Related Articles

Background

The symptom iceberg describes the phenomenon that most symptoms are managed in the community without people seeking professional health care. The size of the iceberg for many symptoms is unknown, as is their association with personal characteristics, including history of a chronic disease.

Aim

To ascertain the size of the symptom iceberg in the UK.

Design of study

A UK-wide community-based postal survey.

Setting

Urban and rural communities across the UK.

Method

A postal survey was sent to an age- and sex-stratified random sample of 2474 adults, aged 18–60 years, drawn from 20 practices around the UK. Questions were aimed at investigating adults' experiences of 25 different symptoms in the previous 2 weeks.

Results

The number of symptoms experienced by one individual in the previous 2 weeks ranged from 0 to 22 (mean 3.66). Of the symptoms examined, the three most common were: feeling tired/run down; headaches; and joint pain. Univariate analysis found symptom prevalence to be significantly associated with a wide range of participant characteristics. However, after adjustment, many of these associations no longer remained significant for a number of the symptoms. Presence of a chronic condition, age, and employment status were the three factors most commonly associated with the 2-week prevalence of symptoms. Reported symptom characteristics (severity, duration, interference, and time off work) varied little by sex or age.

Conclusion

Symptoms in the UK community are common. Symptom prevalence was associated with a number of participant characteristics, although the extent of this association was less than has been reported in previous research. This study provides an important current baseline prevalence of 25 symptoms in the community for those who do, and do not, have a chronic condition.

Background

Symptom characteristics are strong drivers of care seeking. Despite this, incongruous consultation behaviour occurs and has implications for both individuals and health-care services. The aim of this study was to determine how frequently incongruous consultation behaviour occurs, to examine whether it is more common for certain types of symptoms and to identify the factors associated with being an incongruous consulter.

Methods

An age and sex stratified random sample of 8,000 adults was drawn from twenty UK general practices. A postal questionnaire was used to collect detailed information on the presence and characteristics of 25 physical and psychological symptoms, actions taken to manage the symptoms, general health, attitudes to symptom management and demographic/socio-economic details. Two types of incongruous consultation behaviour were examined: i) consultation with a GP for symptoms self-rated as low impact and ii) no consultation with a GP for symptoms self-rated as high impact.

Results

A fifth of all symptoms experienced resulted in consultation behaviour which was incongruous based on respondents' own rating of the symptoms' impact. Low impact consultations were not common, although symptoms indicative of a potentially serious condition resulted in a higher proportion of low impact consultations. High impact non-consultations were more common, although there was no clear pattern in the type of associated symptoms. Just under half of those experiencing symptoms in the previous two weeks were categorised as an incongruous consulter (low impact consulter: 8.3%, high impact non-consulter: 37.1%). Employment status, having a chronic condition, poor health, and feeling that reassurance or advice from a health professional is important were associated with being a low impact consulter. Younger age, employment status, being an ex-smoker, poor health and feeling that not wasting the GPs time is important were associated with being a high impact non-consulter.

Conclusions

This is one of the first studies to examine incongruous consultation behaviour for a range of symptoms. High impact non-consultations were common and may have important health implications, particularly for symptoms indicative of serious disease. More research is now needed to examine incongruous consultation behaviour and its impact on both the public's health and health service use.

Objectives

To investigate the hypothesis that complaints of adverse events related to encounters with healthcare personnel are underreported and to identify barriers to filing such complaints.

Design

A cross-sectional study, where a questionnaire was sent to the respondents asking whether or not they have filed complaints of adverse events. Respondents were also asked whether they have had reasons for doing so but abstained, and if so their reasons for not complaining. The authors also asked about participants' general experience of and trust in healthcare.

Setting

The County of Stockholm, Sweden.

Participants

A random sample of 1500 individuals of the general population registered by the Swedish National Tax Board as living in the County of Stockholm in April 2008. Of the selected group, aged 18–99 years, 50% were women and 50% men. Response rate was 62.1%, of which 58% were women and 42% were men; the median age was 49 years.

Primary and secondary outcome measures

Primary outcome measures were whether the participants have filed a formal complaint with the Patients' Advisory Committee and whether they have had reason to file a complaint but have refrained from doing so. Secondary outcome measures were the participants' general experience of and trust in healthcare.

Results

Official complaints have been filed by 23 respondents (2.7%, 95% CI 1.7% to 3.7%), while 159 (18.5%, 95% CI 15.9% to 21.1%) stated that they have had legitimate reasons to file a complaint but have abstained (p<0.001). The degree of under-reporting was greater among patients with a general negative experience of healthcare (37.3%, 95% CI 31.9% to 42.7%) compared with those with a general positive experience (4.8%, 95% CI 2.4% to 7.2%). The reasons given for abstaining were, among others, ‘I did not have the strength’, ‘I did not know where to turn’ and ‘It makes no difference anyway’. Respondents with a general negative experience also had lower trust in healthcare.

Conclusions

The authors found a considerable discrepancy between the actual complaint rate and the number of respondents stating that they have had reasons to complain but have abstained. This indicates that in official reports of complaints, the authors only see ‘the tip of an iceberg’.

Article summary

Article focus

To test the hypothesis that patients' complaints about adverse events related to negative encounters in healthcare are under-reported.

To study barriers to filing complaints.

To investigate whether trust in and experiences of healthcare are related.

Key messages

Patient complaints about negative encounters are under-reported, disclosing only the tip of an iceberg.

The main barriers to complaints are that patients do not find the strength to make them, do not know where to turn or do not find it worthwhile since they do not believe it will make any difference.

Negative encounters seem to have a negative impact on the exposed patients' trust in healthcare.

Strengths and limitations of this study

The study reveals the barriers to complaining in a clear way, which enables healthcare personnel to work actively to provide a more supportive environment for the patients in case of adverse events.

The study sample was small and there was no time-limit regarding events respondents might consider and refer to, which means that our results cannot be compared with official complaint rates.

Background: Gastroesophageal reflux disease (GERD) has a major impact at the primary care level and there is a need to evaluate whether the diagnosis and therapeutic management of GERD in Europe needs to be improved.

Methods: This project was designed to test the hypothesis that a new primary care management strategy would improve outcomes for patients with GERD, compared with usual care, in Europe. The analysis pools five separate cluster-randomized studies conducted in Austria, Italy, Norway, Spain and Sweden. These studies used a strategy based on the self-administered GerdQ questionnaire to stratify adult patients with symptoms of heartburn or regurgitation according to the frequency and impact of symptoms. A score of ≥8 indicates a high probability of suffering GERD. Patients with a GerdQ impact score ≤2 were treated with generic proton-pump inhibitors according to local guidance, and patients with an impact score ≥3 were treated with esomeprazole 40 mg once daily.

Results: In total, 2400 patients were enrolled across the five studies. The protocols were modified by individual countries according to their local guidelines/requirements. In Norway, the new management strategy was compared with traditional routine endoscopy and 24-hour pH-metry, and encompassed proton-pump inhibitor reimbursement restrictions. Outcome measures differed by country, but included control of GERD symptoms, self-rated health status and work productivity, treatment changes, specialist referrals and physician adherence. GERD-related use of healthcare resources was also evaluated.

Conclusion: The pooled analysis will determine whether a locally adapted primary care management strategy for GERD, using GerdQ as a patient-tailored diagnostic and therapeutic evaluation tool, is beneficial compared with usual care across five countries with different standard approaches to GERD management and control.

Objectives:

To describe the Boston Area Community Health (BACH) survey, a National Institutes of Health[en]supported epidemiological study of symptoms suggestive of the following urologic conditions: urinary incontinence, benign prostatic hyperplasia, interstitial cystitis, chronic pelvic pain of bladder origin, prostatitis, hypogonadism, erectile dysfunction, and female sexual dysfunction.

Methods:

BACH used a two-stage stratified cluster design to recruit a community-based random sample of 5506, divided between males (2301) and females (3205), three racial/ethnic groups (black, Hispanic, and white), and four age groups (30[en]39, 40[en]49, 50[en]59, 60[en]79 yr). Validated questionnaires were used to collect information on urologic symptoms, comorbidities, prescribed and over-the-counter medications, reproductive history, quality of life, health care utilization, physical activity, depressive symptoms, interpersonal stress, smoking, alcohol use, fluid intake, nutrition, menopausal status, sexual activity, abuse, anthropometrics (measured height, weight, hip and waist circumference, pulse rate, blood pressure), and sociodemographics including country of origin, marital status, employment status, and income. Blood samples were collected from 68% of all subjects.

Results:

A large representative community-based sample was successfully recruited to provide both cross-sectional and eventually longitudinal data to address important urologic questions.

Conclusions:

BACH has features distinguishing it from most other epidemiological studies in urology. It uses a random community-based sample of people who are racially/ethnically diverse and includes a broad age range (30[en]79 yr). It includes both males and females The study focuses on symptoms rather than variably defined disease conditions, it is multidisciplinary, and it is designed to become longitudinal.

Background:

Hypertension, dyslipidemia, and other cardiovascular risk factors are linked epidemiologically, clinically, and metabolically. Intensive/Initial Cardiovascular Examination regarding Blood Pressure levels, Evaluation of Risk Groups (ICEBERG) study focuses on the effect of dyslipidemia on cardiovascular risk evaluation and association of lipid profile with other risk factors.

Patients and methods:

The ICEBERG study consisted of two sub-protocols: ICEBERG-1, conducted at 20 university hospitals (Referral Group) and ICEBERG-2, conducted at 197 primary healthcare centers (Primary Care Group). Sub-protocol had two patient profiles: patients previously diagnosed with essential hypertension and under medical treatment (Treated Group) and patients with systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg, with no antihypertensive treatment for at least 3 months before inclusion (Untreated Group). Dyslipidemia was evaluated and cardiovascular risk stratification was performed according to ESC/ESH guidelines.

Results:

More than half of the treated and untreated subjects were classified into high or very high cardiovascular risk groups. In a total of 1817 patients, the percentage of patients in “high” plus “very high” added risk groups increased to 55.2% in Treated Referral Group (p < 0.001), to 62.6% in Untreated Referral Group (p = 0.25) and to 60.7% in Untreated Primary Care Group (p < 0.001), by re-evaluation of patients’ lipid values.

Conclusions:

Serum lipid levels are useful in stratifying hypertensive patients into cardiovascular risk groups more accurately, for appropriate antihypertensive treatment.

Background Management of neuropsychiatric symptoms is a challenging task in primary care. Aims To assess self-reported confidence and knowledge of general practitioners (GPs) regarding the identification and management of behavioural and psychological symptoms of dementia (BPSD).

Methods A self-designed two-page paper questionnaire was sent to a random sample of 160 GPs practising in north Dublin. They were asked to evaluate their confidence and knowledge on several aspects of diagnosis and management of BPSD.

Results Completed questionnaires were returned from 109 GPs (response rate = 68%), of which 106 were usable. In general, GPs were somewhat critical of their self-reported skills in diagnosing (76.4%) and managing (77.4%) BPSD, as well as in discriminating BPSD from other behavioural disturbances (71.7%). Many of them (67.9%) also encountered difficulty accessing specialist services. There was no correlation between demographic characteristics of GPs or patient caseload with respect to their responses to questionnaire items. Although many GPs (92.5%) highly valued the important role of non-pharmacological interventions in BPSD, none of them reported recommending these in their daily practice.

Conclusions Despite the fact that GPs have a wealth of knowledge about BPSD, they are largely critical of their knowledge and management skills of these symptoms. Efforts should be focused on supporting GPs by means of educational interventions that consider all aspects of dementia, but additionally highlight the more challenging neuropsychiatric components of the illness. Health services need to be structured in a way that promotes collaboration between GPs and mental health professionals for a seamless delivery of care.

BACKGROUND: Recent health promotion guidelines reimbursed primary health care teams for targeting lifestyle advice to patients at risk of cardiovascular disease. However, it is unclear whether primary health care teams do target advice, who is targeted, and whether the advice is acted upon. AIM: To assess which factors predict the targeting and recall of lifestyle advice. METHOD: A total of 370 patients with, and 192 without, a computer record of risk factors for cardiovascular disease (hypertension, diabetes, ischaemic heart disease/myocardial infarction/angina, a body mass index > or = 30) from two contrasting Wessex practices were sent a postal questionnaire about medical conditions, recall of lifestyle advice, current lifestyle, and their perceptions about the health of their lifestyle. RESULTS: Seventy-seven per cent of patients responded. There was good agreement between listed risk factors and patients reporting a risk factor (kappa = 0.60), which was similar for both sexes and better in older age groups. Recall of lifestyle advice was not significantly affected by practice, but was more likely in patients with listed risk factors (adjusted odds ratio [OR] = 4.62, 95% confidence intervals [CI] = 2.89-7.37) and in men (OR = 1.64, 95% CI = 1.07-2.52), and less likely in older age groups (age < or = 64 years = 1.00; 65-74 years = 0.47, 95% CI = 0.27-0.81; 75+ years = 0.34, 95% CI = 0.20-0.60). Of patients with listed risk factors, 27% could not recall having received any advice, and recall varied with medical condition. Only 40% of patients with reported high blood pressure recalled being given advice about salt. Those who recalled advice were more likely to report a healthier current lifestyle. Of those with unhealthy lifestyles, 30-50% were unaware that their lifestyle was unhealthy. CONCLUSION: Lifestyle advice is not recalled for some important risk factors, and some patients are unaware of their unhealthy lifestyle. Although advice is being preferentially targeted to those with risk factors, women and older patients recall advice less. Research is needed to assess the cost-effectiveness of advice for both sexes and different ages.

Background

Insomnia is a common public health problem and the prevalence and impact of insomnia in primary care attendees is not well documented in the Asian population.

Objectives

To determine the prevalence of self-reported insomnia symptoms amongst adult primary care attendees and the association with socio-demographic factors; to ascertain the impact of insomnia on daily functioning and to describe the psychological profile of patients with insomnia.

Methods

In this cross-sectional survey, 2049 adult patients (≥18 year old) attending seven primary care clinics in Peninsular Malaysia, completed the questionnaire asking about symptoms of insomnia (defined according to the International Classification of Sleep Disorders and DSM IV criteria) daytime impairment and psychological symptoms (assessed by Hospital Anxiety and Depression Scale).

Results

The response rate was 86.2%. A total of 60% reported insomnia symptoms, 38.9% had frequent insomnia symptoms (>3 times per week), 30.7% had chronic insomnia without daytime consequences and 28.6% had chronic insomnia with daytime dysfunction. Indian ethnicity (OR 1.79; 95%CI, 1.28-2.49), age ≥ 50 or older (OR 1.82; 95%CI, 1.10-3.01), anxiety symptoms (OR 1.65; 95%CI, 1.21-2.22) and depression symptoms (OR 1.65; 95%CI, 1.21-2.26) were risk factors for chronic insomnia with daytime dysfunction. Amongst those with chronic insomnia with daytime dysfunction, 47.8% had anxiety symptoms (OR, 2.01; 95%CI, 1.57-2.59) and 36.5% had depression symptoms (OR, 2.74; 95%CI, 2.04-3.68) based on HADs score. They also had tendency to doze off while driving and to be involved in road traffic accidents.

Conclusions

A third of primary care attendees have insomnia symptoms and chronic insomnia, associated with significant daytime dysfunction and psychological morbidity. By identifying those at risk of having chronic insomnia, appropriate interventions can be commenced.

BACKGROUND: The organization and management of general practice is changing as a result of government policies designed to expand primary health care services. One aspect of practice management which has been underresearched concerns staffing: the recruitment, retention, management and motivation of practice managers. AIM: A study set out to find out who is routinely involved in making decisions about staffing matters in general practice, to establish the extent to which the human resource management function is formalized and specialized, and to describe the characteristics of the practice managers. METHOD: A postal questionnaire was sent to a stratified random sample of 750 general practices in England and Wales in February 1994 enquiring about the practice (for example, the fundholding status and number of general practitioner partners), how the practice dealt with a range of staffing matters and about the practice manager (for example, employment background and training in human resource management). Practices were classed as small (single-handed and two or three general practitioner partners), medium (four or five partners) or large (six or more partners). RESULTS: Replies were received from 477 practices (64%). Practice managers had limited authority to make decisions alone in the majority of practices although there was a greater likelihood of them taking independent action as the size of practice increased. Formality in handling staffing matters (as measured by the existence and use of written policies and procedures) also increased with practice size. Larger practices were more likely than smaller practices to have additional tiers in their management structure through the creation of posts with the titles assistant practice manager, fund manager and senior receptionist. Most practice managers had been recruited from within general practice but larger practices were more likely than smaller practices to recruit from outwith general practice. Three quarters of practice managers reported having received some type of formal training in staff management. CONCLUSION: This study shows that practice size is a major factor associated with differences in the organization and management of staffing. Any initiatives which increase the scale of primary care functions and services would have to address the issues of communication and coordination that might be associated with such a change.

INTRODUCTION

The management of Hirschsprung’s disease continues to evolve. This questionnaire survey aimed to determine current surgical management strategies for Hirschsprung’s disease in Britain.

SUBJECTS AND METHODS

The survey was sent electronically to all British paediatric surgeons. Initial questions explored individual experience and regional service provision. Additional questions, reserved for surgeons who perform definitive Hirschsprung’s disease surgery, addressed specific clinical scenarios.

RESULTS

Surveys were sent to 142 surgeons yielding 85 responses. After exclusions, 64 surveys from 21 centres were analysed. Forty-seven respondents worked in centres with designated ‘Hirschsprung’s disease surgeons’. Forty respondents perform definitive Hirschsprung’s disease surgery. In a well neonate with left-sided Hirschsprung’s disease, 34 of 40 surgeons favour primary pull-through following bowel decompression with rectal washouts; 35 of 40 surgeons aim to perform definitive surgery at less than 3 months of age, with 17 favouring laparoscopic-assisted Soave–Boley and 15 favouring an open Duhamel pull-through. Of the 40 surgeons, 36 use a staged approach to right-sided/total colonic Hirschsprung’s disease with 23 favouring a Duhamel or Long Duhamel pull-through.

CONCLUSIONS

The primary pull-through, using an open Duhamel or laparoscopic-assisted Soave–Boley technique, during the first 3 months of life, has become the operative strategy of choice in rectosigmoid Hirschsprung’s disease in Britain. Marked variation in practice remains for right-sided Hirschsprung’s disease.

Background Significant government spending has resulted in substantial changes to the Australian primary mental healthcare system. Initially producing the Better Outcomes in Mental Health Care (BOiMHC) initiative, this has been replaced by the Better Access to Mental Health Care programme, which allows all general practitioners (GPs) to refer patients for allied psychological health care under Medicare. Aim To examine changes in patient management and referral for care following the BOiMHC initiative.

Method Comparison of results of a 2006 postal survey of Australian GPs examining self-reported management of patients with depression with a similar survey conducted in 2001–2002, prior to the BOiMHC initiative.

Results One hundred and thirty-three (33%) GPs responded. The main self-reported strategies for managing patients with depression were similar to the previous study: supportive counselling and medication. No significant difference was found in rates of self-reported formal training in psychological treatments. Significantly higher rates of referral for psychological treatments were reported in 2006 than in 2002. Small trends towards higher reported referral for and reported use of psychological treatments by GPs registered for the BOiMHC initiative were noted when compared with those who were not registered.

Conclusion While GPs' main reported strategies for managing patients with depression were unchanged, reported referral for psychological therapies was significantly higher in 2006, possibly reflecting the impact of changes to the primary mental healthcare system. Ongoing rigorous evaluation of further changes to the primary mental healthcare system are needed to determine whether they deliver effective, evidence-based care, and thus to inform future programmes.

OBJECTIVE

Many factors are at play in the process of clinical decision making, but to date, the interaction of these factors has not been well understood. Such information could have important implications for teaching and promoting evidence-based medicine (EBM) in primary care. This study was designed to explore the relationship between physician-related variables and management of patient-related contextual factors in clinical decision making. A secondary objective was to examine the extent to which this relationship varies by type of clinical decision.

DESIGN

Cross-sectional randomized postal survey of 1134 Canadian primary care physicians stratified by age, sex, and practice location. Nonrespondents were sent reminders at 4 weeks and again at 8 weeks; at 12 weeks, all remaining nonrespondents were mailed replacement copies of the questionnaire.

SETTING

Family practices in Canada.

PARTICIPANTS

Of the final sample of 431 family physicians, 52% were men, 63% practised in urban locations, and 71% were in group practice.

MAIN OUTCOME MEASURES

Self-reported likelihood of considering various contextual factors during the course of clinical decision making.

RESULTS

Despite the three follow-up mailings, the final response rate was 42%; however, nonrespondents did not differ significantly from respondents on three important demographic factors: age, sex, and practice location. Using multinomial logistic regression analysis, the data showed that female family physicians and practitioners less strongly identified with EBM were more likely to consider contextual factors in clinical decision making. The effect was more obvious for ordering tests than for decisions about treatment.

CONCLUSION

The evolving model of EBM should consider important physician-related variables in clinical decision making. Our data indicate that physicians’ sex and identification with the tenets of EBM influence management of contextual factors. These results have important implications because they indicate that clinicians strongly identified with the EBM model of clinical practice are less sensitive to context, which might be an obstacle to efforts to integrate patient values and clinical circumstances into patient-centred care. We believe these findings support continued development of the model of “context-sensitive medicine” previously proposed as an alternative to EBM.

Background

There is no validated way of measuring diagnostic delay in cancer, especially covering patient and primary care delays. An instrument is needed in order to determine the effect of potential interventions to reduce delay and improve cancer morbidity and mortality.

Methods

Development of a postal questionnaire tool to measure patient and primary care time responses to key symptoms and signs. The pilot questionnaire was sent to 184 patients with suspected cancer.

Results

The response rate was only 85/184 (46.2%). Anxiety was cited as one reason for this low response. Patients returning questionnaires were more likely to be women and more likely to be younger. 84/85 (98.8%) provided consent to access medical records, and questions regarding health profile, smoking and socio-economic profile were answered adequately. Outcome data on their cancer diagnosis was linked satisfactorily and the question about GP-initiated investigations was answered well. Estimated dates for symptom duration were preferred for patient delays, but exact dates were preferred for primary care delays; however there was a significant amount of missing data.

Conclusion

A more personal approach to the collection of data about the duration of symptoms in this group of people is needed other than a postal questionnaire. However elements of this piloted questionnaire are likely to figure strongly in future development and evaluation of this tool.

Background

Poor mental health has large social and economic consequences both for the individual and society. In Sweden, the prevalence of mental health symptoms has increased since the beginning of the 1990s. There is a need for a better understanding of the area for planning preventive activities and health care.

Methods

The study is based on a postal survey questionnaire sent to a random sample of men and women aged 18–84 years in 2004. The overall response rate was 64%. The area investigated covers 55 municipalities with about one million inhabitants in central part of Sweden. The study population includes 42,448 respondents. Mental health was measured with self-reported symptoms of anxiety/depression (EQ-5D, 5th question). The association between socio-economic conditions, lifestyle factors and mental health symptoms was investigated using multivariate multinomial logistic regression models.

Results

About 40% of women and 30% of men reported that they were moderately or extremely anxious or depressed. Younger subjects reported poorer mental health than older subjects, the best mental health was found at ages 65–74 years.

Factors that were strongly and independently related to mental health symptoms were poor social support, experiences of being belittled, employment status (receiving a disability pension and unemployment), economic hardship, critical life events, and functional disability. A strong association was also found between how burdensome domestic work was experienced and anxiety/depression. This was true for both men and women. Educational level was not associated with mental health symptoms.

Of lifestyle factors, physical inactivity, underweight and risk consumption of alcohol were independently associated with mental health symptoms.

Conclusion

Our results support the notion that a ground for good mental health includes balance in social relations, in domestic work and in employment as well as in personal economy both among men and women. In addition, physical inactivity, underweight and risk consumption of alcohol are associated with mental health symptoms independent of socio-economic factors.

Objectives: To determine whether practice structure (for example, list size, number of staff) predicts team processes and whether practice structure and team process in turn predict team outcomes

Design: Observational study using postal questionnaires and medical note audit. Team process was assessed through a measure of "climate" which examines shared perceptions of organisational policies, practices, and procedures.

Setting: Primary care.

Subjects: Members of the primary health care team from 42 practices.

Main outcome measures: Objective measures of quality of chronic disease management, patients' evaluations of practices, teams' self-reported ratings of effectiveness, and innovation.

Results: Team climate was better in singlehanded practices than in partnerships. Practices with longer booking intervals provided superior chronic disease management. Higher team climate scores were associated with superior clinical care in diabetes, more positive patient evaluations of practice and self-reported innovation and effectiveness.

Conclusions: Although the conclusions are preliminary because of the limited sample size, the study suggests that there are important relationships between team structure, process, and outcome that may be of relevance to quality improvement initiatives in primary care. Possible causal mechanisms that might underlie these associations remain to be determined.

BACKGROUND: The prevalence of urinary symptoms that impact on quality-of-life will be important in determining resource allocation in primary care groups. AIM: To determine the prevalence of urinary symptoms and their perceived impact in a community population of women. METHOD: A postal survey using a validated self-completed questionnaire among all women aged over 18 years and registered with one general practice in a major British city. The prevalence rates and perceived impact of a wide range of urinary symptoms and their relationship with age was determined. Data were analysed using the chi-squared test and the chi-squared test for trend. Spearman's rank correlation was used to assess the relationship between symptom severity and perceived impact. RESULTS: The number of completed questionnaires returned was 2075, giving an 80% response rate. Of these, the number of women who reported some degree of incontinence in the previous month was 1414 (69%), although only 578 (30%) indicated that it had social or hygienic impact. Other lower urinary tract symptoms reported included nocturia (19%), poor stream (19%), urgency (61%), and dysuria (23%). The most troublesome symptoms were incontinence for no obvious reason, nocturnal incontinence, and nocturia, with 73%, 69%, and 63% of sufferers, respectively, finding these symptoms troublesome. CONCLUSIONS: Incontinence and other urinary symptoms are more common than previously thought. These symptoms are not always perceived as bothersome or as having a social or hygienic impact, and therefore many women who report urinary leakage do not require treatment. Nocturnal symptoms in women are commoner than might have been supposed and are extremely troublesome to sufferers.

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.

Background/Aims

The prevalence of diagnosed gastroparesis is 24.2/100,000 inhabitants, but a large group of people with gastroparesis-like symptoms have never had a gastric emptying (GE) test. Some of them may have undiagnosed gastroparesis. Our aim was to estimate the prevalence of hidden gastroparesis in the community.

Methods

The study was conducted in 2 parts: (1) Patients referred for a scintigraphic GE test completed a validated questionnaire (Bowel Disease Questionnaire). Multiple linear regression models to predict 2 hours and 4 hours GE rates were developed. (2) A revised Bowel Disease Questionnaire was mailed to a random sample of 4,194 Olmsted County residents. GE rates were estimated with the models for each subject and delayed GE was considered when they were lower than normal values. Hidden gastroparesis was defined in community subjects with predicted delayed GE that had not been diagnosed with gastroparesis prior to the survey.

Results

The regression models for GE rates were constructed using data from 450 patients. In addition to age and gender, the symptoms found significant were nausea/vomiting, early satiety, upper abdominal pain, bloating, loss of appetite and weight loss more than 7 pounds. 2,298 (55%) community subjects returned a questionnaire. Five subjects were excluded due to a prior diagnosis of gastroparesis. When models were applied to the community survey data, 42 (1.8%) subjects were estimated to have delayed GE.

Conclusions

Delayed GE was estimated to occur in 1.8% of community subjects. Since the prevalence of diagnosed gastroparesis is low (0.02%), many subjects with gastroparesis may remain undiagnosed.

BACKGROUND. Urinary symptoms are common among middle aged and elderly men. AIM. A study was undertaken to describe the health care sought by men aged 55 years and over with urinary symptoms, the action taken by general practitioners and urologists, and the men's views on prostatectomy. METHOD. A postal questionnaire was sent to 516 men aged 55 years and over in the North West Thames Regional Health Authority, with previously identified mild, moderate or severe urinary symptoms. RESULTS. The response rate among eligible subjects was 83%. Of 420 respondents 45% had seen their general practitioner for their symptoms. General practitioners had referred 62% of these men to a urologist, reassured 21% and prescribed medication to 17%. The probability of a man seeking medical advice increased with increasing symptom severity. In contrast, the decision to refer was independent of symptom severity. Of the men referred to a urologist, the majority (71%) were offered and accepted surgery. The remainder were reassured (17%), or received a prescription (4%). Eight per cent were offered surgery but declined. When presented with details and information on the risks and benefits of prostatectomy, 22% of men with symptoms would probably or definitely refuse treatment, while a further 47% of men were unsure. CONCLUSION. There are many men who do not seek treatment for urinary symptoms and, of those who do, subsequent referral is not associated with symptom severity. There is scope for improving the referral process through the shared development of guidelines between general practitioners, hospitals and commissioning agencies.

Objectives

To assess concordance of the management of chronic gout in UK primary care with the European League Against Rheumatism (EULAR) gout recommendations.

Methods

A postal questionnaire was sent to all adults aged >30 years registered with two general practices. Patients with possible gout attended for clinical assessment, at which the diagnosis was verified clinically. Aspects of chronic gout management, including provision of lifestyle modification advice, use of urate‐lowering therapies (ULT) including dose titration to serum urate (SUA) level, prophylaxis against acute attacks, and diuretic cessation were assessed in accordance with the EULAR recommendations.

Results

Of 4249 (32%) completed questionnaires returned, 488 reported gout or acute attacks and were invited for clinical assessment. Of 359 attendees, 164 clinically confirmed cases of gout were identified. Advice regarding alcohol consumption was recalled by 59 (41%), weight loss by 36 (25%) and diet by 42 (29%). Allopurinol was the only ULT used and was taken by 44 (30%); 31 (70%) were taking 300 mg daily. Mean SUA was lower in allopurinol users than non‐users (318 vs 434 μmol/l) and was less often >360 μmol/l in allopurinol users (23% vs 75%). Eight patients had recently commenced allopurinol; two of these also were taking prophylactic colchicine or non‐steroidal anti‐inflammatory drugs. Of 25 patients with diuretic‐induced gout, 16 (64%) were still taking a diuretic.

Conclusion

Treatment of chronic gout is often suboptimal and poorly concordant with EULAR recommendations. Lifestyle advice is infrequently offered, and allopurinol is restricted to a minority. Persistent hyperuricaemia was often seen in allopurinol non‐users, but was also in allopurinol users, suggesting that doses >300 mg are often necessary.

Background

Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC).

Methods

1592 persons aged 56–88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire.

Results

Males and those who had received screening advice from a doctor were at significantly higher odds of ever seeking medical advice for rectal bleeding. Persons who had private health coverage, consulted a doctor because the ‘symptom was serious’, or who did not wait to consult a doctor for another reason were at significantly higher odds of seeking early medical advice (< 2 weeks). For change in bowel habit, persons with lower income, within the healthy weight range, or who had discussed their family history of CRC irrespective of whether informed of ‘increased risk’ were at significantly higher odds of ever seeking medical advice. Persons frequenting their GP less often and seeing their doctor because the symptom persisted were at significantly higher odds of seeking early medical advice (< 2 weeks).

Conclusions

The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.

Background: For the early detection of gynaecological malignancy, guidance based on presenting symptoms exists to aid a general practitioner (GP) in determining who to investigate or refer. The evidence for this advice is based on the prevalence of symptoms in women with gynaecological malignancy or within specialist clinics. There are no studies on the incidence of symptoms within the community.

Aim: To provide an estimate of the incidence of self-reported symptoms of menstrual loss in the community population of a single general practice.

Design of study: A prospective population-based cohort study of women identified through a baseline postal survey and followed 6 and 12 months later.

Setting: An urban general practice with four partners and 10 000 registered patients.

Method: A postal baseline survey was undertaken on all women aged 18–54 years on the practice age–sex register. Responders who consented to follow-up were sent further questionnaires at 6 and 12 months. All questionnaires enquired about the presence or absence of symptoms related to vaginal bleeding. Twelve-month cumulative incidence rates were calculated using responders to the baseline, 6-month and 12-month questionnaires.

Results: A total of 2435 questionnaires were initially sent out at baseline and 1513 (62%) women replied to all three questionnaires. The 12–month cumulative incidence of symptoms in menstruating women was: menorrhagia 25% (95% confidence interval [CI] = 22 to 29); periods heavier than usual, 21% (95% CI = 18 to 23); change in pattern of cycle, 29% (95% CI = 26 to 32); short cycle 21% (95% CI = 19 to 24); long cycle 15% (95% CI = 13 to 18); intermenstrual bleeding 17% (95% CI = 14 to 19); postcoital bleeding 6% (95% CI = 5 to 8); prolonged period 9% (95% CI = 7 to 11).

Conclusion: The development of symptoms of menstrual loss among women in the community is common, in contrast to the rarity of gynaecological malignancy. This raises concern about the usefulness of current guidelines, based on symptoms, advising women when to consult, and for the early detection of gynaecological malignancy in the community and primary care.

Objective To assess the impact of different management strategies in urinary tract infections.

Design Randomised controlled trial.

Setting Primary care.

Participants 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

Intervention Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

Main outcome measures Symptom severity (days 2 to 4) and duration, and use of antibiotics.

Results Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

Conclusion All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

Study registration National Research Register N0484094184 ISRCTN: 03525333.

In spite of the increased awareness of ovarian cancer symptoms, the predictive value of symptoms remains very low. The aim of this paper is to obtain the views of general practitioners (GPs) in relation to symptom-based detection of ovarian cancer and to assess their knowledge for family history of breast and/or ovarian cancer as a predisposing factor for ovarian cancer. In this questionnaire survey, postal questionnaires were sent to 402 GPs in 132 primary care clinics, out of which we obtained 110 replies (27.4%). Approximately 26% of respondent GPs thought that the symptoms were more likely to be frequent, sudden, and persistent, and one-fifth were unsure of the importance of family history of breast cancer in relation to ovarian cancer. The participant GPs scored a set of symptoms for their relevance to ovarian cancer from 0 (not relevant) to 10 (most relevant). The highest scored symptoms were abdominal swelling (mean ± SD, 8.19 ± 2.33), abdominal bloating (7.01 ± 3.01), and pelvic pain (7.46 ± 2.26). There was a relative lack of awareness for repetitive symptoms as well as gastrointestinal symptoms as an important feature in a symptom-based detection of ovarian cancer.