients, we received 353 (66.1%) answers. Two-thirds of the cancer survivors had discussed physical rehabilitation needs with their GPs. Many (51%) feared cancer relapse, but they rarely presented this fear to the GP or the hospital staff. The same applied to social problems and problems within the family. Good physical and mental condition and low confidence in the GP were associated with no contact to the GP after hospital discharge.

Conclusion. Cancer survivors have many psychosocial rehabilitation needs and intervention should effectively target these needs. If this task is assigned to the GPs, they need to be proactive when assessing psychosocial aspects.

Objective. To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands.

Methods. The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians’ (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs’ diagnosis of COPD.

Results. After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1–4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3–83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice.

Conclusions. There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

Objective. To investigate the association between statin use and the reporting of muscular complaints by patients and simultaneously control for several known factors of musculoskeletal complaints.

Methods. In a cross-sectional study with 1031 consecutive patients (>50 years of age) in 26 offices of GPs, two investigators collected the data from the office files and by interviewing the patients. A logistic regression model was used to identify variables affecting the odds of muscular symptoms.

Results. The prevalence of lipid-lowering drug prescription was 23% (n = 239) and that of muscular complaints was 40% (n = 411). In all, 44% (n = 106) of the patients with lipid-lowering drug prescription had muscular complaints compared to 39% (n = 305) of the patients without lipid-lowering drug therapy. Statin prescription and 10 variables remained in the final model. Statin prescription is associated with a 1.5-fold odds of musculoskeletal complaints compared to non-prescription {odds ratio [OR] = 1.5 [95% confidence interval (CI), 1.1–2.0], P = 0.02}.

Conclusion. Having a statin prescription appears to be an independent factor associated with musculoskeletal symptoms in primary care settings. Statin use may be more often associated with musculoskeletal complaints than previously assumed.

Methods. Primary care physicians participating in the SSSN were guided by diagnostic criteria for asthma. Rates of asthma episodes per 1000 consultations were calculated for all, for first and subsequent asthma episodes and for allergic and non-allergic asthma. Allergic asthma was defined as asthmatic manifestations in conjunction with eczema and/or hay fever. The smoothed time trend and its 95% confidence intervals were determined using generalized additive models with a loess smoother adjusting for seasonality.

Results. Consultations for allergic asthma have decreased between 1999 and 2005. Looking at different age groups, asthma associated with hay fever was reported with decreasing frequency in all age groups, whereas when associated with eczema, the other used marker of allergic asthma, slightly increased among young children.

Conclusions. The decrease of consultations for asthma is most probably due to the allergic component of asthma. Diagnostic shift over time and ready available medications probably contributed to this phenomenon. Our findings indicate a real decline of allergic asthma.

Practice recommendations. Consultations for asthma have decreased over recent years. The decrease of consultations for asthma is most probably due to the allergic component of asthma. Diagnostic shift over time and available medications probably contributed to this phenomenon. Strength of Recommendation Taxonomy (SORT) rating: strength of recommendation = C, level of evidence = 3.

Objective. To find the relationship between treatment satisfaction of diabetic patients and socio-demographic, clinical, adherence, treatment and health perception factors.

Methods. Patients were interviewed by telephone about their socio-demographic parameters, health status, clinical data and treatment factors. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) was used to measure satisfaction and adherence. This is a cross-sectional study, as part of a larger study of chronic patients in Israel. Subjects were randomly selected diabetes patients. The main outcome measures were DTSQ levels. A multivariate linear regression model was constructed to identify factors independently associated with patients’ satisfaction.

Results. In all, 630 patients were included in the study. Multivariate analysis indicated that demographic parameters (e.g. female gender, P = 0.036), treatment factors (e.g. type of medication, P < 0.001), adherence factors (e.g. difficulty attending follow-up or taking medications, P < 0.001) and clinical factors (e.g. diabetes complications, P < 0.01) were independently associated with lower treatment satisfaction.

Conclusions. Treatment satisfaction is lower among diabetic patients who have a lower educational level, who are insulin treated or have a diabetic complication and is related to difficulties in taking medications and coming to follow-up visits. Addressing the specific needs of these patients might be effective in improving their satisfaction, thus having a positive influence on other clinical outcomes.

Objective. To explore GPs' experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease.

Methods. Fourteen experienced GPs from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis.

Results. The overall theme was ‘dilemmas’ in GPs' treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Second, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Third, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourth, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties in integrating science into reality.

Conclusions. The five dilemmas in the GPs' approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs' professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence.

Methods. Qualitative study using phenomenology. In-depth interviews with patients and their treating GPs. General practices in the northern suburbs of Perth, Western Australia. Participants. Maximum variation sample of nine patients suffering from mild to moderate whiplash and their treating GPs. GPs identified patients with recent whiplash. In-depth interviews were conducted with both groups. Patients were telephoned 3 months later to evaluate progress. Analysis used a constant comparative process and independent transcript review assisted by N-Vivo software.

Results. Patients articulated a need to be understood by a physician whom they knew and trusted. For all, the principal underlying concerns were about pain and the financial and physical impact of the injury, particularly in view of its perceived potential to harm the spine. While most patients expected medical interventions to help facilitate speedy recovery, physicians were far more pessimistic. Despite acknowledging the importance of addressing psychological needs, most GPs underestimated the degree of patient distress in the post-injury period. Although guardedly supportive of the local insurance system, GPs were scornful of patients seeking inappropriate compensation.

Conclusions. Findings highlight the influence of the patient–doctor relationship on clinical care in patients with whiplash, suggesting that the path to patient recovery and physician satisfaction may benefit if clinicians better understand patient experiences. The disconnect between patient and practitioner conceptualization of the problem challenges quality patient-centred care.

Objective. To identify variations in ways of understanding drug prescribing among GPs.

Methods. A descriptive qualitative study was conducted with 20 Swedish physicians. Informants were recruited purposively and their understandings about prescribing were studied in semi-structured interviews. Data were analysed using a phenomenographic approach.

Results. Five categories were identified as follows: (A) GP prescribed safe, reliable and well-documented drugs for obvious complaints; (B) GP sought to convince the patient of the most effective drug treatment; (C) GP chose the best drug treatment taking into consideration the patient's entire life situation; (D) GP used clinical judgement and close follow-up to minimize unnecessary drug prescribing and (E) GP prescribed drugs which are cheap for society and environmentally friendly. The categories are interrelated, but have different foci: the biomedical, the patient and the society. Each GP had more than one view but none included all five. The findings also indicate that complexity increases when a drug is prescribed for primary or secondary prevention.

Conclusions. GPs understand prescribing differently despite similar external circumstances. The most significant factor to influence prescribing behaviour was the physician's patient relation approach. GPs may need to reflect on difficulties they face while prescribing to enhance their understandings.

Methods. The project had a multi-level recruitment strategy requiring recruitment of randomly selected practices before randomly selecting GPs, practice nurses and caregivers of children enrolled at those practices. Detailed quantitative and qualitative recruitment data were recorded on an access database. Post-recruitment, recruiters underwent semi-structured interviews. Analysis was mixed method, with triangulation of descriptive statistics of the number of calls and time course to recruitment and general inductive thematic analysis of qualitative data.

Results. Identifying key decision makers and how individual practice processes work can save significant recruitment time. Factors identified as assisting practice recruitment included using a personal approach from doctor to doctor, getting buy-in from all practice staff, streamlining the research process to minimize disruption to the practice and flexibility to accommodate practices.

Conclusions. The task of recruiting should not be underestimated. Adequate time and resource need to be allocated from the onset. Long periods where practices have no added burdens such as audits, mass vaccination programmes or influenza season are unlikely, therefore there are always considerable challenges in recruiting practices for research. Remaining flexible to individual practice styles and influences and acknowledging the commitment of participants is important.

Methods. The RCT was not powered to detect differences in the cost-effectiveness; therefore, we adopted a decision analytic model approach as a way of gaining precision in our cost-effectiveness comparisons [e.g. prednisolone only (PO) versus acyclovir only versus prednisolone and acyclovir versus placebo, prednisolone versus no prednisolone (NP) and acyclovir versus no acyclovir]. We assumed that trial interventions affect the probability of being cured/not cured but their consequences are independent of the initial therapy. We used the percentage of individuals with a complete recovery (based on House–Brackmann grade = 1) at 9 months and Quality Adjusted Life Years (e.g. derived on responses to the Health Utilities Index III) as measures of effectiveness. Other parameter estimates were obtained from trial data.

Results. PO dominated—i.e. was less costly and more effective—all other therapy strategies in the four arms model [77% probability of cost-effective (CE)]. Moreover, Prednisolone dominated NP (77% probability of being CE at £30 000 threshold) while no acyclovir dominated aciclovir (85% chance of CE), in the two arms models, respectively.

Conclusions. Treatment of BP with prednisolone is likely to be considered CE while treatment with acyclovir is highly unlikely to be considered CE. Further data on costs and utilities would be useful to confirm findings.

Objective. To evaluate the prevalence of heart failure and the pharmacological management of heart failure in relation to European Society of Cardiology (ESC) and National Institute for Health and Clinical Excellence guidelines.

Methods. Retrospective cohort study using routinely collected data from 163 general practices across Great Britain contributing data to the Doctors Independent Network (DIN-LINK) database over a 5-year period until December 31, 2006.

Results. From a patient population of nearly 1.43 million, 9311 patients with heart failure were identified [mean age 78 years (SD 12)], giving an estimated prevalence of 0.7%. Of these, 7410 (79.6%) were prescribed a loop diuretic, 6620 (71.1%) were prescribed an angiotensin-converting enzyme (ACE) inhibitor or ARB, 3403 (36.6%) were prescribed β-blockers but only 2732 (29.3%) were prescribed an ACE inhibitor or ARB and a β-blocker in combination. Thirty-five per cent of patients prescribed ACE inhibitor and 11.5% of those prescribed β-blockers met ESC guideline target doses. Age, gender and comorbidity predicted whether patients received β-blocker or ACE inhibitor with younger males being more likely to receive maximal therapy.

Conclusions. These data suggest that while most patients with heart failure receive an ACE inhibitor/ARB in primary care, few are titrated to target dose and many do not receive a β-blocker. Optimum treatment appears to be most likely for young men. New strategies are required to ensure equitable and optimal treatment for all.

Objective. To evaluate the effectiveness of exercise in the management of PND.

Methods. Systematic review and meta-analysis of randomized controlled trials (RCTs). Data sources involved in the study are Cochrane Library (CENTRAL), MEDLINE, EMBASE, PsycINFO, Science Citation Index and Social Science Citation Index, CINAHL and SPORTDiscus.

Review methods. Selection criteria are RCTs and quasi-RCTs that compared any type of exercise intervention with other treatments or no treatment in women with PND. Database searches and abstracts were reviewed independently by two authors. The Delphi criteria were used to assess the quality of included studies. Data were abstracted by two reviewers. Data synthesis is meta-analysis. Main outcome measure is post-natal depression.

Results. Five studies fulfilled our inclusion criteria. When compared with no exercise, exercise reduced symptoms of PND {SMD = –0.81 [95% confidence interval (CI): –1.53 to –0.10]}. The overall WMD in Edinburgh Post-natal Depression Scale score was –4.00 points (95% CI: –7.64 to –0.35). However, significant heterogeneity was found. The effect size was reduced considerably (non-significant) when the trial that included exercise as a co-intervention with social support was excluded [SMD = –0.42 (95% CI: –0.90 to 0.05)] and heterogeneity was no longer present.

Conclusions. Due to heterogeneity, it is uncertain whether exercise reduces symptoms of PND. Caution is also required when interpreting findings from the main analysis as only five small trials were included and CIs were wide. Further research is evidently required.

Objective. To determine the costs and cost savings to the NHS of instalment dispensing for newly prescribed medicines and to quantify the extra costs incurred by patients.

Methods. Patients were randomized to receive either a normal (n = 103) or an instalment (n = 101) prescription.

Results. The difference between prescribed and dispensed drug costs in the intervention group was £0.98 per patient (95% confidence interval £0.14–£1.82), giving a 7% reduction in drug costs. The costs of the additional pharmacy time required to implement the intervention was calculated to be £5.02 per patient.

Conclusions. Introduction of a system of instalment dispensing produced savings in the general practice of drugs bill, but these were not large enough to offset additional costs for pharmacists.

Objective. Prevalence and detection rates of COPD in smokers in German general practice.

Methods. Twenty-eight of 34 invited and eligible GP surgeries in/around Duesseldorf, Germany, took part in the non-announced 2-day investigation of all smokers (≥40 years) who visited the surgeries. Lung function test by hand-held spirometer, peak flow, sympton part of St George's Respiratory Questionnaire, and data on smoking habits were used. GOLD criteria for COPD were employed. GPs had to give their diagnosis not knowing the test results.

Results. Of 3157 patients attending the 28 surgeries, 538 were smokers. Four hundred and thirty-seven of these agreed to participate, 5 had to be excluded for medical reasons/unacceptable spirometry. Three hundred and ninety-eight patients have not been previously diagnosed with COPD or asthma. Thirty patients were disgnosed with COPD, making a prevalence of 6.9%, of which 15 patients were already known as having COPD.

Conclusion. Our result of low prevalence differs strongly from all other studies in general practice. Considering our study design which avoids selection bias found in nearly all other studies (no pre-announcement, no self-selection of patients or GPs, high participation rate and testing all patients), we strongly believe that our findings reflect the current situation of COPD in German general practice.

Objective. We assessed the diagnostic value of CRP in primary care and accident and emergency departments in terms of ruling in or ruling out CAP.

Methods. Diagnostic accuracy systematic review, we searched PubMed from January 1966 to September 2008 and EMBASE from January 1980 to September 2008 using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of CRP at different cut-points against a reference standard of chest X-ray. We calculated pooled positive and negative likelihood ratios (LRs) and assessed heterogeneity using the I² index.

Results. Eight studies incorporating 2194 patients were included. The median prevalence of CAP was 14.6% (range 5%–89%). At a CRP cut-point of ≤20 mg/l, the pooled positive LR+ was 2.1 [95% confidence interval (CI) 1.8–2.4] and the pooled negative LR– was 0.33 (95% CI 0.25–0.43). At the two other CRP cut-points (≤50, >100 mg/l), the results were heterogeneous, so the pooled results should be interpreted with caution.

Conclusions. CRP may be of value in ruling out a diagnosis of CAP in situations where the probability of CAP >10%, typically accident and emergency departments. In primary care, additional diagnostic testing with CRP is unlikely to alter the probability of CAP sufficiently to change subsequent management decisions such as antibiotic prescribing or referral to hospital.

Objective. To assess the accuracy of the ABI measured using a stethoscope comparatively to that of the current eligible method for the diagnosis of PAD, the Doppler ABI, and describe the characteristics of this new approach.

Methods. We conducted a diagnostic study of ABI measured with a stethoscope and a Doppler probe and compared the results. Eighty-eight patients were accessed by both methods.

Results. Mean stethoscope ABI, 1.01 ± 0.15, and mean Doppler ABI, 1.03 ± 0.20, (P = 0.047) displayed a good correlation. Measurements of stethoscope ABI diagnostic accuracy in recognizing a Doppler ABI are described. The comparison of this data with the current gold standard method results gave a sensitivity of 71.4% [95% confidence interval (CI), 41.9–91.6] and specificity of 91.0% (95% CI, 81.5–96.6), with predictive positive value of 62.5% (95% CI, 38.6–81.5) and negative predictive value of 93.8% (95% CI, 85.2–97.6). The study accuracy was 87.7%. The area under the ROC curve was 0.895 (95% CI, 0.804–0.986, P < 0.0001).

Conclusions. According to our study, the stethoscope ABI is a useful method to detect PAD and it may be suitable for its screening in the primary care setting.

Objective. This paper explores qualitative descriptions of how depression in gay men and HIV-positive men is managed by GPs.

Methods. As part of the qualitative component of a mixed method study on HIV and depression, semi-structured interviews were conducted with 16 GPs in three geographical settings in Australia: Sydney, Adelaide and a rural coastal town.

Results. GPs identified a range of features in their experience of managing depression in gay men and in HIV-positive men. Some were common to the care of other groups with depression, but this paper reports on features unique to this patient group. These include capitalizing on the high frequency of contact with this patient group, taking advantage of the specialist multidisciplinary teams who provide support, building upon the unusual willingness of this patient group to take medication, appreciating the central importance to many gay men of sexual functioning, and recreational drug use, responding to social isolation in this patient group and coping with increasing challenges for the HIV general practice workforce.

Conclusions. Despite the identification of several key strengths in working with this patient group, the ability of GPs to develop their capacity to manage depression in gay men and men with HIV is uncertain in the context of a growing range of challenges for GPs in both mental health and HIV care.

Objective. To understand GPs’ explanatory models (EMs) and management strategies for IBS.

Methods. Qualitative, semi-structured interviews with 30 GPs (15 from the UK and 15 from The Netherlands).

Results. Diagnosing IBS in primary care is a complex process, involving symptoms, tests, history and risk calculation. GPs were uncertain about the aetiology of IBS, but often viewed it as a consequence of disordered bowel activity in response to stress, which was viewed as a function of people's responses to their environment. GPs tend to diagnose IBS by exclusion, rather than with formal diagnostic criteria. They endeavoured to present the IBS diagnosis to their patients in a way that they would accept, fearing that many would not be satisfied with a diagnosis that had no apparent physical cause. GPs focused on managing symptoms and reassuring patients. Many GPs felt that patients needed to take the responsibility for managing their IBS and for minimizing its impact on their daily lives. However, the GPs had limited awareness of the extent to which IBS affected their patients’ daily lives.

Conclusions. GPs’ diagnostic procedures and EMs for IBS are at odds with patient expectations and current guidelines. Shared discussion of what patients believe to be triggers for symptoms, ways of coping with symptoms and the role of medication may be helpful.

Objectives. To understand the EMs, experiences and expectations for management of patients with IBS.

Methods. Qualitative, semi-structured interviews were conducted with 51 primary care patients (31 in the UK, 20 in The Netherlands) meeting the Rome II diagnostic criteria for IBS.

Results. Although IBS often had a significant dampening effect on daily life, IBS patients made great efforts not to allow the condition to take over their lives. Triggers of symptoms were more important to patients than understanding the underlying aetiology of IBS. Diet and stress were both recognized as important triggers, but views about which foods were problematic and the extent to which stress was modifiable were inconsistent. Diagnosis and treatment were often a confusing and frustrating process, and patients often expected more diagnostic tests than they were offered before receiving a diagnosis of IBS. However, the often poor outcome of medical interventions does not, in general, appear to have a negative impact on the patient–doctor relationship.

Conclusions. Clinicians should be aware of the extensive impact of IBS on sufferers’ daily life and the frustration that results from repeatedly trying treatments with little effect. Clearly explaining the guidelines for diagnosing IBS and the range of treatment options may help patients to make sense of the diagnostic and treatment processes. The personal EM should be addressed during the consultation with the IBS patient, ensuring that any successive medical interventions match with the patients’ disease perception.

Objective. To identify factors that experienced research staff consider important in successful recruitment and retention and their confidence in achieving them.

Methods. An iterative series of three workshops was held. The third used a modified nominal group technique to categorize whether factors related to the ‘context’ in which the research took place, the ‘content’ of the study or the recruitment ‘process’ and to prioritize them by their importance to success.

Results. Eighteen research staff participated in the prioritization workshop. They prioritized positive attitudes of primary care staff towards research and trust of researchers by potential participants as major contextual factors affecting recruitment. Studies needed to be considered safe and relevant by staff and fit with practice systems. They proposed that researchers strengthen relationships with staff and participants and minimize workload for primary care teams. Although confident in many recruitment processes, respondents remained uncertain how to achieve cultural change so that research became part of normal practice activity and how best to motivate patients to participate.

Conclusions. Research workers taking part identified factors which might be important in recruitment, several of which they expressed little confidence in addressing. Understanding how to improve recruitment is crucial if current efforts to strengthen primary care research are to bear fruit.

Objective. To evaluate the effects of offering an educational programme to home visitors and GPs on mortality, functional ability and nursing home admissions among home-dwelling older people.

Methods. Design: Municipality pair-matched randomized trial.

Setting: Danish primary care.

Subject: 2863 home-dwelling 75-year-olds and 1171 home-dwelling 80-year-olds living in 34 municipalities.

Intervention: Home visitors received regular education for a period of 3 years. In nine of 17 intervention municipalities, GPs participated in one small group training session during the first year.

Main outcome measures: Mortality, functional ability and nursing home admission during 41/2 years of follow-up.

Results. Intervention was not associated with mortality. Home visitor education was associated with reduction in functional decline among home-dwelling 80-year-olds after the three intervention years in municipalities where GPs accepted and participated in small group-based training. Effects did not persist after the intervention ended. When analyses were restricted to baseline non-disabled persons, intervention was associated with beneficial effects on functional ability after three intervention years among 80-year-olds, regardless of education was given to home visitors alone or to visitors and GPs. Nursing home admission rates were lower among the 80-year-olds living in the intervention municipalities.

Conclusion. A brief, practicable interdisciplinary educational programme for primary care professionals postponed functional decline in non-disabled 80-year-old home-dwelling persons.