Amanda Howe

Management of depression in UK general practice in relation to scores on depression severity questionnaires: analysis of medical record data.

Objective To determine if general practitioner rates of antidepressant drug prescribing and referrals to specialist services for depression vary in line with patients’ scores on depression severity questionnaires. Design Analysis of anonymised medical record data. Setting 38 general practices in three sites—Southampton, Liverpool, and Norfolk. Data reviewed Records for 2294 patients assessed with severity questionnaires for depression between April 2006 and March 2007 inclusive. Main outcome measures Rates of prescribing of antidepressants and referrals to specialist mental health or social services. Results 1658 patients were assessed with the 9 item patient health questionnaire (PHQ-9), 584 with the depression subscale of the hospital anxiety and depression scale (HADS), and 52 with the Beck depression inventory, 2nd edition (BDI-II). Overall, 79.1% of patients assessed with either PHQ-9 or HADS received a prescription for an antidepressant, and 22.8% were referred to specialist services. Prescriptions and referrals were significantly associated with higher severity scores. However, overall rates of treatment and referral were similar for patients assessed with either measure despite the fact that, with PHQ-9, 83.5% of patients were classified as moderately to severely depressed and in need of treatment, whereas only 55.6% of patients were so classified with HADS. Rates of treatment were lower for older patients and for patients with comorbid physical illness (including coronary heart disease and diabetes) despite the fact that screening for depression among such patients is encouraged in the quality and outcomes framework. Conclusions General practitioners do not decide on drug treatment or referral for depression on the basis of questionnaire scores alone, but also take account of other factors such as age and physical illness. The two most widely used severity questionnaires perform inconsistently in practice, suggesting that changing the recommended threshold scores for intervention might make the measures more valid, more consistent with practitioners’ clinical judgment, and more acceptable to practitioners as a way of classifying patients.

Portfolios in continuing medical education – effective and efficient?

A cross over comparison between ‘traditional’ continuing medical education (CME) activities and portfolio‐based learning in general practice is described.

Towards an understanding of resilience and its relevance to medical training

Medical Education 2012: 46: 349–356

Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial

Objective To test whether a drug review and symptom self management and lifestyle advice intervention by community pharmacists could reduce hospital admissions or mortality in heart failure patients. Design Randomised controlled trial. Setting Home based intervention in heart failure patients. Participants 293 patients diagnosed with heart failure were included (149 intervention, 144 control) after an emergency admission. Intervention Two home visits by one of 17 community pharmacists within two and eight weeks of discharge. Pharmacists reviewed drugs and gave symptom self management and lifestyle advice. Controls received usual care. Main outcome measures The primary outcome was total hospital readmissions at six months. Secondary outcomes included mortality and quality of life (Minnesota living with heart failure questionnaire and EQ-5D). Results Primary outcome data were available for 291 participants (99%). 136 (91%) intervention patients received one or two visits. 134 admissions occurred in the intervention group compared with 112 in the control group (rate ratio=1.15, 95% confidence interval 0.89 to 1.48; P=0.28, Poisson model). 30 intervention patients died compared with 24 controls (hazard ratio=1.18, 0.69 to 2.03; P=0.54). Although EQ-5D scores favoured the intervention group, Minnesota living with heart failure questionnaire scores favoured controls; neither difference was statistically significant. Conclusion This community pharmacist intervention did not lead to reductions in hospital admissions in contrast to those found in trials of specialist nurse led interventions in heart failure. Given that heart failure accounts for 5% of hospital admissions, these results present a problem for policy makers who are faced with a shortage of specialist provision and have hoped that skilled community pharmacists could produce the same benefits. Trial registration number ISRCTN59427925.

Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study

Objective To gain understanding of general practitioners’ and patients’ opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. Design Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. Participants 34 general practitioners and 24 patients. Setting 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. Results Patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment (“phronesis”) to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. Conclusions Despite general practitioners’ caution about measures of severity for depression, these may benefit primary care consultations by increasing patients’ confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires.

Involving patients in medical education

Patients have always been part of medical education, but we can no longer assume that they will choose to participate. The drive towards informed consent and a more equal partnership in shared decision making in clinical practice implies a need for different approaches to involving patients.1 In addition, recent reforms of medical education now use more structured and extensive patient contact,2 3 and this cannot be achieved solely through opportunistic patient contact in clinics and on wards. Using original data and background literature, we examine what is known about involving patients in medical education and suggest ways to improve learning and patient satisfaction. Consent must be obtained from all patients before they are involved in teaching Credit: WILL AND DENI McINTYRE/SPL This article is based on a search of Medline and references from primary sources, using the keywords consent, patient involvement, patient participation, empowerment, medical, and clinical education and the findings of a workshop at the University of East Anglia examining best practice for involving patients in student learning. The university took its first MBBS students in October 2002. We used purposive sampling to draw participants from groups likely to have a role in involving patients in medical education. Invitations to key organisations resulted in 49 delegates, with about one third clinical staff, one third key education-alists (tutors, faculty members, etc), and one third patients or their advocates. We used focus groups to discuss the following questions: We compiled data …

Effects of payment for performance in primary care: qualitative interview study.

Objectives To understand the effects of a large scale ‘payment for performance’ scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service. Methods Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics. Results Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from ‘patient led’ consultations and listening to patients’ concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about ‘box-ticking’ and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives. Conclusions Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients’ concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.

Prevalence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in three regions of England: a repeated cross-sectional study in primary care

BackgroundMyalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) or chronic fatigue syndrome (CFS) has been used to name a range of chronic conditions characterized by extreme fatigue and other disabling symptoms. Attempts to estimate the burden of disease have been limited by selection bias, and by lack of diagnostic biomarkers and of agreed reproducible case definitions. We estimated the prevalence and incidence of ME/CFS in three regions in England, and discussed the implications of frequency statistics and the use of different case definitions for health and social care planning and for research.MethodsWe compared the clinical presentation, prevalence and incidence of ME/CFS based on a sample of 143,000 individuals aged 18 to 64 years, covered by primary care services in three regions of England. Case ascertainment involved: 1) electronic search for chronic fatigue cases; 2) direct questioning of general practitioners (GPs) on cases not previously identified by the search; and 3) clinical review of identified cases according to CDC-1994, Canadian and Epidemiological Case (ECD) Definitions. This enabled the identification of cases with high validity.ResultsThe estimated minimum prevalence rate of ME/CFS was 0.2% for cases meeting any of the study case definitions, 0.19% for the CDC-1994 definition, 0.11% for the Canadian definition and 0.03% for the ECD. The overall estimated minimal yearly incidence was 0.015%. The highest rates were found in London and the lowest in East Yorkshire. All but one of the cases conforming to the Canadian criteria also met the CDC-1994 criteria, however presented higher prevalence and severity of symptoms.ConclusionsME/CFS is not uncommon in England and represents a significant burden to patients and society. The number of people with chronic fatigue who do not meet specific criteria for ME/CFS is higher still. Both groups have high levels of need for service provision, including health and social care. We suggest combining the use of both the CDC-1994 and Canadian criteria for ascertainment of ME/CFS cases, alongside careful clinical phenotyping of study participants. This combination if used systematically will enable international comparisons, minimization of bias, and the identification and investigation of distinct sub-groups of patients with possibly distinct aetiologies and pathophysiologies, standing a better chance of translation into effective specific treatments.

Patient-centred medicine through student-centred teaching : a student perspective on the key impacts of community-based learning in undergraduate medical education

The UK General Medical Council has proposed that increased use of community settings is essential to enhancement of medical education. However, such curriculum developments have been directed by educationalists and clinical faculty; there is to date little to show whether student perspectives accord with such expectations.

New perspectives--approaches to medical education at four new UK medical schools.

With the expansion in UK medical student numbers, four new medical schools have been established. The authors, all senior faculty members at these new schools at the time of writing, discuss how much the schools have in common in their approaches to medical education