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1.  Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial 
British Journal of Cancer  2011;105(4):475-480.
The trial aimed to investigate whether a general practitioner's (GP) letter encouraging participation and a more explicit leaflet explaining how to complete faecal occult blood test (FOBT) included with the England Bowel Cancer Screening Programme invitation materials would improve uptake.
A randomised controlled 2 × 2 factorial trial was conducted in the south of England. Overall, 1288 patients registered with 20 GPs invited for screening in October 2009 participated in the trial. Participants were randomised to either a GP's endorsement letter and/or an enhanced information leaflet with their FOBT kit. The primary outcome was verified with return of the test kit within 20 weeks.
Both the GP's endorsement letter and the enhanced procedural leaflet, each increased participation by ∼6% – the GP's letter by 5.8% (95% CI: 4.1–7.8%) and the leaflet by 6.0% (95% CI: 4.3–8.1%). On the basis of the intention-to-treat analysis, the random effects logistic regression model confirmed that there was no important interaction between the two interventions, and estimated an adjusted rate ratio of 1.11 (P=0.038) for the GP's letter and 1.12 (P=0.029) for the leaflet. In the absence of an interaction, an additive effect for receiving both the GP's letter and leaflet (11.8%, 95% CI: 8.5–16%) was confirmed. The per-protocol analysis indicated that the insertion of an electronic GP's signature on the endorsement letter was associated with increased participation (P=0.039).
Including both an endorsement letter from each patient's GP and a more explicit procedural leaflet could increase participation in the English Bowel Cancer Screening Programme by ∼10%, a relative improvement of 20% on current performance.
PMCID: PMC3170960  PMID: 21829202
colorectal cancer; cancer screening; primary care; patient information
2.  Determining which automatic digital blood pressure device performs adequately: a systematic review 
Journal of Human Hypertension  2010;24(7):431-438.
The aim of this study is to systematically examine the proportion of accurate readings attained by automatic digital blood pressure (BP) devices in published validation studies. We included studies of automatic digital BP devices using recognized protocols. We summarized the data as mean and s.d. of differences between measured and observed BP, and proportion of measurements within 5 mm Hg. We included 79 articles (10 783 participants) reporting 113 studies from 22 different countries. Overall, 25/31 (81%), 37/41 (90%) and 34/35 (97%) devices passed the relevant protocols [BHS, AAMI and ESH international protocol (ESH-IP), respectively]. For devices that passed the BHS protocol, the proportion of measured values within 5 mm Hg of the observed value ranged from 60 to 86% (AAMI protocol 47–94% and ESH-IP 54–89%). The results for the same device varied significantly when a different protocol was used (Omron HEM-907 80% of readings were within 5 mm Hg using the AAMI protocol compared with 62% with the ESH-IP). Even devices with a mean difference of zero show high variation: a device with 74% of BP measurements within 5 mm Hg would require six further BP measurements to reduce variation to 95% of readings within 5 mm Hg. Current protocols for validating BP monitors give no guarantee of accuracy in clinical practice. Devices may pass even the most rigorous protocol with as few as 60% of readings within 5 mm Hg of the observed value. Multiple readings are essential to provide clinicians and patients with accurate information on which to base diagnostic and treatment decisions.
PMCID: PMC2897978  PMID: 20376077
blood pressure; validation; sphygmomanometer
3.  Mortality from heart failure in an English population, 1979–2003: study of death certification 
Objective: It is widely held that there will be an epidemic of heart failure in Europe and North America as a result of increased survival from myocardial infarction and other coronary heart disease. The study objective was to discover if the decline in mortality from coronary heart disease has been accompanied by a rise in mortality from heart failure in the study population.
Design: Analysis of database of mortality records including all certified causes of death, not just the underlying cause, from 1979–2003.
Setting: Former Oxford NHS Region, England.
Patients: Data from death certificates of all who died in the population covered.
Main results: Mortality rates for heart failure fell at very similar rates as those from coronary heart disease. In men, the average annual fall in mortality from coronary heart disease was –2.7% (95% confidence intervals –2.8 to –2.5) and that from heart failure was –2.9% (–3.2 to –2.5). In women, the average annual fall in mortality from coronary heart disease was –2.3% (–2.6 to –2.1) and that from heart failure was –2.6% (–3.0 to –2.3).
Conclusions: The decline in mortality from coronary heart disease has not been accompanied by a rise in mortality from heart failure. A future epidemic of heart failure, as a consequence of the decline in mortality from coronary heart disease, seems unlikely.
PMCID: PMC1733147  PMID: 16100317
4.  Parents measuring pulses; an observational study 
Archives of Disease in Childhood  2004;89(3):274-275.
PMCID: PMC1719831  PMID: 14977710
6.  Risk factors for adenocarcinoma and squamous cell carcinoma of the cervix in women aged 20–44 years: the UK National Case–Control Study of Cervical Cancer 
British Journal of Cancer  2003;89(11):2078-2086.
PMCID: PMC2376844  PMID: 14647141
cervix neoplasms; risk factors; adenocarcinoma; squamous cell carcinoma
8.  An assessment of morbidity registers for coronary heart disease in primary care. ASSIST (ASSessment of Implementation STrategy) trial collaborative group. 
BACKGROUND: Organised care delivered systematically to all patients with established coronary heart disease (CHD) can reduce their risk factors and improve their quality of life. Therefore, identifying all patients with established CHD in a general practice population is an important first step for delivering this effective healthcare. However, there is little information on how registers are compiled, the factors that predict inclusion on the register or the relationship between registration and level of care provided. AIM: To assess the completeness of morbidity registers for CHD in primary care, the factors that predict inclusion on the register, and the relationship between registration and level of care provided. METHOD: Observational study at baseline of 1979 patients aged 55 to 75 years with established CHD in 18 general practices recruited for a cluster randomised controlled trial. RESULTS: The proportion of CHD patients correctly identified on practice morbidity registers varied from 29.3% to 100%. Four factors were significantly and independently associated with being on a register: a relevant surgery contact since diagnosis (OR = 2.1, 95% CI = 1.6%-2.9%); a relevant repeat prescription since diagnosis (OR = 1.6, 95% CI = 1.1%-2.3%); a diagnosis of myocardial infarction (OR = 1.5, 95% CI = 1.2%-1.9%); and a revascularisation procedure (OR = 1.5, 95% CI = 1.1%-2.0%). Inclusion on a register was strongly associated with being adequately assessed (i.e. assessed for smoking status, blood pressure, and cholesterol) (OR = 1.8, 95% CI = 1.3%-2.3%) and with treatment with aspirin or a lipid-lowering agent (OR = 1.4 for each agent). CONCLUSION: A wide variation in registration levels between practices exists. There is evidence that practices using multiple methods of case detection achieve higher levels of registration. The association between registration and better care does not prove causality but an effective call-recall system is impossible without complete registration.
PMCID: PMC1313797  PMID: 11050785
9.  Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. 
BACKGROUND: Routine follow-up of breast cancer patients in specialist clinics is standard practice in most countries. Follow-up involves regularly scheduled breast cancer check-ups during the disease-free period. The aims of follow-up are to detect breast cancer recurrence and to provide psychosocial support to the patient; however, little is known about patients' views on breast cancer follow-up. AIM: To assess the effect on patient satisfaction of transferring primary responsibility for follow-up of women with breast cancer in remission from hospital outpatient clinics to general practice. METHOD: Randomized controlled trial with 18 months' follow-up in which women received routine follow-up either in hospital outpatient clinics or from their own general practitioner. Two hundred and ninety-six women with breast cancer in remission receiving regular follow-up care at two district general hospitals in England were included in the study. Patient satisfaction was measured by means of a self-administered questionnaire supplied three times during the 18-month study period. RESULTS: The general practice group selected responses indicating greater satisfaction than did the hospital group on virtually every question. Furthermore, in the general practice group there was a significant increase in satisfaction over baseline; a similar significant increase in satisfaction over baseline was not found in the hospital group. CONCLUSION: Patients with breast cancer were more satisfied with follow-up in general practice than in hospital outpatient departments. When discussing follow-up with breast cancer patients, they should be provided with complete and accurate information about the goals, expectations, and limitations of the follow-up programme so that they can make an informed choice.
PMCID: PMC1313497  PMID: 10756611
10.  Biochemical diagnosis of ventricular dysfunction in elderly patients in general practice: observational study 
BMJ : British Medical Journal  2000;320(7239):906-908.
To investigate the usefulness of measuring plasma concentrations of B type natriuretic peptide in the diagnosis of left ventricular systolic dysfunction in an unselected group of elderly people.
Observational study.
General practice with four centres in Poole, Dorset.
155 elderly patients aged 70 to 84 years.
Main outcome measures
Diagnostic characteristics of plasma B type natriuretic peptide measured by radioimmunoassay as a test for left ventricular systolic dysfunction assessed by echocardiography.
The median plasma concentration of B type natriuretic peptide was 39.3 pmol/l in patients with left ventricular systolic dysfunction and 15.8 pmol/l in those with normal function. The proportional area under the receiver operator curve was 0.85. At a cut-off point of 18.7 pmol/l the test sensitivity was 92% and the predictive value 18%.
Plasma concentration of B type natriuretic peptide could be used effectively as an initial test in a community screening programme and, possibly, using a low cut-off point, as a means of ruling out left ventricular systolic dysfunction. It is, however, not a good test to “rule in” the diagnosis, and access to echocardiography remains essential for general practitioners to diagnose heart failure early.
PMCID: PMC27331  PMID: 10741999
11.  Prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in general practice setting: cross sectional survey 
BMJ : British Medical Journal  1999;318(7180):368-372.
To assess the prevalence and clinical characteristics of left ventricular dysfunction among elderly patients in the general practice setting by echocardiographic assessment of ventricular function.
Cross sectional survey.
Four centre general practice in Poole, Dorset.
817 elderly patients aged 70-84 years.
Main outcomes
Echocardiographic assessment of left ventricular systolic function including measurement of ejection fraction by biplane summation method where possible, clinical symptoms, and signs of left ventricular dysfunction.
The overall prevalence of left ventricular systolic dysfunction was 7.5% (95% confidence interval 5.8% to 9.5%); mild dysfunction (5.0%) was considerably more prevalent than moderate (1.6%) or severe dysfunction (0.7%). Measurement of ejection fraction was possible in 82% of patients (n=667): in patients categorised as having mild, moderate, or severe dysfunction, the mean ejection fraction was 48% (SD 12.0), 38% (8.1), and 26% (7.9) respectively. At all ages the prevalence was much higher in men than in women (odds ratio 5.1, 95% confidence interval 2.6 to 10.1). No clinical symptom or sign was both sensitive and specific. In around half the patients with ventricular dysfunction (52%, 32/61) heart failure had not been previously diagnosed.
Unrecognised left ventricular dysfunction is a common problem in elderly patients in the general practice setting. Appropriate treatment with angiotensin converting enzyme inhibitors has the potential to reduce hospitalisation and mortality in these patients, but diagnosis should not be based on clinical history and examination alone. Screening is feasible in general practice, but it should not be implemented until the optimum method of identifying left ventricular dysfunction is clarified, and the cost effectiveness of screening has been shown.
Key messagesLeft ventricular dysfunction detected by echocardiography is common in elderly peopleMen are much more likely to be affected than womenThe accuracy of clinical diagnosis is very limited in this age groupMany patients who would benefit from treatment remain undetected
PMCID: PMC27725  PMID: 9933201
12.  R&D in primary care--an NHS priority. 
PMCID: PMC1409910  PMID: 9604405
13.  Routine follow up of breast cancer in primary care: randomised trial. 
BMJ : British Medical Journal  1996;313(7058):665-669.
OBJECTIVE: To assess the effect on time to diagnosis of recurrence and on quality of life of transferring primary responsibility for follow up of women with breast cancer in remission from hospital to general practice. DESIGN: Randomised controlled trial with 18 month follow up in which women received routine follow up either in hospital or in general practice. SUBJECTS AND SETTING: 296 women with breast cancer in remission receiving regular follow up care at district general hospitals in England. MAIN OUTCOME MEASURES: Time between first presentation of symptoms to confirmation of recurrence; quality of life measured by specific dimensions of the SF-36 schedule, the EORTC symptom scale, and hospital anxiety and depression scale. RESULTS: Most recurrences (18/26, 69%) presented as interval events, and almost half (7/16, 44%) of the recurrences in the hospital group presented first to general practice. The median time to hospital confirmation of recurrence was 21 days in the hospital group (range 1-376 days) and 22 days in the general practice group (range 4-64). The differences between groups in the change in SF-36 mean scores from baseline were small: -1.8 (95% confidence interval -7.2 to 3.5) for social functioning, 0.5 (-4.1 to 5.1) for mental health, and 0.6 (-3.6 to 4.8) for general health perception. The change from baseline in the mean depression score was higher in the general practice group at the mid-trial assessment (difference 0.6, 0.1 to 1.2) but there was no significant difference between groups in the anxiety score or the EORTC scales. CONCLUSION: General practice follow up of women with breast cancer in remission is not associated with increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life. Most recurrences are detected by women as interval events and present to the general practitioner, irrespective of continuing hospital follow up.
PMCID: PMC2351993  PMID: 8811760
14.  Warfarin in stroke prevention. 
PMCID: PMC1239379  PMID: 7546879
15.  Role of primary care in the prevention of malignant melanoma. 
One of the targets for health in the United Kingdom is the reduction in the year-on-year increase in the incidence of skin cancer. Most of the mortality associated with skin cancer is attributable to malignant melanoma. One possible way to reduce the incidence of malignant melanoma is to develop a strategy for prevention based in primary care. This paper considers the arguments for and against three possible strategies: giving general advice; identifying patients at high risk; and undertaking early diagnosis. It is concluded that elements of all three strategies are likely to prove useful, but that major studies need to be undertaken before any strategy is adopted on a national basis.
PMCID: PMC1239051  PMID: 7748650
16.  Hormone replacement therapy: characteristics of users and non-users in a British general practice cohort identified through computerised prescribing records. 
STUDY OBJECTIVE--To assess the feasibility of recruiting a cohort of women, including long term users of postmenopausal hormone replacement therapy (HRT), through computerised general practice prescribing records, and to compare clinical and demographic characteristics of users and non-user controls. DESIGN--Cross sectional analysis of questionnaire data. SETTING--Subjects were recruited through 17 general practices in the Oxfordshire, south west Thames, and north west Thames regions that contributed to the VAMP Research Database. PARTICIPANTS--A total of 2964 women aged 45-64 years were identified. Altogether 1482 were long term (> 1 year) users of HRT and 1482 were non-user controls: 1037 (70%) of the users and 819 (55.3%) of the controls agreed to participate and provided questionnaire data. MAIN RESULTS--Users of HRT were more likely to have undergone hysterectomy than controls. Most women with a history of hysterectomy used unopposed oestrogen, while those with intact uteri generally used a combination of oestrogen and a progestagen. Among women who had undergone hysterectomy, HRT users did not differ significantly from controls over a range of demographic and clinical characteristics but they were more likely to be past users of oral contraceptives. Among women with intact uteri, users were similar to controls in terms of reported clinical characteristics, but were of higher social class and were more likely to be past users of oral contraceptives and to have had a mammogram after the age of 50. Compared with the general population, all categories of women recruited to the study were of higher social class and exhibited more health conscious behaviours. CONCLUSIONS--Electronic general practice prescribing records provide a feasible and efficient method for recruiting women to a cohort of HRT. Women who agreed to participate in this study were not representative of the general population, emphasising the importance of internal controls in such a study. Among participants, HRT users who had not undergone hysterectomy showed evidence of better health than non-users on some dimensions. In the whole sample, however, there were no appreciable differences in social class and self reported health indicators between users and controls.
PMCID: PMC1060127  PMID: 7650462
18.  Randomised trial of lipid lowering dietary advice in general practice: the effects on serum lipids, lipoproteins, and antioxidants. 
BMJ : British Medical Journal  1995;310(6979):569-573.
OBJECTIVE--To determine the relative efficacy in general practice of dietary advice given by a dietitian, a practice nurse, or a diet leaflet alone in reducing total and low density lipoprotein cholesterol concentration. DESIGN--Randomised six month parallel trial. SETTING--A general practice in Oxfordshire. SUBJECTS--2004 subjects aged 35-64 years were screened for hypercholesterolaemia; 163 men and 146 women with a repeat total cholesterol concentration of 6.0-8.5 mmol/l entered the trial. INTERVENTIONS--Individual advice provided by a dietitian using a diet history, a practice nurse using a structured food frequency questionnaire, or a detailed diet leaflet sent by post. All three groups were advised to limit the energy provided by fat to 30% or less and to increase carbohydrate and dietary fibre. MAIN OUTCOME MEASURES--Concentrations of total cholesterol and low density and high density lipoprotein cholesterol after six months; antioxidant concentration and body mass index. RESULTS--No significant differences were found at the end of the trial between groups in mean concentrations of lipids, lipoproteins, and antioxidants or body mass index. After data were pooled from the three groups, the mean total cholesterol concentration fell by 1.9% (0.13 mmol/l, 95% confidence interval 0.06 to 0.22, P < 0.001) to 7.00 mmol/l, and low density lipoprotein cholesterol also fell. The total carotenoid concentration increased by 53 nmol/l (95% confidence interval 3.0 to 103, P = 0.039). CONCLUSIONS--Dietary advice is equally effective when given by a dietitian, a practice nurse, or a diet leaflet alone but results in only a small reduction in total and low density lipoprotein cholesterol. To obtain a better response more intensive intervention than is normally available in primary care is probably necessary.
PMCID: PMC2548942  PMID: 7888933
19.  Health checks--time to check out? 
PMCID: PMC1238782  PMID: 8179945
21.  General practice careers: changing experience of men and women vocational trainees between 1974 and 1989. 
The aim of this study was to consider the careers pursued by men and women general practitioner trainees following the completion of their training, and to assess changes since 1974. It was based on a postal questionnaire survey involving 995 doctors who had completed general practice vocational training in the Oxford region between 1974 and 1989. A total of 796 doctors replied to the questionnaire (498 men and 298 women, overall response rate 80%). The vast majority of ex-trainees were working in general practice at the time of the survey (men 87%, women 71%). Women were less likely to have become principals than men (75% versus 97%). Most women (71% of those completing training before 1988) reported at least one period of non-employment. While the duration of maternity leave dropped only slightly during the 15 years studied, the length of voluntary and involuntary unemployment experienced by women fell markedly. Men experienced little unemployment with no change in length of unemployment over time. Considerably fewer women than men (6% versus 13%) had become involved in teaching or training. The degree of difficulty in choosing and following a general practice career remained constant over time for women. In contrast there was a significant increase in the difficulties experienced by men. The proportion of men and women completing training in 1984-89 who found following a general practice career 'difficult or very difficult' was similar (10% of men, 13% of women). The possibility of improving these experiences, particularly by encouraging flexibility in the early years after completion of training, is discussed.
PMCID: PMC1372356  PMID: 8323799
22.  Motivational effect of cholesterol measurement in general practice health checks. 
A randomized trial was conducted in five general practices in and around Aylesbury, Buckinghamshire to assess the motivational effect of cholesterol measurement on compliance with advice to reduce dietary fat intake and to stop smoking. The advice was given by practice nurses during health checks for cardiovascular risk factors. A total of 578 patients were recruited to the study and randomized into two groups. Both groups were given the same advice and were followed up after a median of three months, but the intervention group was also given immediate feedback on their cholesterol concentration. Follow up was completed for 88.2% of subjects, and those who were not followed up were assumed not to have changed their behaviour. The mean fall in total cholesterol at follow up was 0.11 mmol l-1 (95% confidence interval 0.03 to 0.18) in the intervention group who were told their cholesterol result and 0.02 mmol l-1 (95% CI -0.06 to 0.10) in the control group who were not. The proportion of smokers who were not smoking at follow up was 10.7% and 10.1% in the two groups, respectively. Patients in the intervention group with an initial total cholesterol level of 6.50 mmol l-1 or greater showed a mean fall of 6.2% in cholesterol level whereas those with an initial cholesterol level of less than 5.20 mmol l-1 experienced a mean increase of 3.6%, but as differences of this magnitude were also seen in the control group they probably reflect regression to the mean rather than an effect of knowledge of cholesterol level.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1372270  PMID: 1472394
23.  Factors affecting response to an invitation to attend for a health check. 
OBJECTIVE--To describe the characteristics of general practice patients who fail to respond to an invitation to attend for a health check, in relation to demographic variables, risk factor status, health status, and attitudes to behaviour modification. DESIGN--Postal questionnaire before invitation to attend a health check and subsequent record of attendance. SETTING--Five urban general practices in Bedfordshire, UK. SUBJECTS--A total of 2678 patients aged 35-64 years were invited for a health check in 1989-90. RESULTS--The number of patients who did not attend was low overall but was higher among men than women (21 v 15%, p < 0.001), and in unmarried than married patients (24 v 16%, p < 0.001). Failure to attend was also higher among people in manual than in non-manual occupations (21 v 15%, p < 0.001), in people living in rented accommodation than in homeowners (29 v 16%, p < 0.001), and in those without access to a car than in car users (27 v 16%, p < 0.001). There was no difference in non-attendance rate according to age at completion of full time education. After adjustment for age, sex, marital state, and social class, the odds ratio for non-attendance was 1.74 (95% confidence interval (CI) 1.41, 2.14) for smokers; 1.07 (95% CI 0.76, 1.51) for heavy drinkers; 1.91 (95% CI 1.41, 2.58) for those with a less healthy diet; and 1.50 (95% CI 1.09, 2.07) for those who were obese. Patients who had visited their general practice more frequently and those who indicated a willingness to change their behaviour were significantly more likely to attend the health check. CONCLUSIONS--Health check attendance was lowest among patients who rarely attended the surgery and those who reported higher risk behaviour. Attendance was not, however, confined to the 'worried well'. Equal numbers of those with and without chest pain attended, as did at least three quarters of those in each risk group. This high rate of attendance reflects the time and effort invested in systematic recruitment. The development of a robust recruiting strategy is essential if substantial numbers, and particularly those at highest risk, are to be reached.
PMCID: PMC1059771  PMID: 8350036
24.  Patient compliance with colorectal cancer screening in general practice. 
A randomized controlled trial to test patient compliance with screening for colorectal cancer in association with general practice health checks was carried out in six practices (three urban and three rural). A total of 1588 patients aged 45-64 years were randomized to one of four intervention groups. In the first group patients were posted a Haemoccult test (Kline Beckman) kit. This group was not invited for a health check. In the second group patients were posted the Haemoccult test kit, together with an invitation to attend for a health check. In the third group patients were posted an invitation for a health check, which explained that the patient would be offered the Haemoccult test kit by the nurse at the health check. In the fourth group patients were just invited for a health check. It was found that combining faecal occult blood testing with the health check did not reduce attendance at the health check--43.5% of patients attended when the Haemoccult test kit was offered by the nurse at the health check, 43.6% attended when a test kit was included with the invitation to attend the health check and 42.9% attended when the health check invitation was posted on its own. Overall, compliance with Haemoccult testing was not significantly increased by associating it with a health check (26.2% versus 25.5%) but compliance was higher when the faecal occult blood testing kit was enclosed with the health check invitation than when it was offered at the health check (31.7% versus 20.6%, P less than 0.001). It is easier and cheaper to combine various screening procedures. Although the overall use of the Haemoccult test in the study population was low, there is no reason why the relatively higher compliance rate obtained on posting the test kit with a health check invitation cannot be achieved in previously unscreened populations with higher expected compliance rates. However, faecal occult blood screening for colorectal cancer should not be undertaken on a population basis until its effectiveness in reducing mortality has been proven by randomized trial.
PMCID: PMC1371962  PMID: 1586526
25.  Breast self examination and survival from breast cancer. 
British Journal of Cancer  1992;66(5):917-918.
The survival of 616 women aged 15-59 with breast cancer, 226 of whom had been taught and practised breast self examination (BSE) prior to diagnosis and 390 of whom had not, is reported. Six year survival rates were 73.1% in the BSE taught group and 66.1% in other women (P = 0.07).
PMCID: PMC1977961  PMID: 1419636

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