Pilot studies to test methods to determine the incidence, agents, risk factors and socioeconomic costs of infectious intestinal disease (IID) in England were carried out as recommended by the Committee on the Microbiological Safety of Food (the Richmond Committee) by eight general practices. There were case control and enumeration studies of patients presenting to general practice with IID, a population-based prospective cohort study, and a survey of socioeconomic costs of cases of IID. Information on risk factors was obtained by questionnaire (self-administered compared with interview) and a stool sample was requested on all cases and controls. Response rates in the GP case control study were 75% for case questionnaires and 74% for stools; for controls the figures were 70% and 68% respectively. The acceptance rate into the cohort study was 49%; this was significantly higher where phone contact was made. The rate was similar if recruitment was by individual or household. Follow-up of the cohort by negative reporting was complete for up to 6 months. Direct postage by subject was required to obtain fresh stool specimens. Estimates were obtained of presentation rates of IID and the distribution of risk factors which were used to plan the main study. The pilot study demonstrated that it is possible to undertake a national study based in general practice to determine the incidence of IID in the population and presenting to GPs and its agents, risk factors and costs.
Revalidation for UK doctors is expected to be introduced from late 2012. For general practitioners (GPs), this entails collecting supporting information to be submitted and assessed in a revalidation portfolio every five years. The aim of this study was to explore the feasibility of GPs working in secure environments to collect supporting information for the Royal College of General Practitioners’ (RCGP) proposed revalidation portfolio.
We invited GPs working in secure environments in England to submit items of supporting information collected during the previous 12 months using criteria and standards required for the proposed RCGP revalidation portfolio and complete a GP issues log. Initial focus groups and initial and follow-up semi-structured face-to-face and telephone interviews were held to explore GPs’ views of this process. Quantitative and qualitative data were analysed using descriptive statistics and identifying themes respectively.
Of the 50 GPs who consented to participate in the study, 20 submitted a portfolio. Thirty-eight GPs participated in an initial interview, nine took part in a follow-up interview and 17 completed a GP issues log. GPs reported difficulty in collecting supporting information for valid patient feedback, full-cycle clinical audits and evidence for their extended practice role(s) as sessional practitioners in the high population turnover custodial environment. Peripatetic practitioners experienced more difficulty than their institution based counterparts collating this evidence.
GPs working in secure environments may experience difficulties in collecting the newer types of supporting information for the proposed RCGP revalidation portfolio primarily due to their employment status within a non-medical environment and characteristics of the detainee population. Increased support from secure environment service commissioners and employers will be a prerequisite for these practitioners to enable them to re-license using the RCGP revalidation proposals.
Revalidation; Re-licensing; Medical continuing professional development; General practitioners; Family physicians; Sessional GPs; Salaried GPs; Secure environments; Prisons
A lesbian woman will have to choose whether to disclose or not in every new encounter, including when consulting her general practitioner (GP). She may fear a negative reaction in the doctor, based on knowledge of marginalization and prejudice of homosexuals throughout history.
To explore patients’ experiences concerning disclosure of their lesbian orientation to general practitioners (GPs), focusing on why they find it important, and what GPs can do to promote disclosure.
One group interview was conducted, audiotaped, and transcribed verbatim. Qualitative analysis was conducted by systematic text condensation inspired by Giorgi's phenomenological approach. Six women aged 28–59 years, who self-identified as lesbian, were recruited through a web-based, publicly accessible network for research on homosexuality.
Main outcome measures
Accounts of experiences where the patient thought that information of a lesbian sexual orientation was of importance in the consultation with a GP.
Disclosure can imply information of medical relevance, explain circumstances, and generate a feeling of being seen as one's true self. The intentional use of common consultation techniques may facilitate disclosure.
Lesbian patients may want to disclose their sexual orientation to the general practitioner but they experience certain barriers. These can be overcome when the GP provides an open and permissive context. GPs can benefit from knowledge concerning sexual orientation in their work with lesbian patients.
Communication; family practice; female; homosexuality; truth disclosure
OBJECTIVE--To assess the impact on general practitioners and hospital consultants of hospital outpatient dispensing policies in England. DESIGN--Postal questionnaire and telephone interview survey of general practitioners and hospital consultants in January 1991. SETTING--94 selected major acute hospitals in England. PARTICIPANTS--20 general practitioners in the vicinity of each of 94 selected hospitals and eight consultants from each, selected by chief pharmacists. MAIN OUTCOME MEASURES--Proportions of general practitioners unable to assume responsibility for specialist drugs and of consultants wishing to retain responsibility; association between dispensing restrictions and the frequency of general practitioners being asked to prescribe hospital initiated treatments. RESULTS--Completed questionnaires were obtained from 1207 (64%) of 1887 general practitioners and 457 (63%) of 729 consultants. 570 (46%) general practitioners felt unable to take responsibility for certain treatments, principally because of difficulty in detecting side effects (367, 30%), uncertainty about explaining treatment to patients (332, 28%), and difficulty monitoring dosage (294, 24%). Among consultants 328 (72%) wished to retain responsibility, principally because of specialist need for monitoring (93, 20%), urgent need to commence treatment (64, 14%), and specialist need to initiate or stabilise treatment (63, 14%). The more restricted the drug supply to outpatients, the more frequently consultants asked general practitioners to prescribe (p less than 0.01) and complete a short course of treatment initiated by the hospital (p less than 0.001). CONCLUSIONS--Restrictive hospital outpatient dispensing shifts clinical responsibility on to general practitioners. Hospital doctors should be able to retain responsibility for prescribing when the general practitioner is unfamiliar with the drug or there is a specialist need to initiate, stabilise, or monitor treatment.
To describe the prevalence of parasitic and bacterial gastrointestinal infection (excluding enterotoxigenic Escherichia coli) among international travellers attending the International Travel Clinic at The University of Calgary.
Data were abstracted from the records of the first visit after travel of all persons making a post travel visit between January 1, 1986 and March 31, 1990.
Data were available for 886 first visits (840 persons). Stools were submitted by 692 travellers. The frequency of stool submission varied by the duration of travel abroad, and the frequency of diarrhea either during or after the trip was greater among those who had submitted a stool specimen. The prevalence of stools positive for ova, parasites or pathogenic bacteria was 41.2%. When only pathogenic organisms were considered, the prevalence of infection was 19.4%. The most commonly isolated pathogenic parasites were Dientamoeba fragilis, Giardia lamblia, and Entamoeba histolytica. The most commonly isolated bacteria were Campylobacter species and Salmonella species.
Although the prevalence of positive stool screens among returned travellers in this population was high, only about one-fifth of persons tested were positive for pathogens.
Diarrhea; Diarrhea prevention and control; Epidemiology; Retrospective studies; Travel
Non-cholera Vibrio infections are an important public health problem. Non-cholera Vibrio species usually cause sporadic infections, often in coastal states, and have also caused several recent nationwide outbreaks of gastroenteritis in the United States. We report a survey of laboratory stool culturing practices for Vibrio among randomly selected clinical laboratories in Gulf Coast states (Alabama, Florida, Louisiana, Mississippi, and Texas). Interviews conducted with the microbiology supervisors of 201 clinical laboratories found that 164 (82%) received stool specimens for culture. Of these, 102 (62%) of 164 processed stool specimens on site, and 20 (20%) of these 102 laboratories cultured all stool specimens for Vibrio, indicating that at least 34,463 (22%) of 152,797 stool specimens were cultured for Vibrio. This survey suggests that despite an increased incidence of non-cholera Vibrio infections in Gulf Coast states, a low percentage of clinical laboratories routinely screen all stool specimens, and fewer than 25% of stool specimens collected are routinely screened for non-cholera Vibrio.
Use of routine urine submission rates for estimation of patient enrolment in primary care studies of acute urinary symptoms may overestimate patient recruitment rate.
To compare the rates of submission of urines and significant bacteriuria from patients presenting with acute urinary symptoms in study general practices to routine microbiology laboratory urines.
Routine laboratory urine submissions were determined by counting all mid‐stream urine specimens submitted to the laboratory from 12 large general practitioner (GP) practices served by Gloucester and Southmead microbiology departments over two years (2000–02). Urine specimens were requested from all patients with acute urinary symptoms referred at research nurse practice visits over the same time period. The annual study urine submission was calculated using the ratio of the number of nurse practice visits to the annual number of possible consulting sessions. Significant bacteriuria was defined as a urine growing a single organism reported as >105 colony forming units/ml. Rates per 1000 patients were calculated using practice population data.
The urine submission rate from study patients with acute urinary symptoms was one‐third the routine urine submission rate from the same practices. The significant bacteriuria rate attained from the study was less than half the routine significant bacteriuria rate.
Two‐thirds of routine urine samples submitted by GPs are probably not for the investigation of acute urinary symptoms. Basing consultation sample size power calculations for primary care studies or sentinel practice‐based surveillance in urinary tract infection on routine laboratory submissions is unreliable and will lead to significant overestimation of recruitment rate.
BACKGROUND: Consultation skills are essential for general practice. Tools for measuring consultation skills in everyday practice are not well developed AIM: To examine and develop the content validity of the MAAS History-taking and Advice Checklist GP (MAAS-GP) tool which is used in The Netherlands for testing consultation skills, with simulated patients in United Kingdom general practice from the perspectives of both general practitioners and patients. DESIGN OF STUDY: Qualitative research using semi-structured interviews. SETTING: Alternate patients attending seven general practices in the north west of England. METHOD: Thematic analysis of the contents of patient and GP interviews, and of focus groups, mapping key themes to the MAAS-GP. RESULTS: There was strong agreement between patients and GPs on issues mapping to 46 out of 68 items of the MAAS-GP. Eight further MAAS-GP items were linked to issues only raised by patients and four to issues raised only by GPs. The remaining 10 items could not be related to issues raised by either. All of the issues raised by GPs could be mapped but 27 patient items could not. These were included in a revised checklist, the Liverpool MAAS (LIV-MAAS). CONCLUSION: the revised tool seems to have content validity in measuring consultation skills. Measurement of its relability is now required.
During one year, out of 1829 faecal specimens examined at the Chelmsford Public Health Laboratory, campylobacters were isolated from 109 (6%), 21 of the positive cultures were from hospital in-patients and 3 were from hospital staff. The remaining 85 isolates were from specimens sent in by general practitioners. The authors' figures show a marked season variation with most of the infections occurring from June to September. The highest incidence (36%) was in the 20 to 30 age group, 99% of patients had diarrhoea, usually watery, occasionally explosive, and 9% had visible blood in their stools. Eighteen per cent. of patients had abdominal pain, 5 of the 21 hospital in-patients underwent abdominal surgery. Fifty-nine faecal specimens were examined microscopically and 30 of these had blood and pus cells or pus cells alone. Three patients had rectal biopsies showing a nonspecific colitis, 11 patients had recently been abroad.
In January 2011, Sydney South West Public Health Unit was notified of a large number of people presenting with gastroenteritis over two days at a local hospital emergency department (ED).
Case-finding was conducted through hospital EDs and general practitioners, which resulted in the notification of 154 possible cases, from which 83 outbreak cases were identified. Fifty-eight cases were interviewed about demographics, symptom profile and food histories. Stool samples were collected and submitted for analysis. An inspection was conducted at a Vietnamese bakery and food samples were collected and submitted for analysis. Further case ascertainment occurred to ensure control measures were successful.
Of the 58 interviewed cases, the symptom profile included diarrhoea (100%), fever (79.3%) and vomiting (89.7%). Salmonella Typhimurium multiple-locus-variable number tandem repeats analysis (MLVA) type 3–10–8-9–523 was identified in 95.9% (47/49) of stool samples. Cases reported consuming chicken, pork or salad rolls from a single Vietnamese bakery. Environmental swabs detected widespread contamination with Salmonella at the premises.
This was a large point-source outbreak associated with the consumption of Vietnamese-style pork, chicken and salad rolls. These foods have been responsible for significant outbreaks in the past. The typical ingredients of raw egg butter or mayonnaise and pate are often implicated, as are the food-handling practices in food outlets. This indicates the need for education in better food-handling practices, including the benefits of using safer products. Ongoing surveillance will monitor the success of new food regulations introduced in New South Wales during 2011 for improving food-handling practices and reducing foodborne illness.
The emergency care practitioner (ECP) is a generic practitioner who combines extended nursing and paramedic skills. The "new" role emerged out of changing workforce initiatives intended to improve staff career opportunities in the National Health Service and ensure that patients' health needs are assessed appropriately.
To describe the development of ECP Schemes in 17 sites, identify criteria contributing to a successful operational framework, analyse routinely collected data and provide a preliminary estimate of costs.
There were three methods used: (a) a quantitative survey, comprising a questionnaire to project leaders in 17 sites, and analysis of data collected routinely; (b) qualitative interpretation based on telephone interviews in six sites; and (c) an economic costing study.
Of 17 sites, 14 (82.5%) responded to the questionnaire. Most ECPs (77.4%) had trained as paramedics. Skills and competencies have been extended through educational programmes, training, and assessment. Routine data indicate that 54% of patient contacts with the ECP service did not require a referral to another health professional or use of emergency transport. In a subset of six sites, factors contributing to a successful operational framework were strategic visions crossing traditional organisational boundaries and appropriately skilled workforce integrating flexibly with existing services. Issues across all schemes were patient safety, appropriate clinical governance, and supervision and workforce issues. On the data available, the mean cost per ECP patient contact is £24.00, which is less than an ED contact of £55.00.
Indications are that the ECP schemes are moving forward in line with original objectives and could be having a significant impact on the emergency services workload.
emergency care practitioner; intermediate care; extended skills; avoided admission
The distribution of Shigella serotypes is of epidemiological importance and antimicrobial therapy for shigellosis can prevent potential complications of shigellosis. Studies done fifty years ago in Ghana indicated the predominance of Shigella flexneri.
To describe the distribution of Shigella serogroups and serotypes and their antibiogram profiles.
A prospective descriptive study.
The Microbiology Department of the Korle Bu Teaching Hospital.
Consecutive stool specimens from patients with diarrhoea submitted between February 2004 and June 2005 were cultured for Shigella and the isolates typed with commercial anti-sera. The susceptibilities of the isolates were also tested against eleven antimicrobial agents by the disc diffusion method. Minimum inhibitory concentrations (MIC) of isolates to ciprofloxacin were also determined by the E-test.
Five hundred and ninety four diarrhoea stool specimens yielded 24 Shigella isolates with the following serogroup distribution: S. flexneri 70.8%, S. dysenteriae 16.7%, S. sonnei 8.3% and S. boydii 4.2%. Approximately 96% of the isolates were multi-drug resistant but all twenty four were susceptible to nalidixic acid and the fluoroquinolones (ofloxacin and ciprofloxacin). The MICs of twenty one of the isolates to ciprofloxacin were ≤ 0.064 µg ml-1.
The predominance of S. flexneri was confirmed and Shigella isolates from Accra are susceptible to nalidixic acid and the fluoroquinolones. Surveillance of antimicrobial resistance particularly to monitor the emergence of Shigella strains resistant to nalidixic acid and the fluoroquiolones is important.
Shigella; serogroups; serotypes; multi-drug resistant; MIC
BACKGROUND: The inclusion of growth assessment and nutrition-related anticipatory guidance in all well-child visits is recommended. Although prior studies have assessed whether these topics are discussed, the content of the discussions has not been explored from the maternal perspective. Objective: To explore what mothers of preschoolers recall and understand about growth assessment and nutrition anticipatory guidance provided at their child's most recent well-child visit. METHODS: Qualitative, semistructured telephone interviews were performed with 20 mothers of preschoolers recruited from a Head Start program. Interviews were recorded and transcribed. Themes were identified and refined in an iterative process. RESULTS: Three main findings emerged: 1) although mothers generally recalled the use of growth charts and often recalled their child's height and weight percentiles, they were generally unable to articulate the meaning of these percentiles; 2) most mothers stated that their nutrition-related decisions were not influenced by growth chart findings. However, when growth chart findings were interpreted as positive, mothers found them reassuring. Conversely, when growth chart findings were interpreted as negative, mothers discounted the growth chart in favor of other comparisons of growth; 3) a considerable proportion of mothers reported that nutrition was not discussed at the most recent well-child visit, which mothers commonly attributed to a lack of weight or feeding problems for their child. CONCLUSION: Among the low-income mothers studied, growth chart use and findings were memorable but frequently misunderstood, while nutrition-related anticipatory guidance was not consistently recalled. These findings suggest opportunities to improve physician-patient communication regarding these topics.
Objective To explore the experiences and perceptions of general practitioners and community nurses in discussing preferences for place of death with terminally ill patients.
Design Qualitative study using semistructured interviews and thematic analysis.
Participants 17 general practitioners and 19 nurses (16 district nurses, three clinical nurse specialists).
Setting 15 general practices participating in the Gold Standards Framework for palliative care from three areas in central England with differing socio-geography. Practices were selected on the basis of size and level of adoption of the standards framework.
Results All interviewees bar one had experience of discussing preferred place of death with terminally ill patients. They reported that preferences for place of death frequently changed over time and were often ill defined or poorly formed in patients’ minds. Preferences were often described as being co-created in discussion with the patient or, conversely, inferred by the health professional without direct questioning or receiving a definitive answer from the patient. This inherent uncertainty challenged the practicability, usefulness, and value of recording a definitive preference. The extent to which the assessment of enabling such preferences can be used as a proxy for the effectiveness of palliative care delivery is also limited by this uncertainty. Generally, interviewees did not find discussing preferred place of death an easy area of practice, unless the patient broached the subject or led the discussions.
Conclusions Further research is needed to enable development of appropriate training and support for primary care professionals. Better understanding of the importance of place of death to patients and their carers is also needed.
In 2006 the Department of Health and the National Institute for Health and Clinical Excellence (NICE) published guidance on the management of childhood obesity, for use by primary care practitioners. Little is known, however, about practitioners' views and experiences of managing childhood obesity in primary care.
To explore practitioners' views of primary care as a setting in which to treat childhood obesity.
Design of study
Qualitative interview study.
Primary care and other community settings based in Bristol, England.
Interviews explored practitioners' views and experiences of managing childhood obesity and their knowledge of the recent guidance provided by the Department of Health and NICE. Interviews were audiotaped and transcribed verbatim. Analysis was thematic and comparisons made both within and across the interviews.
Thirty practitioners were interviewed: 12 GPs, 10 practice nurses, four school nurses, and four health visitors. Participants varied in their views about whether primary care is an appropriate treatment setting for childhood obesity. However, all described factors that limited the extent to which they could intervene effectively: a lack of expertise, resources, and contact with primary school children; the causes of childhood obesity; and the need to work with parents. It was also apparent that very few participants had knowledge of the recent guidance.
Practitioners do not currently view primary care as an effective treatment setting for childhood obesity and it is unlikely that the guidance from the Department of Health and NICE will have a meaningful impact on their management of this condition.
child health; obesity; primary health care; qualitative research
The present study was conducted to compare two stool antigen detection kits with PCR for the diagnosis of Entamoeba histolytica infections by using fecal specimens submitted to the Department of Microbiology at St. Vincent's Hospital, Sydney, and the Institute of Medical and Veterinary Science, Adelaide, Australia. A total of 279 stool samples containing the E complex (E. histolytica, Entamoeba dispar, and Entamoeba moshkovskii) were included in this study. The stool specimens were tested by using two commercially produced enzyme immunoassays (the Entamoeba CELISA PATH and TechLab E. histolytica II kits) to detect antigens of E. histolytica. DNA was extracted from all of the samples with a Qiagen DNA stool mini kit (Qiagen, Hilden, Germany), and a PCR targeting the small-subunit ribosomal DNA was performed on all of the samples. When PCR was used as a reference standard, the CELISA PATH kit showed 28% sensitivity and 100% specificity. The TechLab ELISA (enzyme-linked immunosorbent assay) kit did not prove to be useful in detecting E. histolytica, as it failed to identify any of the E. histolytica samples which were positive by PCR. With the TechLab kit, cross-reactivity was observed for three specimens, one of which was positive for both E. dispar and E. moshkovskii while the other two samples contained E. moshkovskii. Quantitative assessment of the PCR and ELISA results obtained showed that the ELISA kits were 1,000 to 10,000 times less sensitive, and our results show that the CELISA PATH kit and the TechLab ELISA are not useful for the detection of E. histolytica in stool samples from patients in geographical regions where this parasite is not endemic.
Patients are increasingly using the internet for health-related information and may bring this to a GP consultation. There is scant information about why patients do this and what they expect from their GP.
The aim was to explore patients’ motivation in presenting information, their perception of the GP’s response and what they wanted from their doctor.
Design and setting
Qualitative study based in North London involving patients with experience of bringing health information from the internet to their GP.
Semi-structured face-to-face and telephone interviews using a critical incident technique, recorded, transcribed verbatim, and subjected to thematic analysis by a multidisciplinary team of researchers.
Twenty-six interviews were completed. Participants reported using the internet to become better informed about their health and hence make best use of the limited time available with the GP and to enable the GP to take their problem more seriously. Patients expected their GP to acknowledge the information; discuss, explain, or contextualise it; and offer a professional opinion. Patients tended to prioritise the GP opinion over the internet information. However, if the GP appeared disinterested, dismissive or patronising patients reported damage to the doctor–patient relationship, occasionally to the extent of seeking a second opinion or changing their doctor.
This is the first in-depth qualitative study to explore why patients present internet information to their GP within the consultation and what they want when they do this. This information should help GPs respond appropriately in such circumstances.
family practice; internet; patient participation; physician–patient relations; qualitative research
Background and aim: Several cases of acute colitis induced by non-steroidal anti-inflammatory drugs (NSAIDs) have been reported but the general role of recent NSAID intake as a risk factor for acute diarrhoea has not been studied to date. The aim of our study was to determine whether the risk of acute diarrhoea is increased by NSAIDs in a prospective series of acute diarrhoea cases which were seen by general practitioners in France and were serious enough to require a stool culture.
Patients, physicians, and methods: A total of 285 consecutive patients with acute diarrhoea, seen by Sentinel general practitioners (GPs) between December 1998 and July 1999, were enrolled in a case crossover study in which each case served as his/her own control. GPs collected information on exposure to NSAIDs during the four month period preceding the onset of diarrhoea. The relative risk of NSAID related acute diarrhoea was estimated by comparing exposure to NSAIDs during a risk period preceding the onset of diarrhoea with exposure during the first part of the four month observation period. Three risk periods lasting for one, three, and six days before the onset of diarrhoea were considered.
Results: The relative risks of acute diarrhoea due to recent NSAID intake were increased for all three risk periods. These risks and their confidence intervals were 2.9 (1.4–6.1) for the one day risk period, 2.7 (1.4–5.1) for the three day period, and 3.3 (2.0–5.4) for the six day period.
Conclusion: Recent NSAID intake emerges as a risk factor for acute diarrhoea. We suggest that acute diarrhoea seen in general practice, and not only acute colitis seen by gastroenterologists, should be considered as a potential complication of recent NSAID intake.
non-steroidal anti-inflammatory drugs; acute diarrhoea; case crossover
Gastrointestinal symptoms are not an uncommon manifestation of an influenza virus infection. In the present study, we aimed to investigate the presence of influenza viruses in the stools of adult patients consulting their general practitioner for uncomplicated acute diarrhea (AD) and the proportion of concurrent infections by enteric and influenza viruses.
A case-control study was conducted from December 2010 to April 2011. Stool specimens were collected and tested for influenza viruses A (seasonal A/H3N2 and pandemic A/H1N1) and B, and for four enteric viruses (astrovirus, group A rotavirus, human enteric adenovirus, norovirus of genogroups I – NoVGI - and genogroup II - NoVGII).
General practitioners enrolled 138 cases and 93 controls. Of the 138 stool specimens collected, 92 (66.7%) were positive for at least one of the four enteric viruses analysed and 10 (7.2%) tested positive for one influenza virus. None of these 10 influenza positive patients reported respiratory symptoms. In five influenza-positive patients (3.6%), we also detected one enteric virus, with 4 of them being positive for influenza B (2 had co-detection with NoVGI, 1 with NoVGII, and 1 with astrovirus). None of the 93 controls tested positive for one of the enteric and/or other influenza viruses we investigated.
In this study we showed that the simultaneous detection of influenza and enteric viruses is not a rare event. We have also reported, for the first time in general practice, the presence of seasonal and pandemic influenza viruses in the stools of adult patients consulting for uncomplicated AD. A simultaneous investigation of enteric and influenza viruses in patients complaining of gastrointestinal symptoms could be useful for future studies to better identify the agents responsible for AD.
Influenza virus; Enteric virus; Stools; Co-infection; General practice
Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems.
A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together.
Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health.
Service delivery components – e.g. peer support groups, personal planning – advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings.
Long term conditions; Mental health; Self-care; Self-management; Peer support
Reported efficacies of drugs used to treat Strongyloides stercoralis infection vary widely. Because diagnostic methods are insensitive, therapeutic trials generally require multiple negative posttreatment stool specimens as evidence of drug efficacy. However, only a single positive stool specimen is usually required for study enrollment. To determine the reproducibility of detection of S. stercoralis larvae in the stool, 108 asymptomatic infected men submitted 25 g of fresh stool once a week for eight consecutive weeks for examination by the Baermann technique. During the 8-week study, 239 (27.7%) of 864 stool specimens were positive for S. stercoralis. Rates of detection of larvae in the stool specimens ranged from eight of eight specimens in 3 (2.8%) men to none of eight specimens in 36 (33.3%) men. Of 43 men for whom S. stercoralis was detected in at least two of the first four stool specimens, only 1 (2.3%) man tested negative on all of the next four specimens. In comparison, of 29 men who had detectable larvae in only one of the first four specimens, 22 (75.9%) tested negative on all of the next four samples. Thus, if these 29 men had been enrolled in a therapeutic trial between the first and second sets of four specimens, the efficacy of a drug with no activity against this parasite would have been estimated to be 76%. These data suggest that patterns of S. stercoralis detection vary widely among infected persons and that intermittent larval shedding can lead to inflated estimates of drug efficacy. Before a patient is entered in a clinical trial of drug efficacy, four consecutive stool specimens should be examined for S. stercoralis; only persons with two or more positive specimens should be enrolled.
The methylene blue stain for fecal leukocytes (FL) is widely used as an adjunct to slower but more accurate tests of diarrheal etiology, such as stool culture (SCx) or toxin assays for Clostridium difficile. Prior studies investigating the utility of FL for predicting SCx and C. difficile toxin assay (CDTA) results did not evaluate the importance of inpatient versus outpatient status. We conducted a study of patients who submitted a stool specimen to the Stanford Hospital Microbiology Laboratory between May 1998 and April 1999. The results for stool specimens that were tested by FL and by a confirmatory test (either SCx or CDTA) were used to determine whether the FL method helped to predict the results of these tests. Of 797 stools that were tested by FL method and at least one confirmatory test, 502 stools were tested by CDTA, and 473 stools were cultured. The FL test was 14% sensitive and 90% specific for C. difficile with a diagnostic threshold of one white blood cell/high-power field (WBC/HPF). The overall likelihood ratio (LR) for a positive CDTA was 1.4 with a 95% confidence interval (CI) of 0.5 to 3.7 (P = 0.5) and was similar among inpatients and outpatients. In contrast, the presence of ≥1 WBC/HPF was 52% sensitive and 88% specific for the 27 positive SCx results and helped to predict a positive SCx result (LR, 4.2; 95% CI, 2.7 to 6.5; P < 0.001). The sensitivity of ≥1 WBC/HPF was 57%, and its predictive value for SCx was higher among outpatients (outpatient LR, 5.0; 95% CI, 2.9 to 8.6; P < 0.001; inpatient LR, 1.9; 95% CI, 0.3 to 10.8; P = 0.5). Among inpatients, only 4 (1.5%) of the 273 SCx results were positive, and the presence of ≥1 WBC/HPF was insensitive (25%) and did not predict a positive SCx (LR, 1.9; 95% CI, 0.3 to 10.8; P = 0.5). When the data were reanalyzed using a diagnostic threshold of five WBC/HPF for FL, the predictive power of the FL method was similar. Thus, FL was of no value in predicting CDTA positivity, nor was it helpful in predicting SCx results for inpatients. Neither SCx nor the FL method should routinely be performed on samples from inpatients. Among outpatients, presence of FLs should suggest a bacterial diarrhea in clinically compatible cases.
Rapid Access Outpatient Units (RAOUs) have been suggested as an alternative to hospital inpatient units for the management of some acutely unwell children. These units can provide ambulatory care, delivered close to home, and may prevent unnecessary hospital admission. There are no qualitative data on the views of primary care practitioners regarding these types of facilities. The aim of the study was to explore the opinions of primary care practitioners regarding a newly established RAOU.
The RAOU was established locally at a district general hospital when inpatient beds were closed and moved to an inpatient centre, based six miles away at the tertiary teaching hospital.
Qualitative, practice based group interviews with primary care practitioners (general practitioners (GPs), nurse practitioners and practice nurses) on their experiences of the RAOU. The data collection consisted of three practice based interviews with 14 participants. The interviews were recorded and transcribed verbatim. Thematic content analysis was used to evaluate the data.
There was positive feedback regarding ease of telephone access for referral, location, and the value of a service staffed by senior doctors where children could be observed, investigated and discharged quickly. There was confusion regarding the referral criteria for the assessment unit and where to send certain children. A majority of the practitioners felt the utility of the RAOU was restricted by its opening hours. Most participants felt they lacked sufficient information regarding the remit and facilities of the unit and this led to some uneasiness regarding safety and long term sustainability.
Practitioners considered that the RAOU offered a rapid senior opinion, flexible short term observation, quick access to investigations and was more convenient for patients. There were concerns regarding opening hours, safety of patients and lack of information about the unit's facilities. There was confusion about which children should be sent to the unit. This study raises questions regarding policy in regard to the organisation of paediatric services. It highlights that when establishing alternative services to local inpatient units, continual communication and engagement of primary care is essential if the units are to function effectively.
To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.
Qualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.
Teaching hospital and nearby general hospital plus general practices in Birmingham.
38 consultants and 56 general practitioners who regularly referred to the teaching hospital.
Main outcome measures
Reasons for prescribing a new drug; sources of information used for new drugs; extent of contact between consultants and general practitioners; and amount of study drugs used in hospitals and by general practitioners.
Consultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.
The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.
What is already known on this topicUK studies show that use of new drugs by general practitioners is influenced by consultants, the nature of the drug, and perceived riskWhat this study addsConsultants generally introduced fewer drugs than general practitioners, usually within their specialtyDecisions were said to be based mainly on the evidence from the scientific literature and meetingsGeneral practitioners prescribed more new drugs and the basis of decisions was more variedDoctors' interpretations of using a new drug were not consistent
To explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation.
Mixed-method, multisite and case study research.
Six clinical commissioning groups and local clusters in the East of England area, covering in total 208 GPs and 1 662 000 population.
Semistructured interviews with 56 lead GPs, practice managers and staff from the local health authorities (primary care trusts, PCT) as well as various healthcare professionals; 21 observations of clinical commissioning group (CCG) board and executive meetings; electronic survey of 58 CCG board members (these included GPs, practice managers, PCT employees, nurses and patient representatives) and subsequent social network analysis.
Main outcome measures
Collaborative relationships between CCG board members and stakeholders from their healthcare network; clarifying the role of GPs as network leaders; strengths and areas for development of CCGs.
Drawing upon innovation network theory provides unique insights of the CCG leaders’ activities in establishing best practices and introducing new clinical pathways. In this context we identified three network leadership roles: managing knowledge flows, managing network coherence and managing network stability. Knowledge sharing and effective collaboration among GPs enable network stability and the alignment of CCG objectives with those of the wider health system (network coherence). Even though activities varied between commissioning groups, collaborative initiatives were common. However, there was significant variation among CCGs around the level of engagement with providers, patients and local authorities. Locality (sub) groups played an important role because they linked commissioning decisions with patient needs and brought the leaders closer to frontline stakeholders.
With the new commissioning arrangements, the leaders should seek to move away from dyadic and transactional relationships to a network structure, thereby emphasising on the emerging relational focus of their roles. Managing knowledge mobility, healthcare network coherence and network stability are the three clinical leadership processes that CCG leaders need to consider in coordinating their network and facilitating the development of good clinical commissioning decisions, best practices and innovative services. To successfully manage these processes, CCG leaders need to leverage the relational capabilities of their network as well as their clinical expertise to establish appropriate collaborations that may improve the healthcare services in England. Lack of local GP engagement adds uncertainty to the system and increases the risk of commissioning decisions being irrelevant and inefficient from patient and provider perspectives.
Health Services Administration & Management; Qualitative Research