Robert K McKinley

Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

abstract Objectives: To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community. Design: Postal questionnaire survey using Nijmegen questionnaire. Setting: One general practice with 7033 patients. Participants: All adult patients aged 17-65 with diagnosed asthma who were receiving treatment. Main outcome measure: Score23 on Nijmegen questionnaire. Results: 227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored 23. Those scoring 23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally. Conclusions: About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma. What is already known on this topic Abnormal breathing patterns may cause characteristic symptoms and impair quality of life Effective interventions exist for dysfunctional breathing Dysfunctional breathing has been described in patients attending hospital respiratory clinics What this study adds 29% of adults treated for asthma in primary care had symptoms suggestive of dysfunctional breathing Affected patients were more likely to be female and younger, but no differences were found with severity of asthma Some patients with asthma may benefit from breathing therapy

Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the united kingdom: development of a patient questionnaire

Abstract Objective: To develop a reliable, valid measure of patient satisfaction with out of hours care suitable for large scale service evaluation. Design: Focus group meetings and semistructured interviews with patients to identify issues of importance to patients and possible questionnaire items; interviews and two pilot studies to test and identify new questionnaire items; modification or removal of items to eliminate ambiguity and reduce non-response and skewed responses; questionnaire survey of out of hours care. Setting: Greater Manchester and Leicester. Subjects: 11 general practice patients participated in the focus groups and 28 in the semistructured interviews; 41 in the preliminary interviews; 41 and 378 in the postal pilots; and 1466 in the survey of out of hours care. Results: A 32 item questionnaire was developed. Component analysis indicated seven scales (satisfaction with communication and management, doctors attitude, continuity of care, delay until visit, access to out of hours care, initial contact person, telephone advice) related to overall satisfaction and containing issues identified as important to patients. Levels of reliability were satisfactory, Cronbachs α correlation coefficient exceeding 0.60 for all scales. Conclusion: A reliable, valid measure of patient satisfaction has been developed, suitable for large scale evaluation of out of hours care. Key messages The provision of out of hours primary medical care is changing, and these changes need to be evaluated and monitored Patient satisfaction is an important measure of the outcome of health care A reliable and valid measure of patient satisfaction with out of hours primary medical care has been developed Development of such scales is demanding on time and experience but is feasible Ad hoc measures of satisfaction should be avoided and when possible reliable, valid scales used

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial

Background: Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing. Methods: 33 adult patients aged 17–65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores ⩾23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores Results: Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05–1.12) and 0.09 (−0.25–0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11–1.17) and 0.09 (−0.58–0.5) for the symptoms domain (p=0.042), 0.52 (0.09–1.25) and 0 (−0.45–0.45) for the activities domain (p=0.007), and 0.50 (0–1.50) and −0.25 (−0.75–0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (−0.10–1.71) and −0.05 (−0.74–0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months. Conclusion: Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.

Breathing exercises for asthma: a randomised controlled trial

Background: The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain. Methods: A prospective, parallel group, single-blind, randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention) was performed. Subjects with asthma with impaired health status managed in primary care were randomised to receive three sessions of either physiotherapist-supervised breathing training (n = 94) or asthma nurse-delivered asthma education (n = 89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyper-responsiveness, exhaled nitric oxide, induced sputum eosinophil count and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores. Results: One month after the intervention there were similar improvements in AQLQ scores from baseline in both groups but at 6 months there was a significant between-group difference favouring breathing training (0.38 units, 95% CI 0.08 to 0.68). At the 6-month assessment there were significant between-group differences favouring breathing training in HAD anxiety (1.1, 95% CI 0.2 to 1.9), HAD depression (0.8, 95% CI 0.1 to 1.4) and Nijmegen (3.2, 95% CI 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 95% CI 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyper-responsiveness. Conclusion: Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication.

Model for directly assessing and improving clinical competence and performance in revalidation of clinicians

It is now clear that revalidation and clinical governance will drive continuing professional development in medicine in the United Kingdom. 1 2 Thus patients, society, and the profession are to be assured that individual doctors not only are fit to practise but are providing high quality care for patients. The focus of professional revalidation is rightly moving from the requirement that practitioners merely provide evidence of participation in continuing education towards the requirement that they provide evidence that better reflects their clinical practice. 3 4 Nevertheless, the primary screening procedures that have been proposed for revalidation are indirect (see box).4 If used at all, tests of clinical competence come much later in the process, but few tests include direct observation of practice. We present the case for the primacy of obtaining direct evidence of clinical competence of any doctor being revalidated; discuss the essential attributes of any process of obtaining such evidence; describe the ways in which such evidence can be gathered; explore the limitations of review tools currently available; and suggest an appropriate model for performance review. #### Summary points The measures currently proposed for assessing competence in clinician revalidation are mainly indirect or proxy As the consultation is the single most important event in clinical practice, the central focus of revalidation should be the assessment of consultation competence Such assessment should be by direct observation and satisfy five criteria—reliability, validity, acceptability, feasibility, and educational impact Assessment of consultation competence would be followed by assessment of specific skills and regular performance review Such an assessment procedure is recommended for use in the revalidation of all clinicians #### Recent proposed components of revalidation in United Kingdom Indirect …

Patient satisfaction with out of hours primary medical care

Objectives—To describe the relationship between patient satisfaction with out of hours care provided by deputising and practice doctors in four urban areas in England and characteristics of the service provided and patients, the care given, and health outcomes. Setting—Fourteen general practices in four urban areas in England. Participants—People who requested out of hours care. Design—Analysis of data from a study of out of hours care. Patients were interviewed within 5 days of their request for out of hours care. Data on the service provided were obtained from medical records and all other data were collected at interview. Satisfaction was measured using a valid reliable instrument. Results—2152 patients were recruited to the study and 1466 were interviewed. Satisfaction data were available on 1402 patients. “Overall satisfaction” was associated with age, doctor type, lack of access to a car at the time of the request, and health outcome. The relationships between satisfaction subscales and patient characteristics (age, sex, ethnicity, and access to a car at the time of the request), service characteristics (doctor type and delay between the request and visit), whether a prescription was given, and health outcome were variable. If an expected home visit was not received, “overall satisfaction” and satisfaction with “communication and management”, “doctors attitude”, and “initial contact person” were reduced. Conclusion—Patient satisfaction is dependent on many factors. Mismatch between patient expectation and the service received is related to decreased satisfaction. This may increase as general practitioners delegate more out of hours care to cooperatives and deputising services.

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment Package

To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter‐assessor reliability, acceptability, feasibility and educational impact.

Checklists for assessment and certification of clinical procedural skills omit essential competencies: a systematic review

Objective  To develop generic criteria for the global assessment of clinical procedural competence and to quantify the extent to which existing checklists allow for holistic assessment of procedural competencies.

Development of a behaviour change intervention: a case study on the practical application of theory

BackgroundUse of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation.MethodsThe development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified.ResultsThe behaviour change intervention presented the GPs with a well-defined proposal for change; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication); and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised ‘context-bound communication skills training.’ Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA.ConclusionsA stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.

Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study

BACKGROUND Health care is increasingly provided in general practice. To meet this demand, the English Department of Health recommends that 50% of all medical students should train for general practice after qualification. Currently 19% of medical students express general practice as their first career choice. Undergraduate exposure to general practice positively influences future career choice. Appropriate undergraduate exposure to general practice is therefore highly relevant to workforce planning AIM This study seeks to quantify current exposure of medical students to general practice and compare it with past provision and also with postgraduate provision. DESIGN AND SETTING A cross-sectional questionnaire in the UK. METHOD A questionnaire regarding provision of undergraduate teaching was sent to the general practice teaching leads in all UK medical schools. Information was gathered on the amount of undergraduate teaching, how this was supported financially, and whether there was an integrated department of general practice. The data were then compared with results from previous studies of teaching provision. The provision of postgraduate teaching in general practice was also examined. RESULTS General practice teaching for medical students increased from <1.0% of clinical teaching in 1968 to 13.0% by 2008; since then, the percentage has plateaued. The total amount of general practice teaching per student has fallen by 2 weeks since 2002. Medical schools providing financial data delivered 14.6% of the clinical curriculum and received 7.1% of clinical teaching funding. The number of departments of general practice has halved since 2002. Provision of postgraduate teaching has tripled since 2000. CONCLUSION Current levels of undergraduate teaching in general practice are too low to fulfil future workforce requirements and may be falling. Financial support for current teaching is disproportionately low and the mechanism counterproductive. Central intervention may be required to solve this.