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1.  PHL2/340: West of Scotland Primary Care Internet Project 
The UK Government has now spent £7 million to link together every GP practice in Scotland on the NHSnet. The Scottish Health Minister recently stated that "The GP will have at his fingertips a wealth of up-to-date information, new procedures, and the best of current thinking in the NHS". The uptake of this new technology, together with the knowledge of how to put it into practice, is extremely varied amongst Primary Care Staff. A little knowledge can be dangerous and very distressing for the less adept patient faced with the bare facts about their disease. Therefore, it is important to know how people who have access to the Internet use the medical information available to them and the response of the Family Doctors and Practice Nurses in the West of Scotland to caring for people with such information.
A structured questionnaire was distributed to Family Doctors and General Practice Nurses in all Primary Care Practices throughout Glasgow.
Initial results show 86% of GPs and 66% of Practice Nurses access the Internet either from their Practice or from Home. Those clinicians that have not yet accessed, the net highlight "Time Restraints" and "Unsure of Technology" as the most common reasons for stopping them. 67% of patients have presented Internet-based healthcare information that is new to the Doctor or Nurse. Only, 78 % of the information presented by the patient was accurate, while half of the patients had correctly interpreted the information. On the other hand, 90% of clinicians found the consultation with this type of patient to be more interactive than usual, while 78% of clinicians felt their patients had higher expectations. Finally, it was found that 90% of clinicians discovered that, a patient presenting with healthcare information from the Internet participated more actively in their treatment.
Approximately, three quarters of clinicians questioned have seen patients who supplemented their consultation with information obtained from the Internet. Those patients have higher expectations than the average patient and are found to participate, more actively, in their treatment. With the continued proliferation of health sites on the Internet and the fact that more patients are empowered by new PCs and free Internet access, this type of patient consultation can only increase.
PMCID: PMC1761773
Internet; Education; Primary Care; Training
2.  Contribution of general practitioner hospitals in Scotland. 
The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.
PMCID: PMC1441003  PMID: 6424859
3.  Impact of a national audit project on gynaecologists in Scotland. 
Quality in Health Care  1995;4(1):37-39.
The objectives of the study were (a) to determine consultant gynaecologists' awareness of and views on a national audit project (the gynaecology audit project in Scotland) and (b) to measure changes in their reported practice in relation to 12 specific elements of care related to three audit topics (induced abortion, endometriosis, and vulvar carcinoma) for which recommendations for change had been made within the project. The study comprised a postal questionnaire survey of all 128 consultant gynaecologists in NHS practice in Scotland. The response rate was 90%. Of the respondents, 96% (109/113) recalled receiving feedback material from the audit project team and around 75% (range 66/89 to 84/105) had retained feedback reports for future reference. For the two more common clinical topics (induced abortion and endometriosis), over two thirds of the respondents indicated that they had been prompted to reconsider or change aspects of practice. Significant changes in reported practice, in line with project recommendations, were found for seven of the 12 specific elements of care examined. Thus, gynaecologists in Scotland showed a high level of awareness of and positive views towards a national audit project. Significant changes in reported practice, in accordance with circulated recommendations, were measurable in relation to several elements of clinical care.
PMCID: PMC1055264  PMID: 10142033
4.  Coordinating and standardizing long-term care: evaluation of the west of Scotland shared-care scheme for hypertension. 
BACKGROUND. The long-term management of patients with chronic conditions such as hypertension presents problems for the health services. Shared care addresses these by coordinating care and defining responsibilities. AIM. This study set out to investigate the feasibility, acceptability and cost effectiveness of shared general practitioner-hospital care for well-controlled hypertensive patients in an urban area by comparing three matched groups of patients. METHOD. A total of 554 outpatient clinic attenders, considered suitable for shared care by their consultant, were randomly allocated to shared care or follow up in the outpatient clinic; a third group of 277 patients was selected from a nurse practitioner clinic. Main outcome measures were the proportion of patients in the second year of follow up who had undergone a complete review (blood pressure measurement, serum creatinine level result and electrocardiograph report), acceptability to patients and general practitioners as assessed by questionnaire, and cost per complete review in year two (National Health Service and patient costs). RESULTS. After two years 220 (82%) shared care patients had had a complete review compared with 146 (54%) outpatient clinic attenders and 202 (75%) nurse practitioner clinic attenders. Blood pressure control was similar in each group. Of 297 general practitioners invited, 85% wished to participate in the study; 61% of questionnaire respondents subsequently wanted shared care to continue while 25% were unsure. Half of the patients receiving shared care preferred this method of follow up. The rank order of cost-effectiveness ratios was shared care, nurse practitioner care and conventional outpatient care, relative differences being most marked when only patient costs were considered. CONCLUSION. Shared care for hypertension is feasible in an urban setting, acceptable to the majority of participants and is a cost-effective method of long-term follow up.
PMCID: PMC1239016  PMID: 7748631
5.  Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability and discriminant validity. 
BACKGROUND: Primary health care services are the most frequently used in the health care system. Consumer feedback on these services is important. Research in this area relates mainly to doctor-patient relationships which fails to reflect the multidisciplinary nature of primary health care. AIM: A pilot study aimed to examine the feasibility of using a patient satisfaction questionnaire designed for use with general practitioner consultations as an instrument for measuring patient satisfaction with community nurses. METHOD: The questionnaire measuring patient satisfaction with general practitioner consultations was adapted for measuring satisfaction with contacts with a nurse practitioner, district nurses, practice nurses and health visitors. A total of 1575 patients in three practices consulting general practitioners or community nurses were invited to complete a questionnaire. Data were subjected to principal components analysis and the dimensions identified were tested for internal reliability and replicability. To establish discriminant validity, patients' mean satisfaction scores for consultations with general practitioners, the nurse practitioner, health visitors and nurses (district and practice nurses) were compared. RESULTS: Questionnaires were returned relating to 400 general practitioner, 54 nurse practitioner, 191 district/practice nurse and 83 health visitor consultations (overall response rate 46%). Principal components analysis demonstrated a factor structure similar to that found in an earlier study of the consultation satisfaction questionnaire. Three dimensions of patient satisfaction were identified: professional care, depth of relationship and perceived time spent with the health professional. The dimensions were found to have acceptable levels of reliability. Factor structures obtained from data relating to general practitioner and community nurse consultations were found to correlate significantly. Comparison between health professionals showed that patients rated satisfaction with professional care significantly more highly for nurses than for general practitioners and health visitors. Patients' rating of satisfaction with the depth of relationships with health visitors was significantly lower than their ratings of this relationship with the other groups of health professionals. There were so significant differences between health professional groups regarding patients' ratings of satisfaction with the perceived amount of time spent with health professionals. CONCLUSION: The pilot study showed that it is possible to use the consultation satisfaction questionnaire for both general practitioners and community nurses. Comparison between health professional groups should be undertaken with caution as data were available for only a small number of consultations with some of the groups of health professionals studied.
PMCID: PMC1239507  PMID: 8745848
6.  Exploring potential explanations for the increase in antidepressant prescribing in Scotland using secondary analyses of routine data 
Antidepressant prescribing in general practice has dramatically increased since the beginning of the last decade.
To determine if the increase in antidepressants prescribed in Scotland between 1995 and 2001 was due to increase in incidence, prevalence, care-seeking behaviour by patients, or identification by GPs of depression.
Secondary analysis of routine data. Prescribing information was obtained from Information and Statistics Division Scotland, psychosocial morbidity from the Scottish Health Surveys of 1995 and 1998 and GP consultations from the continuous morbidity recording (CMR) dataset. Annual trends in antidepressant prescribing for prescriptions, gross ingredient cost and defined daily doses (DDDs) were examined for all Scottish Practices and 54 stable CMR practices (175 955 patients). Prevalence of psychological morbidity in responders with a General Health Questionnaire score ≥4, their contact probability and contact frequency was compared in the 1995 and 1998 Scottish Health Surveys. Changes in diagnostic and GP consultation patterns in CMR practices were compared.
Total prescriptions for antidepressants increased from 1.5 million in 1995–1996 to 2.8.million in 2000–2001. The gross ingredient cost increased from £20 to £44 million and total DDDs from 44.5 to 93.2 million. Prescription trends in CMR practices were similar. Overall prevalence of psychological morbidity was the same in the 1995 and 1998 Scottish Health Surveys. Percentage of consultations in CMR practices for new diagnoses of depression decreased from 1.7 to 1.3%, the depression-related contact rate decreased and annual prevalence rates for depressive illness were stable between 1998–1999 and 2000–2001.
There is no evidence of an increase in incidence, prevalence, care-seeking behaviour or identification of depression during the period of a sharp increase in antidepressant prescribing. Further work is required to explain the increase.
PMCID: PMC1839016  PMID: 16762123
depression; drugs; health services; mental health; primary care
7.  Inpatient Management: Variations in some Aspects of Practice in Scotland 
British Medical Journal  1971;1(5747):495-498.
Data for four aspects of inpatient management—namely, variations in length of stay, the time patients spend in hospital before or after operation, and the proportion of patients operated on in surgical units—show considerable variations in certain aspects of practice by Scottish consultants. It is suggested that there may be simple explanations for some of the observed variations. The differences could be due to great variation in the constraints encountered by the consultants in their work, or to wide differences of opinion about the optimum treatment for specific diagnoses.
PMCID: PMC1795180  PMID: 5544013
8.  Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training 
Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations.
Design: Interview and postal survey.
Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003).
Participants: Staff proportionally representative of professional groups involved in maternity care.
Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for "generalists" in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use.
Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.
PMCID: PMC1743960  PMID: 15692001
9.  Epidemiology and implications of ocular trauma admitted to hospital in Scotland. 
OBJECTIVES: To describe the current epidemiology of serious ocular trauma which necessitates admission to hospital so that health and safety strategies for the prevention of ocular injuries and their role within the national health strategy, The Health of the Nation, can be better informed. DESIGN: A prospective observational study of all patients with ocular trauma admitted to hospital under the care of a consultant ophthalmologist between 1 November 1991 and 31 October 1992. SETTING: All ophthalmic department in Scotland. SUBJECTS: All patients with ocular trauma admitted to hospital in Scotland. The population of Scotland represented the population at risk of injury. MEASURES AND MAIN RESULTS: Measures included the type and cause of injury, the place where it occurred, and awareness of risk and safety. All ophthalmic departments in Scotland participated and 428 admissions were reported. The home was the most common place for a serious injury to occur (30.2%), followed by the workplace (19.6%) and a sports or leisure facility (15.8%). The home was the single most frequent place of injury for the 0-15 year and 65 year and over age groups. Tools or machinery, either at home (13.9%) or at work (10.3%), were collectively (24.2%) the most frequent cause of injury, followed by assault (21.8%) and sports-related activities (12.5%). The most frequent type of injury was a blunt injury (54.4%). Six per cent (n = 25) of all injuries were bilateral. Only 13.2% of patients were aware of any risk of injury, with 5.6% aware of any risk at home. When applicable, protective eye wear was only available to 48.6% of patients and only 19.4% of these used it. CONCLUSION: Serious ocular trauma frequently occurs at home and the young and the elderly are particularly at risk. This represents a significant change in the epidemiology of serious ocular trauma and has important implications for prevention. Health and safety strategies specifically aimed at preventing eye injury should now include the home as a high risk environment in addition to the work-place and sports/leisure facilities. The target groups for accident prevention in The Health of the Nation strategy include those at risk of serious ocular trauma with potentially sight threatening sequelae. Those involved in implementing the national accident prevention strategy should be aware of this, for in this process it is possible that some serious eye injuries may also be prevented.
PMCID: PMC1060315  PMID: 8882228
10.  Guidelines and management of mild hypertensive conditions in pregnancy in rural general practices in Scotland: issues of appropriateness and access 
Quality & safety in health care  2003;12(4):286-290.
Objectives: To assess the diagnosis and management of mild non-proteinuric hypertension in pregnancy in rural general practices against guideline recommendations.
Design: Postal survey and telephone interview.
Setting: All 174 designated rural general practices in Scotland.
Sample: 171 GPs and 158 midwives responsible for antenatal care stratified by distance from a specialist maternity hospital.
Main outcome measures: Accuracy of diagnosis and appropriateness of management compared with guideline.
Results: At least one respondent replied for 91% (158/174) of rural practices. Response rates were 68% (117/170) for GPs and 77% (121/158) for midwives. Both GP and midwife replied for 46% (80/174) of practices. Most GPs (80%, 87/109) and midwives (63%, 71/113) overdiagnosed the scenario. Intended management was therefore most often referral or admission to specialist hospital (59%, 132/224), both courses of action beyond guideline recommendations. There was an association between distance of practice from specialist maternity hospital and professionals' report of intended referral or admission. Explanatory factors from telephone interviews included a poor knowledge base, cautious risk assessment, and perceived inflexibility of guidelines for remote situations.
Conclusions: There is a lack of accuracy in the diagnosis of a common antenatal problem and intended management is consistent with overdiagnosis. The results suggest that women in rural settings may experience more antenatal referrals and admissions than are clinically appropriate according to the guidelines. At a time of increasing centralisation of maternity services, this could increase inappropriate referrals and increase costs to service and patients. Quality of care may be improved by developing consensual local guidelines with rural maternity care professionals and support maintained skills and confidence in decision making.
PMCID: PMC1743728  PMID: 12897362
11.  Bone densitometry at a district general hospital: evaluation of service by doctors and patients. 
Quality in Health Care  1996;5(1):36-43.
OBJECTIVE--To assess doctors' and patients' views about a district general hospital bone densitometry service and to examine existing practice to influence future provision. DESIGN--Three postal surveys: (a) of doctors potentially using the service, (b) of patients undergoing a bone densitometry test during a six month period, and (c) of the referring doctors of the patients undergoing the test. SETTING--Bone densitometry service at South Cleveland Hospital, Middlesbrough and two district health authorities: South Tees and Northallerton. SUBJECTS--All general practitioners (n=201) and hospital consultants in general medicine, rheumatology, obstetrics and gynaecology, orthopaedics, radio therapy and oncology, haematology, and radiology (n=61); all patients undergoing an initial bone densitometry test (n=309) during a six month period; and their referring doctors. MAIN MEASURES--Service awareness and use, knowledge of clinical indications, test results, influence of test results on patient management, satisfaction with the service and its future provision. RESULTS--The overall response rates for the three surveys were 87%, 70%, and 61%. There was a high awareness of the service among doctors and patients; 219(84%) doctors were aware and 155 of them (71%) had used it, and patients often (40%) suggested the test to their doctor. The test was used for a range of reasons including screening although the general use was consistent with current guidelines. Two hundred (65%) bone densitometry measurements were normal, 71(23%) were low normal, and 38(12%) were low. Although doctors reported that management of patients had been influenced by the test results, the algorithm for decision making was unclear. Patients and doctors were satisfied with the service and most (n=146, 68%) doctors wanted referral guidelines for the service. CONCLUSIONS--There was a high awareness of, use of, and satisfaction with the service. Patients were being referred for a range of reasons and a few of these could not be justified, many tests were normal, and clinical decision making was not always influenced by the test result. It is concluded that bone densitometry services should be provided but only for patients whose management will be influenced by test results and subject to guidelines to ensure appropriate use of the technology.
PMCID: PMC1055352  PMID: 10157271
12.  Twenty years of vocational training in the west of Scotland. 
BMJ : British Medical Journal  1991;302(6767):28-30.
OBJECTIVE--To assess the career paths of doctors who completed vocational training in the west of Scotland between 1968 and 1987 and their views on the hospital component of their training. DESIGN--Retrospective analysis of the experience and opinions of vocationally trained doctors obtained from a postal questionnaire. SETTING--West of Scotland. SUBJECTS--1255 Doctors identified from Glasgow University records who had been vocationally trained in the west of Scotland between 1968 and 1987. MAIN OUTCOME MEASURES--Personal details; employment; jobs held currently; additional professional commitments; importance of hospital posts held in various specialties to respondents currently in general practice; and retrospective choice of hospital posts, based on subsequent experience. RESULTS--619 Responses were received, 543 initially and 76 after a letter of reminder, from a possible total of 974 (excluding 153 questionnaires returned by the post office and 128 returned because of misunderstanding between the name and address); the overall response rate was therefore 64%. 607/619 (98%) Respondents were employed at the time of the study, of whom 517/607 (85%) were in general practice. A third (202/609) had been unemployed at some point, significantly more of them women (122/243, 50% v 80/376, 21%; chi 2 = 54.8, p less than 0.001). 510/563 (91%) Respondents held one postgraduate qualification or more, and 284/612 (46%) had additional professional commitments. The hospital posts most commonly held were in obstetrics and gynaecology, psychiatry, paediatrics, and medicine. Medicine, obstetrics, paediatrics, and dermatology were considered to be the most relevant hospital specialties by those who had experience of them and were now in general practice. Although ophthalmology and ear, nose, and throat were not rated highly by these doctors, other respondents wished that they had held posts in these specialties (32 and 40 respectively). During the hospital training 354/475 (75%) respondents thought that they were looked on as a junior hospital doctor and not as a trainee for general practice. CONCLUSIONS--Most of those who had entered vocational training were in employment, and most were in general practice. According to them, the most beneficial hospital posts for vocational training are medicine, obstetrics, paediatrics, and dermatology. Trainees should be encouraged to attend clinics in gynaecology, ear, nose, and throat, and ophthalmology.
PMCID: PMC1668750  PMID: 2053933
13.  Junior doctor titles following implementation of Modernising Medical Careers in the UK 
JRSM Short Reports  2011;2(3):22.
Recent changes in postgraduate medical training in the UK collectively organized under the auspices of Modernising Medical Careers (MMC) have created new labels for junior doctors in training. It would appear that many nurses and other health workers do not understand the new terminology. We aimed to investigate the knowledge of nursing staff about new junior doctor titles in a district general hospital. As far as we are aware, this is the first survey to determine the views and knowledge of the new terms among staff working in the NHS.
Questionnaire study.
District general hospital, West Midlands, UK.
Fifty-five randomly selected staff nurses working in the surgical directorate.
Main outcome measure
Questions were asked about their views and knowledge of the current nomenclature. To objectively assess knowledge of the new titles respondents were asked to match equivalent positions with those based on the old system.
Only 22% (n = 12) of respondents felt that they fully understand current terms in usage. Seventy-six percent (n = 42) felt that it was ‘very important’ that titles accurately convey role and seniority of the doctor. The most common titles correctly matched were FY1 and House Officer (n = 45, 81%) and FY2 and First Year Senior House Officer (n = 35, 64%). Only 9% (n = 5) of staff nurses correctly matched ST3 to Junior Registrar and 13% (n = 7) correctly matched ST7 to Senior Registrar. Ward-based staff nurses demonstrated greater familiarity with titles when compared to nurses who work mainly in the outpatient clinic and theatre setting (p = 0.017). We did not identify a statistically significant association with demographic characteristics (age, gender, experience) and knowledge of the new terms (p > 0.05). Approximately 98% (n = 54) of the staff surveyed felt that terms are confusing to nurses and need to be simplified.
Our survey revealed that nursing staff lacked knowledge of the current terminology to describe doctors in training. This may have implications for staff expectations regarding specific role of junior doctor in terms of clinical decision-making, working relationships and communication between team members, and ultimately patient care.
PMCID: PMC3086326  PMID: 21541090
14.  Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals 
Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.
PMCID: PMC2422837  PMID: 18485235
15.  Ethical issues in public health: a qualitative study of public health practice in Scotland 
Study objective: To identify ethical issues encountered by staff in the development and implementation of public health activities at two sites in Scotland.
Design: Qualitative research study involving face to face semi-structured interviews with participants.
Setting: A public health directorate in a National Health Service Trust, and a public health demonstration project in child health.
Participants: Health promotion specialists, managers, nurses, public health consultants and specialists, researchers, trainees, and other public health staff.
Main results: Three main categories of ethical issues were identified: paternalism, responsibilities, and ethical decision making. Consulting with the community and sharing information raised issues of paternalism and honesty. Participants identified multiple and sometimes conflicting responsibilities. Barriers to fulfilling responsibilities included meeting targets, working with partners, and political influences. Defining the limits of responsibilities posed challenges. Participants identified values for ideal decision making, but lack of time often led to a more pragmatic approach.
Conclusion: These empirical findings complement and extend existing discussions of public health ethics, emphasising the complex nature of ethical issues in public health. The implications for public health policy and future research are discussed.
PMCID: PMC1732787  PMID: 15143108
16.  A blended knowledge translation initiative to improve colorectal cancer staging [ISRCTN56824239] 
A significant gap has been documented between best practice and the actual practice of surgery. Our group identified that colorectal cancer staging in Ontario was suboptimal and subsequently developed a knowledge translation strategy using the principles of social marketing and the influence of expert and local opinion leaders for colorectal cancer.
Opinion leaders were identified using the Hiss methodology. Hospitals in Ontario were cluster-randomized to one of two intervention arms. Both groups were exposed to a formal continuing medical education session given by the expert opinion leader for colorectal cancer. In the treatment group the local Opinion Leader for colorectal cancer was detailed by the expert opinion leader for colorectal cancer and received a toolkit. Forty-two centres agreed to have the expert opinion leader for colorectal cancer come and give a formal continuing medical education session that lasted between 50 minutes and 4 hours. No centres refused the intervention. These sessions were generally well attended by most surgeons, pathologists and other health care professionals at each centre. In addition all but one of the local opinion leaders for colorectal cancer met with the expert opinion leader for colorectal cancer for the academic detailing session that lasted between 15 and 30 minutes.
We have enacted a unique study that has attempted to induce practice change among surgeons and pathologists using an adapted social marketing model that utilized the influence of both expert and local opinion leaders for colorectal cancer in a large geographic area with diverse practice settings.
PMCID: PMC1395360  PMID: 16412251
17.  National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland 
Heart  2004;90(10):1129-1136.
Objective: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK.
Design: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000.
Setting: 53 primary care practices (307 741 patients).
Subjects: 2186 adult patients with heart failure.
Results: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients ⩾ 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients ⩾ 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a β blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p  =  0.29 versus men), 7% (p  =  0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a β blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients ⩾ 75 years were 19% (p  =  0.04 versus patients < 75), 7% (p  =  0.04), and 33% (p < 0.001).
Conclusions: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women.
PMCID: PMC1768509  PMID: 15367505
heart failure; epidemiology; prescribing; primary care
18.  Opinion leaders and changes over time: a survey 
Opinion leaders represent one way to disseminate new knowledge and influence the practice behaviors of physicians. This study explored the stability of opinion leaders over time, whether opinion leaders were polymorphic (i.e., influencing multiple practice areas) or monomorphic (i.e., influencing one practice area), and reach of opinion leaders in their local network.
We surveyed surgeons and pathologists in Ontario to identify opinion leaders for colorectal cancer in 2003 and 2005 and to identify opinion leaders for breast cancer in 2005. We explored whether opinion leaders for colorectal cancer identified in 2003 were re-identified in 2005. We examined whether opinion leaders were considered polymorphic (nominated in 2005 as opinion leaders for both colorectal and breast cancer) or monomorphic (nominated in 2005 for only one condition). Social-network mapping was used to identify the number of local colleagues identifying opinion leaders.
Response rates for surgeons were 41% (2003) and 40% (2005); response rates for pathologists were 42% (2003) and 37% (2005). Four (25%) of the surgical opinion leaders identified in 2003 for colorectal cancer were re-identified in 2005. No pathology opinion leaders for colorectal cancer were identified in both 2003 and 2005. Only 29% of surgical opinion leaders and 17% of pathology opinion leaders identified in the 2005 survey were considered influential for both colorectal cancer and breast cancer. Social-network mapping revealed that only a limited number of general surgeons (12%) or pathologists (7%) were connected to the social networks of identified opinion leaders.
Opinion leaders identified in this study were not stable over a two-year time period and generally appear to be monomorphic, with clearly demarcated areas of expertise and limited spheres of influence. These findings may limit the practicability of routinely using opinion leaders to influence practice.
PMCID: PMC3205036  PMID: 21988924
19.  Control of blood pressure in Scotland: the rule of halves. 
BMJ : British Medical Journal  1990;300(6730):981-983.
OBJECTIVE--Audit of detection, treatment, and control of hypertension in adults in Scotland. DESIGN--Cross sectional survey with random population sampling. SETTING--General practice centres in 22 Scottish districts. SUBJECTS--5123 Men and 5236 women aged 40-59 in the Scottish heart health study, randomly selected from 22 districts throughout Scotland, of whom 1262 men and 1061 women had hypertension (defined as receiving antihypertensive treatment or with blood pressure above defined cut off points). MAIN OUTCOME MEASURE--Hypertension (assessed by standardised recording, questionnaire on diagnosis, and antihypertensive drug treatment) according to criteria of the World Health Organisation (receiving antihypertensive treatment or blood pressure greater than or equal to 160/95 mm Hg, or both) and to modified criteria of the British Hypertension Society. RESULTS--In half the men with blood pressure greater than or equal to 160/95 mm Hg hypertension was undetected (670/1262, 53%), in half of those in whom it had been detected it was untreated (250/592, 42%), and in half of those receiving treatment it was not controlled (172/342, 50%). In women the numbers were: 486/1061, 46%; 188/575, 33%; and 155/387, 40% respectively. Assessment of blood pressure according to the British Hypertension Society's recommendations showed an improvement, but in only a quarter of men and 42% of women was hypertension detected and treated satisfactorily (142/561, 215/514 respectively). IMPLICATIONS--The detection and control of hypertension in Scotland is unsatisfactory, affecting management of this and other conditions, such as high blood cholesterol concentration, whose measurement is opportunistic and selective and depends on recognition of other risk factors.
PMCID: PMC1662684  PMID: 2344507
20.  Recovery in Scotland: Beyond service development 
Over the last ten years there has been significant activity related to the promotion and support of recovery in Scotland, much of it linked to the work of the Scottish Recovery Network. A range of government policies have consistently identified recovery as a guiding principle of both service design and mental health improvement efforts. New learning has been developed and shared, workforce competencies reviewed and training developed, and a range of national initiatives put in place. In Scotland, as elsewhere, these efforts have tended to focus primarily on ensuring that mental health services offer environments and practices that support personal recovery. While service improvement is crucial, a wider challenge is ensuring that opportunities and support for self-directed recovery are enhanced outside statutory services. Providing examples, this paper will look at the development of recovery in Scotland – including the work of the Scottish Recovery Network – and consider the potential for building on progress made by rebalancing efforts to support personal recovery, highlighting the importance of public attitudes and community-based learning approaches. We will also touch on the role of identity in personal recovery and consider cultural issues related to the promotion of recovery in Scotland.
PMCID: PMC3581058  PMID: 22385428
21.  Twenty years of vocational training in the west of Scotland: the practice component. 
A retrospective analysis of the experience and opinions of doctors receiving vocational training in general practice was obtained by postal questionnaire. Questionnaires were received by 974 doctors who had been vocationally trained in the west of Scotland between 1968 and 1987. The response rate was 64%. It was found that 94% of the respondents had enjoyed their trainee period, 82% had been given a choice of training practice and 86% had spent 12 months in a training practice. Only 81 respondents had trained in two practices. The most common method of monitoring the trainee's consultation was the trainer sitting in on the consultation; half of the doctors had experience of this (51%). For the majority regular tutorials were commonplace, but for 41% of respondents this was not so. However, those training after 1979 were significantly less likely to have never had tutorials than those training earlier. Nearly half of the doctors (49%) felt that certain aspects had been poorly covered or omitted from their training, notably practice management and finance. Again, this was significantly less likely among those training after 1979. When asked to give a rating of the training they had received 21% of the respondents rated it as excellent, 37% as very good, 30% as fairly good and 12% as poor/fairly poor or very poor. Notably, significantly fewer respondents training after 1979 rated their training as poor/fairly poor or very poor. Very few respondents had participated in a practice exchange but virtually all of those who had felt it had been beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1371859  PMID: 1807324
22.  New Role, New Country: introducing US physician assistants to Scotland 
This paper draws from research commissioned by the Scottish Executive Health Department (SEHD). It provides a case study in the introduction of a new health care worker role into an already well established and "mature" workforce configuration It assesses the role of US style physician assistants (PAs), as a precursor to planned "piloting" of the PA role within the National Health Service (NHS) in Scotland.
The evidence base for the use of PAs is examined, and ways in which an established role in one health system (the USA) could be introduced to another country, where the role is "new" and unfamiliar, are explored.
The history of the development of the PA role in the US also highlights a sometimes somewhat problematic relationship between P nursing profession. The paper highlights that the concept of the PA role as a 'dependent practitioner' is not well understood or developed in the NHS, where autonomous practice within regulated professions is the norm. In the PA model, responsibility is shared, but accountability rests with the supervising physician. Clarity of role definition, and engendering mutual respect based on fair treatment and effective management of multi-disciplinary teams will be pre-requisites for effective deployment of this new role in the NHS in Scotland.
PMCID: PMC1885268  PMID: 17480211
23.  Progress in the development of integrated mental health care in Scotland 
The development of integrated care through the promotion of ‘partnership working’ is a key policy objective of the Scottish Executive, the administration responsible for health services in Scotland. This paper considers the extent to which this goal is being achieved in mental health services, particularly those for people with severe and enduring mental illness. Distinguishing between the horizontal and vertical integration of services, exploratory research was conducted to assess progress towards this objective by examining how far a range of functional activities in Primary Care Trusts (PCTs) and their constituent Local Health Care Co-operatives (LHCCs) were themselves becoming increasingly integrated. All PCTs in Scotland were surveyed by postal questionnaire, and followed up by detailed telephone interviews. Six LHCC areas were selected for detailed case study analysis. A Reference Group was used to discuss and review emerging themes from the fieldwork. The report suggests that faster progress is being made in the horizontal integration of services between health and social care organisations than is the case for vertical integration between primary health care and specialist mental health care services; and that there are significant gaps in the extent to which functional activities within Trusts are changing to support the development of integrated care. A number of models are briefly considered, including the idea of ‘intermediate care’ that might speed the process of integration.
PMCID: PMC1480385  PMID: 16896397
Scotland; mental health services; integration; social care; intermediate care; severe and enduring mental illness; Primary Care Trusts (PCTs)
24.  Risk adjusted and population based studies of the outcome for high risk infants in Scotland and Australia 
OBJECTIVES—To compare outcomes of care in selected neonatal intensive care units (NICUs) for very low birthweight (VLBW) or preterm infants in Scotland and Australia (study 1) and perinatal care for all VLBW infants in both countries (study 2).
DESIGN—Study 1: risk adjusted cohort study; study 2: population based cohort study.
SUBJECTS—Study 1: all 2621 infants of < 1500 g birth weight or < 31 weeks' gestation admitted to a volunteer sample of hospitals comprising eight of all 17 Scottish NICUs and six of all 12 tertiary NICUs in New South Wales and Queensland in 1993-1994; study 2: all 5986infants of 500-1499 g birth weight registered as live born in Scotland and Australia in 1993-1994.
MAIN OUTCOMES—Study 1: (a) hospital death; (b) death or cerebral damage, each adjusted for gestation and CRIB (clinical risk index for babies); study 2: neonatal (28 day) mortality.
RESULTS—Study 1. Data were obtained for 1628 admissions in six Australian NICUs, 775 in five Scottish tertiary NICUs, and 148 in three Scottish non-tertiary NICUs. Crude hospital death rates were 13%, 22%, and 22% respectively. Risk adjusted hospital mortality was about 50% higher in Scottish than in Australian NICUs (adjusted mortality ratio 1.46, 95% confidence interval (CI) 1.29 to 1.63,p < 0.001). There was no difference in risk adjusted outcomes between Scottish tertiary and non-tertiary NICUs. After risk adjustment, death or cerebral damage was more common in Scottish than Australian NICUs (odds ratio 1.9, 95% CI 1.5 to 2.5). Both these risk adjusted adverse outcomes remained more common in Scottish than Australian NICUs after excluding all infants < 28 weeks' gestation from the comparison. Study 2. Population based neonatal mortality in infants of 500-1499 g was higher in Scotland (20.3%) than Australia (16.6%) (relative risk 1.22, 95% CI 1.08 to 1.39, p = 0.002). In a post hoc analysis, neonatal mortality was also higher in England and Wales than in Australia.
CONCLUSIONS—Study 1: outcome was better in the Australian NICUs. Study 2: perinatal outcome was better in Australia. Both results may be consistent, at least in part, with differences in the organisation and implementation of neonatal care.

PMCID: PMC1721047  PMID: 10685984
25.  Hospital volume of throughput and periprocedural and medium‐term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17 417 procedures undertaken in Scotland, 1997–2003 
Heart  2006;92(11):1667-1672.
To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium‐term events, and whether any associations are independent of differences in case mix.
Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six‐year period.
All PCIs in Scotland during 1997–2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models.
Of the 17 417 PCIs, 4900 (28%) were in low‐volume hospitals and 3242 (19%) in high‐volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high‐volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p  =  0.002). Over two years, patients in high‐volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p  =  0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events.
Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high‐volume hospitals. Over two years, patients treated in high‐volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.
PMCID: PMC1861259  PMID: 16709693

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