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1.  Ascertaining the size of the symptom iceberg in a UK-wide community-based survey 
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.
To ascertain the size of the symptom iceberg in the UK.
Design of study
A UK-wide community-based postal survey.
Urban and rural communities across the UK.
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.
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.
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.
PMCID: PMC3020067  PMID: 21401979
community-based; epidemiology; prevalence; signs and symptoms; symptom iceberg
2.  Incongruous consultation behaviour: results from a UK-wide population survey 
BMC Family Practice  2012;13:21.
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.
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.
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.
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.
PMCID: PMC3338366  PMID: 22433072
Signs & symptoms; Community-based; Health care services; Primary care
3.  The tip of an iceberg? A cross-sectional study of the general public's experiences of reporting healthcare complaints in Stockholm, Sweden 
BMJ Open  2012;2(1):e000489.
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.
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.
The County of Stockholm, Sweden.
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.
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.
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.
PMCID: PMC3269049  PMID: 22282539
4.  Structured management strategy versus usual care for gastroesophageal reflux disease: rationale for pooled analysis of five European cluster-randomized trials 
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.
PMCID: PMC3036966  PMID: 21317991
gastroesophageal reflux disease; GerdQ; pooled analysis
5.  Who is targeted for lifestyle advice? A cross-sectional survey in two general practices. 
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.
PMCID: PMC1313532  PMID: 10885085
6.  Evolution in the management of Hirschsprung’s disease in the UK and Ireland: a national survey of practice revisited 
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.
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.
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.
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.
PMCID: PMC3293269  PMID: 20738896
Hirschsprung disease; Diagnosis; Operative procedures; Laparoscopy; Surgical stomas
7.  Measuring the Urologic Iceberg: Design and Implementation of The Boston Area Community Health (BACH) Survey 
European urology  2007;52(2):389-396.
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.
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.
A large representative community-based sample was successfully recruited to provide both cross-sectional and eventually longitudinal data to address important urologic questions.
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.
PMCID: PMC2020848  PMID: 17383808
Epidemiology; Survey sampling; Symptom research; Urology
8.  Impact of dyslipidemia on cardiovascular risk stratification of hypertensive patients and association of lipid profile with other cardiovascular risk factors: results from the ICEBERG study 
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.
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.
Serum lipid levels are useful in stratifying hypertensive patients into cardiovascular risk groups more accurately, for appropriate antihypertensive treatment.
PMCID: PMC3172055  PMID: 21949610
hypertension; dyslipidemia; cardiovascular disease
9.  Team structure, team climate and the quality of care in primary care: an observational study 
Quality & safety in health care  2003;12(4):273-279.
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.
PMCID: PMC1743743  PMID: 12897360
10.  Behavioural and psychological symptoms of dementia in primary care: a survey of general practitioners in Ireland 
Mental Health in Family Medicine  2011;8(4):227-234.
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.
PMCID: PMC3487602  PMID: 23205063
diagnosis; family medicine; general practitioner; health services; neuropsychiatric symptoms
11.  ICEberg: a web-based resource for integrative and conjugative elements found in Bacteria 
Nucleic Acids Research  2011;40(D1):D621-D626.
ICEberg ( is an integrated database that provides comprehensive information about integrative and conjugative elements (ICEs) found in bacteria. ICEs are conjugative self-transmissible elements that can integrate into and excise from a host chromosome. An ICE contains three typical modules, integration and excision, conjugation, and regulation modules, that collectively promote vertical inheritance and periodic lateral gene flow. Many ICEs carry likely virulence determinants, antibiotic-resistant factors and/or genes coding for other beneficial traits. ICEberg offers a unique, highly organized, readily explorable archive of both predicted and experimentally supported ICE-relevant data. It currently contains details of 428 ICEs found in representatives of 124 bacterial species, and a collection of >400 directly related references. A broad range of similarity search, sequence alignment, genome context browser, phylogenetic and other functional analysis tools are readily accessible via ICEberg. We propose that ICEberg will facilitate efficient, multi-disciplinary and innovative exploration of bacterial ICEs and be of particular interest to researchers in the broad fields of prokaryotic evolution, pathogenesis, biotechnology and metabolism. The ICEberg database will be maintained, updated and improved regularly to ensure its ongoing maximum utility to the research community.
PMCID: PMC3244999  PMID: 22009673
12.  Peritoneal adhesion index (PAI): proposal of a score for the “ignored iceberg” of medicine and surgery 
Peritoneal adhesions describe a condition in which pathological bonds form between the omentum, the small and large bowels, the abdominal wall, and other intra-abdominal organs. Different classification systems have been proposed, but they do not resolve the underlying problem of ambiguity in the quantification and definition of adhesions. We therefore propose a standardized classification system of adhesions to universalize their definition based on the macroscopic appearance of adhesions and their diffusion to different regions of the abdomen. By scoring with these criteria, the peritoneal adhesion index (PAI) can range from 0 to 30, unambiguously specifying precise adhesion scenarios. The standardized classification and quantification of adhesions would enable different studies to more meaningfully integrate their results, thereby facilitating a more comprehensive approach to the treatment and management of this pathology.
PMCID: PMC3573980  PMID: 23369320
Adhesions; Classification; PAI; Peritoneal; Abdominal; Occlusion; Surgery; Treatment; Prevention
13.  Human resource management in general practice: survey of current practice. 
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.
PMCID: PMC1239535  PMID: 8855013
14.  Factors associated with consultation behaviour for primary symptoms potentially indicating colorectal cancer: A cross-sectional study on response to symptoms 
BMC Gastroenterology  2012;12:100.
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).
1592 persons aged 56–88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire.
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).
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.
PMCID: PMC3503829  PMID: 22862960
15.  Symptoms and Risk Factors of Ovarian Cancer: A Survey in Primary Care 
ISRN Obstetrics and Gynecology  2012;2012:754197.
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.
PMCID: PMC3432546  PMID: 22957264
16.  An additional dimension to health inequalities: disease severity and socioeconomic position 
OBJECTIVE: To investigate the association between the severity of hip pain and disability, and a number of measures of socioeconomic position, using a range of individual and ecological socioeconomic indicators. DESIGN: Interviewer administered and self completed questionnaires on symptoms of pain and disability, general health and socioeconomic indicators, completed by people reporting hip pain in a cross sectional, postal, screening questionnaire. SETTING: 40 general practices from inner city, suburban and rural areas of south west England. PARTICIPANTS: 954 study participants who had reported hip pain in a postal questionnaire survey of 26,046 people aged 35 and over, selected using an age/sex stratified random probability sample. DATA: Individual indicators of socioeconomic position: social class based on occupation, maximum educational attainment, car ownership, gross household income, manual or non-manual occupation and living alone. Area level measures of socioeconomic position: Townsend scores for material deprivation at enumeration district level; urban or rural location based on the postcode of residence. Severity of hip disease, measured by the pain, disability and independence components of the New Zealand score for major joint replacement. Self reported comorbidity validated using general practice case notes and summary measures of general health. MAIN RESULTS: Increasing disease severity was strongly associated with increasing age and a variety of measures of general health, including comorbidity. The data provide considerable evidence for the systematic association of increased severity of hip disease with decreasing socioeconomic position. Measures of socioeconomic position that were systematically associated with increasing disease severity, standardised for age and sex, included educational attainment (relative index of inequality 1.95 (95% confidence intervals 1.29 to 2.62) and income (relative index of inequality 4.03 (95% confidence intervals 3.43 to 4.64). Those with access to a car (mean disease severity 15.5) had statistically significant lower severity of hip disease than those without (mean 17.5, p < 0.01). Similar results were found for access to higher or further education and living with others. For a given level of income, people with greater comorbidity had more severe hip pain and disability. The gradient in disease severity between rich and poor was steepest among those with the most comorbidity. CONCLUSIONS: People with lower socioeconomic position experience a greater severity of hip disease. The poorest sector of the population seem to be in double jeopardy: they not only experience a greater burden of chronic morbidity but also a greater severity of hip disease. This study has implications for health care provision, if the National Health Service is to live up to its principle of equal treatment for equal medical need.
PMCID: PMC1756792  PMID: 10616672
17.  Contextual factors in clinical decision making 
Canadian Family Physician  2005;51(8):1107.
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.
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.
Family practices in Canada.
Of the final sample of 431 family physicians, 52% were men, 63% practised in urban locations, and 71% were in group practice.
Self-reported likelihood of considering various contextual factors during the course of clinical decision making.
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.
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.
PMCID: PMC1479511  PMID: 16926949
18.  Determining patient and primary care delay in the diagnosis of cancer – lessons from a pilot study of patients referred for suspected cancer 
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.
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.
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.
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.
PMCID: PMC2259302  PMID: 18234092
19.  Organizational commitment among general practitioners: A cross-sectional study of the role of psychosocial factors 
To examine whether general practitioners (GP) working in primary health care have lower organizational commitment compared with physicians working in other health sectors. The authors also tested whether psychosocial factors (job demands, job control, and colleague consultation) explain these differences in commitment between GPs and other physicians.
Cross-sectional postal questionnaire.
Setting and participants
A postal questionnaire was sent to a random sample of physicians (n = 5000) drawn from the Finnish Association database in 2006. A total of 2841 physicians (response rate 57%) returned the questionnaire, of which 2657 (545 GPs and 2090 other physicians) fulfilled all the participant criteria.
Main outcome measures
Organizational commitment was measured with two different indicators: intention to change jobs and low affective commitment.
GPs were less committed to their organizations than other physicians. Work-related psychosocial factors (high job demands, low job control, and poor colleague consultation) were all significant risk factors for low organizational commitment.
The evidence collected suggests that policies that reduce psychological demands, such as job demands and low control, may contribute to better organizational commitment and, thus, alleviate the shortages of physicians in primary care. Furthermore, giving GPs a stronger say in decisions concerning their work and providing them with more variety in work tasks may even improve the quality of primary care. The strategies for workplace development should focus on redesigning jobs and identifying GPs at higher risk, such as those with especially high job strain.
PMCID: PMC3442315  PMID: 20470018
Family practice; general practitioners; job demand-control-support model; organizational commitment; primary healthcare; psychosocial factors
20.  Gender bias revisited: new insights on the differential management of chest pain 
BMC Family Practice  2011;12:45.
Chest pain is a common complaint and reason for consultation in primary care. Few data exist from a primary care setting whether male patients are treated differently than female patients. We examined whether there are gender differences in general physicians' (GPs) initial assessment and subsequent management of patients with chest pain, and how these differences can be explained
We conducted a prospective study with 1212 consecutive chest pain patients. The study was conducted in 74 primary care offices in Germany from October 2005 to July 2006. After a follow up period of 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the etiology of chest pain at the time of patient recruitment (delayed type-reference standard). We adjusted gender differences of six process indicators for different models.
GPs tended to assume that CHD is the cause of chest pain more often in male patients and referred more men for an exercise test (women 4.1%, men 7.3%, p = 0.02) and to the hospital (women 2.9%, men 6.6%, p < 0.01). These differences remained when adjusting for age and cardiac risk factors but ceased to exist after adjusting for the typicality of chest pain.
While observed gender differences can not be explained by differences in age, CHD prevalence, and underlying risk factors, the less typical symptom presentation in women might be an underlying factor. However this does not seem to result in suboptimal management in women but rather in overuse of services for men. We consider our conclusions rather hypothesis generating and larger studies will be necessary to prove our proposed model.
PMCID: PMC3125218  PMID: 21645336
21.  Mental health symptoms in relation to socio-economic conditions and lifestyle factors – a population-based study in Sweden 
BMC Public Health  2009;9:302.
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.
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.
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.
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.
PMCID: PMC2736164  PMID: 19695085
22.  Urinary symptoms and incontinence in women: relationships between occurrence, age, and perceived impact. 
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.
PMCID: PMC1313561  PMID: 10818656
23.  Underwater medicine: a neglected area in Accident and Emergency specialist training. 
We have evaluated the available medical care to sports divers by a postal questionnaire sent to consultants and senior registrars in Accident and Emergency medicine in the UK, assessing their training in underwater medicine. Replies were received from 60 of 96 consultants (63%) and 32 of 58 (55%) senior registrars. Thirty-two per cent of consultants and 50% of senior registrars had previous personal experience in managing an underwater diving accident. Thirty per cent of consultants and only 19% of senior registrars had prior formal postgraduate training in underwater medicine. Twenty-seven per cent of consultants and 13% of senior registrars replying did not know the pattern of referral for specialist advice nor where the nearest recompression chamber was to be found. We believe that more formal postgraduate training in underwater medicine is needed by A and E medical staff. Furthermore, clear guidelines about emergency management and patterns of referral for diving accidents should be displayed prominently in all A and E departments.
PMCID: PMC1478820  PMID: 1751890
24.  Coping strategies as predictors of pain and disability in older people in primary care: a longitudinal study 
BMC Family Practice  2013;14:67.
Musculoskeletal pain in older adults is common. It is hypothesised that coping strategies may be predictive of pain intensity and pain-related disability at six months after initial consultation in primary care.
Consecutive patients aged fifty years and over with musculoskeletal pain were recruited from general practice consultations. A self-completion postal questionnaire was sent to participants at baseline, with a follow-up questionnaire mailed six months later. Coping was assessed using The Coping Strategies Questionnaire (CSQ), pain and pain related disability were measured using domains of The Chronic Pain Grade (CPG). Associations between coping strategies and pain and disability were investigated using ordinary least squares regression.
Crude analysis revealed catastrophizing at baseline was predictive of higher levels of pain and disability at baseline and was predictive of disability at six months. The association between catastrophizing and pain and pain related disability at follow-up was not significant once adjustments were made for age, gender and baseline anxiety and depression. Increasing behaviour and self-statements were not associated with pain or disability at follow-up. Ignoring pain sensations was predictive of increased pain at follow-up.
This study highlights the relationship between catastrophizing in predicting pain and pain related disability may be mediated by other factors such as anxiety and depression. Ignoring sensations in those with high levels of pain may be maladaptive in older people with musculoskeletal pain.
PMCID: PMC3665454  PMID: 23705997
Coping; Catastrophizing; Primary care; Musculoskeletal pain; Longitudinal study
25.  Confidence of primary care physicians in their ability to carry out basic medical genetic tasks—a European survey in five countries—Part 1 
Western health care systems are facing today increasing movement of genetic knowledge from research labs into clinical practice. This paper reports the results of a survey that addressed the confidence of primary care physicians in their ability to carry out basic medical genetic tasks. The survey was conducted in five countries (France, Germany, The Netherlands, Sweden and the UK). Stratified random samples were drawn from primary care physicians in the five countries representing a sampling frame of 139,579 physicians. Stepwise binary logistic regression procedures were performed to identify the predictor variables for self-reported confidence. Three thousand six hundred eighty-six physicians participated and filled out a self-administered questionnaire. The margin of error for accurate representation of each group of European general practitioners and specialists in the total sample is 2.9% for GP, 2.8% for obstetricians/gynaecologists (OB/GYN) and for paediatricians (PAED) 2.6% (95% confidence level). Confidence in their ability to carry out basic medical genetic tasks is low among participating primary care physicians: 44.2% are not confident, 36.5% somewhat confident, confident or very confident are 19.3%. In each country, those confident/very confident represent less than 33% of the participating physicians. Primary care physicians who report the lowest levels of confidence prove to be those least exposed to medical genetics information and training. Although there are significant differences in the way in which professional education is organised and practice is regulated across European countries, there is a need for a coordinated European effort to improve primary care physicians’ background in medical genetics.
PMCID: PMC3186019  PMID: 22109718
Genetic education; Genetic services; Primary care

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