Gerard Bury

A new short form individual quality of life measure (SEIQoL-DW): application in a cohort of individuals with HIV/AIDS

Quality of life is an increasingly important outcome measure in medicine and health care. Many measures of quality of life present patients with predetermined lists of questions that may or may not be relevant to the individual patient. This paper describes a brief measure, the SEIQoL-DW, which is derived from the schedule for evaluation of individual quality of life (SEIQoL). The measure allows respondents to nominate the areas of life which are most important, rate their level of functioning or satisfaction with each, and indicate the relative importance of each to their overall quality of life. Given its practicality and brevity, the measure should prove particularly useful in clinical situations where patient generated data on quality of life is important. This article describes the first clinical application of the measure, assessing the quality of life of a cohort of patients with HIV/AIDS managed in general practice.

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

Abstract Objective: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost. Design: A randomised controlled trial. Setting: A busy inner city hospitals accident and emergency department which employed three local general practitioners on a sessional basis. Patients: All new attenders categorised by the triage system as “semiurgent” or “delay acceptable.” 66% of all attenders were eligible for inclusion. Main outcome measures: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences. Results: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended. 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were £Ir1427 and £Ir117005 respectively. Conclusion: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. Key messages Key messages A study extending this innovation shows that the care provided to non-emergency patients by general practitioners working as an integral part of an accident and emergency department also differs substantially from the care provided by the usual staff in terms of process Compared with the usual accident and emer- gency department staff, general practitioners investigate fewer patients, refer to other hospital services less often, more often refer patients back to their own general practitioners for follow up, admit fewer patients, and prescribe more often General practitioners within an accident and emergency department have no apparent effect on reattendance rates to the department within 30 days, patient satisfaction, or health status one month after the initial attendance As yet there are no explanations for these differ- ences, which warrant further research

Prevalence of fatigue in general practice.

BackgroundFatigue is an important symptom in general practice due to its association with physical, psychological and social problems.AimTo determine the prevalence of fatigue as an unsolicited symptom during general practice consultations.MethodsA random sample of GPs practising in Ireland was invited to provide data on consultations held over one day. Data were recorded on the presence of fatigue as a main or supporting symptom, social and demographic characteristics.ResultsData were recorded by 89 GPs on 1,428 consultations. The prevalence of fatigue was 25%. It was the main reason for attending the dcctor in 6.5% and a secondary reason in 19%. Sixty-two per cent of patients were female and 48% were eligible for free GP services. The mean age was 47.1 years. The presence of fatigue was associated with: attending a female GP, being female, attending a GP who had been qualified for fewer years and attending the GP frequently.ConclusionThe prevalence of fatigue reported in this study is over three times higher than that reported in earlier work. Doctor characteristics appear to be as important as patient characteristics in determining fatigue.

Searching for the evidence in pre-hospital care: a review of randomised controlled trials. On behalf of the Ambulance Response Time Sub-Group of the National Ambulance Advisory Committee.

OBJECTIVES: To identify randomised controlled trials (RCTs) which evaluate aspects of pre-hospital care; to perform categorisation by theme; to compare the sensitivity and precision of the search databases. DATA SOURCES: August 1997 updates of MEDLINE and EMBASE databases, using the Datastar online system. Papers published in 1987 or later were included, with no language restrictions. STUDY SELECTION: A trial was eligible for inclusion if it was judged, by two independent and blinded assessors, that participants followed up in the trial were definitely or possibly assigned prospectively to one of two or more alternative forms of healthcare with random allocation or a quasi-random method of allocation. RESULTS: The literature search retrieved 849 papers, of which 569 (67%) were in MEDLINE and 486 (57%) in EMBASE. Forty one (5%) were confirmed as reports of RCTs or quasi-RCTs, and the total number of individual trials was 38. Ten of these trials dealt with thrombolytic drugs; 14 were concerned with other drugs, 12 with equipment, and two with other interventions. Four trials were based on a sample size of more than 1000, and seven reported a statistically significant effect on mortality. All 41 papers were in EMBASE, and all but one were also in MEDLINE. CONCLUSIONS: Evidence based policy making with respect to the organisation of pre-hospital services cannot depend on RCTs. In the current relative absence of such evidence, practitioners and decision makers must use alternative information sources. A future review could examine a broader range of literature and be based on a wider search of published and unpublished material.

Adherence of Irish general practitioners to European guidelines for acute low back pain: A prospective pilot study

There are no national low back pain (LBP) clinical guidelines in Ireland, and neither the level of adherence of General Practitioners (GPs) to the European guidelines, nor the cost of LBP to the patient and the state, have been investigated.

A qualitative investigation of the views and health beliefs of patients with Type 2 diabetes following the introduction of a diabetes shared care service

Aims  A qualitative research approach was adopted in order to explore the views and health beliefs of patients with Type 2 diabetes who had experienced a new structured diabetes shared care service.

Effect of patients seeing a general practitioner in accident and emergency on their subsequent reattendance: cohort study.

General practitioners working in an accident and emergency department manage non-emergency patients safely and use fewer resources than do usual accident and emergency staff.1 2 In our previous study we speculated that this intervention might have the potential to break the cycle of “inappropriate attendance” at accident and emergency, use of hospital resources, and perceived confirmation of need for a visit.2 We now report the results of a review of the reattendance rates of our original study group. The setting and methodology of our original study have been described.2 In short, patients who had attended St Jamess Hospital accident and emergency department between 1 August 1993 and 1 October 1994 were triaged using a validated system into four categories—“life threatening” (1), “urgent” (2), “semi-urgent” (3), and “delay acceptable” (4). Local general practitioners were employed on a sessional basis to manage patients only from categories 3 and …

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment

BackgroundProblem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care.MethodsThis qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer.ResultsWe identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment.ConclusionsProblem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored.

Management of hepatitis C among drug users attending general practice in Ireland: Baseline data from the Dublin Area Hepatitis C in General Practice Initiative

Objective: In Ireland, general practice is increasingly providing long-term care for injecting drug users, 62–81% of whom are infected with hepatitis C (HCV). Clinical guidelines for the management of HCV among drug users have recently been developed in Ireland, and this study aimed to describe HCV care among drug users attending general practice in the greater Dublin area, prior to the implementation of the clinical practice guidelines. Methods: The clinical records of 196 patients attending 25 general practices in the Eastern Regional Health Authority area of Ireland for methadone maintenance treatment were examined on site and anonymized data collected on HCV care processes. Results: Patients had been attending general practice for methadone maintenance treatment for a mean of 30.7 months, 72% were male and 51% had provided a urine sample testing positive for metabolites of drugs of abuse other than methadone in the previous 3 months. There was evidence that 77%, 69% and 60% had been screened for HCV, human immunodeficiency virus (HIV) and hepatitis B (HBV), respectively. Among those who had been tested, the prevalence of HCV, HIV and HBV infection was 69%, 10% and 11%, respectively. Of those known to be HCV positive, 36 (35%) had been tested for HCV-RNA (29 testing positive), 31 (30%) had been referred to a hepatology clinic, 24 (23%) had attended a clinic, 13 (13%) had a liver biopsy performed and three (3%) had started treatment for HCV. Conclusion: While the majority of patients have been screened for blood-borne viruses, a minority of those infected with HCV have had subsequent investigations or treatment. New interventions to facilitate optimum care in this regard need to be considered.

Determinants of partial or no primary immunisations

Objective To determine if different factors affect children having full, partial or no primary immunisations. Methods This was a crossgenerational cohort study with linkage to primary care and hospital records conducted in urban and rural settings in Ireland, recruiting in 2001–2003 with 5-year follow-up. A total of 749 children with immunisation information took part. Results The uptake of reported primary immunisations was 92.8% full, 4.9% partial and 2.3% no primary immunisations. Adjusted relative risk ratios for children receiving no primary immunisations were significant for: having a mother who had ever visited an alternative practitioner 3.69 (1.05 to 12.9), a mother with means tested full general medical services eligibility 8.11 (1.58 to 41.65), a mother who scored <50 for the World Health Organization Quality of Life (WHO-QOL) scale psychological domain 8.82 (1.79 to 43.6) or living in the west of Ireland (rural) 3.64 (1.0 to 13.2). Being born prematurely was associated with partial primary immunisation, adjusted OR 4.63 (1.24 to 17.3). Conclusions Knowledge of these differences will help target campaigns to increase full uptake of primary immunisations.