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1.  ‘Too much, too late’: mixed methods multi-channel video recording study of computerized decision support systems and GP prescribing 
Objective
Computerized decision support systems (CDSS) are commonly deployed to support prescribing, although over-riding of alerts by prescribers remains a concern. We aimed to understand how general practitioners (GPs) interact with prescribing CDSS in order to inform deliberation on how better to support prescribing decisions in primary care.
Materials and methods
Quantitative and qualitative analysis of interactions between GPs, patients, and computer systems using multi-channel video recordings of 112 primary care consultations with eight GPs in three UK practices.
Results
132 prescriptions were issued in the course of 73 of the consultations, of which 81 (61%) attracted at least one alert. Of the total of 117 alerts, only three resulted in the GP checking, but not altering, the prescription. CDSS provided information and safety alerts at the point of generating a prescription. This was ‘too much, too late’ as the majority of the ‘work’ of prescribing occurred prior to using the computer. By the time an alert appeared, the GP had formulated the problem(s), potentially spent several minutes considering, explaining, negotiating, and reaching agreement with the patient about the proposed treatment, and had possibly given instructions and printed an information leaflet.
Discussion
CDSS alerts do not coincide with the prescribing workflow throughout the whole GP consultation. Current systems interrupt to correct decisions that have already been taken, rather than assisting formulation of the management plan.
Conclusions
CDSS are likely to be more acceptable and effective if the prescribing support is provided much earlier in the process of generating a prescription.
doi:10.1136/amiajnl-2012-001484
PMCID: PMC3715350  PMID: 23470696
Clinical Computerised Decision Support (CDSS); Electronic Health Record; Prescribing Safety; Primary Care; Safety Alerts
2.  Overtreatment of COPD with Inhaled Corticosteroids - Implications for Safety and Costs: Cross-Sectional Observational Study  
PLoS ONE  2013;8(10):e75221.
Introduction
Combined inhaled long-acting beta-agonists and corticosteroids (LABA+ICS) are costly. They are recommended in severe or very severe chronic obstructive pulmonary disease (COPD). They should not be prescribed in mild or moderate disease. In COPD ICS are associated with side-effects including risk of pneumonia. We quantified appropriateness of prescribing and examined the risks and costs associated with overuse.
Methods
Data were extracted from the electronic and paper records of 41 London general practices (population 310,775) including spirometry, medications and exacerbations. We classified severity, assessed appropriateness of prescribing using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for 2009, and performed a sensitivity analysis using the broader recommendations of the 2011 revision.
Results
3537 patients had a diagnosis of COPD. Spirometry was recorded for 2458(69%). 709(29%) did not meet GOLD criteria. 1749(49%) with confirmed COPD were analysed: 8.6% under-treated, 38% over-treated. Over-prescription of ICS in GOLD stage I or II (n=403, 38%) and in GOLD III or IV without exacerbations (n=231, 33.6%) was common. An estimated 12 cases (95%CI 7-19) annually of serious pneumonia were likely among 897 inappropriately treated. 535 cases of overtreatment involved LABA+ICS with a mean per patient cost of £553.56/year (€650.03). Using the broader indications for ICS in the 2011 revised GOLD guideline 25% were still classified as over-treated. The estimated risk of 15 cases of pneumonia (95%CI 8-22) in 1074 patients currently receiving ICS would rise by 20% to 18 (95%CI 9.8-26.7) in 1305 patients prescribed ICS if all with GOLD grade 3 and 4 received LABA+ICS.
Conclusion
Over-prescription of ICS in confirmed COPD was widespread with considerable potential for harm. In COPD where treatment is often escalated in the hope of easing the burden of disease clinicians should consider both the risks and benefits of treatment and the costs where the benefits are unproven.
doi:10.1371/journal.pone.0075221
PMCID: PMC3806778  PMID: 24194824
3.  Goal-setting intervention in patients with active asthma: protocol for a pilot cluster-randomised controlled trial 
Trials  2013;14:289.
Background
Supporting self-management behaviours is recommended guidance for people with asthma. Preliminary work suggests that a brief, intensive, patient-centred intervention may be successful in supporting people with asthma to participate in life roles and activities they value. We seek to assess the feasibility of undertaking a cluster-randomised controlled trial (cRCT) of a brief, goal-setting intervention delivered in the context of an asthma review consultation.
Methods/design
A two armed, single-blinded, multi-centre, cluster-randomised controlled feasibility trial will be conducted in UK primary care. Randomisation will take place at the practice level. We aim to recruit a total of 80 primary care patients with active asthma from at least eight practices across two health boards in Scotland (10 patients per practice resulting in ~40 in each arm). Patients in the intervention arm will be asked to complete a novel goal-setting tool immediately prior to an asthma review consultation. This will be used to underpin a focussed discussion about their goals during the asthma review. A tailored management plan will then be negotiated to facilitate achieving their prioritised goals. Patients in the control arm will receive a usual care guideline-based review of asthma. Data on quality of life, asthma control and patient confidence will be collected from both arms at baseline and 3 and 6 months post-intervention. Data on health services resource use will be collected from all patient records 6 months pre- and post-intervention. Semi-structured interviews will be carried out with healthcare staff and a purposive sample of patients to elicit their views and experiences of the trial. The outcomes of interest in this feasibility trial are the ability to recruit patients and healthcare staff, the optimal method of delivering the intervention within routine clinical practice, and acceptability and perceived utility of the intervention among patients and staff.
Trial registration
ISRCTN18912042
doi:10.1186/1745-6215-14-289
PMCID: PMC3846716  PMID: 24021033
Asthma; Goals; Behaviour change; Intervention; RCT; Primary care
4.  The impact of supported telemetric monitoring in people with type 2 diabetes: study protocol for a randomised controlled trial 
Trials  2013;14:198.
Background
Diabetes prevalence is increasing and current methods of management are unsustainable. Effective approaches to supporting self-management are required. The aim of this randomized controlled trial is to establish whether supported telemetric monitoring of glycemic control and blood pressure results in reductions in glycosylated hemoglobin (HbA1c; the primary outcome of a measure of long-term glycemic control) and secondary outcomes of blood pressure and weight among people with poorly controlled diabetes compared to a control group receiving usual care.
Methods/Design
Design: multi-center, randomized controlled trial with embedded qualitative study.
Setting: primary care in Lothian, Kent, Glasgow and Borders regions in the UK.
Participants: people with type 2 diabetes and confirmed HbA1c >7.5% (58 mmol/mol).
Intervention/comparison: randomization to intervention or control groups will be performed by the Edinburgh Clinical Trials Unit. Participants in the intervention group will be shown how to use blood glucose and blood pressure monitors and weighing scales which use Bluetooth wireless technology to transmit readings via modem to a remote server. These participants will be asked to provide at least twice weekly measurements of morning and evening blood glucose and weekly measurements of weight and blood pressure. Measurements will be checked at least weekly by practice nurses who will contact the patients to adjust therapy according to guidelines and reinforce lifestyle advice. Participants in the control group will receive usual care. All participants will receive an individual education session.
Follow-up: measurements will be performed at practices 9 months after randomization by research nurses blinded to allocation. The primary outcome measure is HbA1c and secondary outcomes measure are daytime systolic and diastolic blood pressure, weight and cost per quality-adjusted life year.
Analysis: intention-to-treat analyses will be performed. The sample size of 320 participants allows for 20% drop-out and has 80% power at 5% significance to detect a 0.5% absolute (6 mmol/mol) fall in HbA1c in the intervention group. The qualitative study will explore the experiences of patients and professionals using the intervention.
Trial registration
Trial registration number ISRCTN71674628
doi:10.1186/1745-6215-14-198
PMCID: PMC3708774  PMID: 23829417
Diabetes; Hypertension; Glycaemic control; Blood pressure; Weight; Self-management; Telehealth
5.  Developing novel evidence-based interventions to promote asthma action plan use: a cross-study synthesis of evidence from randomised controlled trials and qualitative studies 
Trials  2012;13:216.
Background
Long-standing randomised controlled trial (RCT) evidence indicates that asthma action plans can improve patient outcomes. Internationally, however, these plans are seldom issued by professionals or used by patients/carers. To understand how the benefits of such plans might be realised clinically, we previously investigated barriers and facilitators to their implementation in a systematic review of relevant RCTs and synthesised qualitative studies exploring professional and patient/carer views. Our final step was to integrate these two separate studies.
Methods
First, a theoretical model of action plan implementation was proposed, derived from our synthesis of 19 qualitative studies, identifying elements which, if incorporated into future interventions, could promote their use. Second, 14 RCTs included in the quantitative synthesis were re-analysed to assess the extent to which these elements were present within their interventions (that is, ‘strong’, ‘weak’ or ‘no’ presence) and with what effect. Matrices charted each element’s presence and strength, facilitating analysis of element presence and action plan implementation.
Results
Four elements (professional education, patient/carer education, (patient/carer and professional) partnership working and communication) were identified in our model as likely to promote asthma plan use. Thirteen interventions reporting increased action plan implementation contained all four elements, with two or more strongly present. One intervention reporting no effect on action plan implementation contained only weakly present elements. Intervention effectiveness was reported using a narrow range of criteria which did not fully reflect the four elements. For example, no study assessed whether jointly developed action plans increased use. Whilst important from the professional and patient/carer perspectives, the integral role of these elements in intervention delivery and their effect on study outcomes was under-acknowledged in these RCTs.
Conclusions
Our novel approach provides an evidence-base for future action plan interventions. Such interventions need to ensure all elements in our implementation model (patient/carer and professional education to support development of effective partnership working and communication) are strongly present within them and a wider range of criteria better reflecting the realities of clinical practice and living with asthma are used to measure their effectiveness. We now intend to test such a complex intervention using a cluster trial design.
doi:10.1186/1745-6215-13-216
PMCID: PMC3561124  PMID: 23164151
Asthma action plans; Cross-study synthesis; Intervention development; Intervention reporting; Qualitative synthesis; Integration
6.  Effectiveness of Holistic Interventions for People with Severe Chronic Obstructive Pulmonary Disease: Systematic Review of Controlled Clinical Trials 
PLoS ONE  2012;7(10):e46433.
Background
Despite a well-recognised burden of disabling physical symptoms compounded by co-morbidities, psychological distress and social isolation, the needs of people with severe chronic obstructive pulmonary disease (COPD) are typically poorly addressed.
Aim
To assess the effectiveness of interventions designed to deliver holistic care for people with severe COPD.
Methods
We searched 11 biomedical databases, three trial repositories (January 1990-March 2012; no language restrictions) and contacted international experts to locate published, unpublished and in-progress randomised controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that investigated holistic interventions to support patients with severe COPD in any healthcare context. The primary outcome was health-related quality of life (HRQoL). Quality assessment and data extraction followed Cochrane Collaboration methodology. We used a piloted data extraction sheet and undertook narrative synthesis.
Results
From 2,866 potentially relevant papers, we identified three trials: two RCTs (from United States and Australia), and one CCT (from Thailand): total 216 patients. Risk of bias was assessed as moderate in two studies and high in the third. All the interventions were led by nurses acting in a co-ordinating role (e.g. facilitating community support in Thailand, providing case-management in the USA, or co-ordinating inpatient care in Australia). HRQoL improved significantly in the Thai CCT compared to the (very limited) usual care (p<0.001), in two sub-domains in the American trial, but showed no significant changes in the Australian trial. Exercise tolerance, dyspnoea, and satisfaction with care also improved in the Thai trial.
Conclusions
Some 15 years after reports first highlighted the unmet needs of people with severe COPD, we have been unable to find robust trial evidence about interventions that can address those needs. There is an urgent need to develop and evaluate holistic care interventions designed improve HRQoL for people with severe COPD.
Systematic Review Registration
PROSPERO (CRD42012002430).
doi:10.1371/journal.pone.0046433
PMCID: PMC3479091  PMID: 23110052
7.  Perspectives of patients and healthcare professionals on the impact of telemetrically supported patient self-management for chronic obstructive pulmonary disease (COPD): a qualitative study nested in the TELESCOT trial 
Background
Early identification of exacerbations reduces hospital admissions and may slow disease progression. The TELESCOT randomised control trial based in Lothian, Scotland, is investigating the impact of a tele-monitoring service for COPD with the primary aim of reducing hospitalisation.
Aim
The nested qualitative study explored the views of patients and professionals on models of telemetric service delivery and the impact on self-management.
Method
We undertook semi-structured interviews with patient and professional participants at different time points in the TELESCOT COPD trial. Transcribed, coded data were analysed thematically. Interpretation was supported by multidisciplinary discussion.
Results
38 patients (47% male, mean age 67.5 years) and 32 healthcare professionals provided 70 interviews. Both patients and professionals considered that home tele-monitoring had the potential to reduce the risk of hospital admission. Patients generally appreciated being ‘watched over’ by the tele-monitoring, which gave them confidence to manage their own condition. They used tele-data to improving their understanding of COPD, determine their current state of health and influence decisions about their daily activities. Numerical data (e.g. oxygen saturations) were particularly valued. Changes in readings validated their decisions to adjust treatment or seek timely professional advice, and eased access to clinical care. Patients valued the personalised care provided by tele-monitoring staff familiar with their circumstances and state of health. Professionals emphasised the potential role of telemetry in encouraging prompt compliance with medically defined behaviours and attitudes, though some doubted whether it would be sufficient to overcome a perceived reluctance on the part of patients to acknowledge and take ownership of the disease. There was also a concern that ‘fixation’ on monitoring physiological parameters (especially oxygen saturation levels), promoted a medical model of the disease and might increase dependence on services in some patients. The GPs and community nursing or physiotherapy teams who provided the supporting services emphasised the importance of ‘knowing the patient’ and ‘knowing what’s normal for the individual’ in using their clinical skills to interpret incoming tele-monitoring data.
Conclusion
Enthusiasm for tele-monitoring as a means of facilitating self-management and thereby reducing admissions is tempered by concerns about increased medicalisation and dependence on support services. Tele-monitoring provides data which can be used to support self-management decisions and acts as a channel for seeking professional support. The patient-practitioner relationship, personalisation and continuity of care were prioritised as important elements in delivering clinical support for tele-monitoring services by patients and professionals.
PMCID: PMC3571143
telehealth; COPD; self-management; primary care; continuity of care
8.  Living and dying with severe chronic obstructive pulmonary disease: multi-perspective longitudinal qualitative study 
Objectives To understand the perspectives of people with severe chronic obstructive pulmonary disease (COPD) as their illness progresses, and of their informal and professional carers, to inform provision of care for people living and dying with COPD.
Design Up to four serial qualitative interviews were conducted with each patient and nominated carer over 18 months. Interviews were transcribed and analysed both thematically and as narratives.
Participants 21 patients, and 13 informal carers (a family member, friend, or neighbour) and 18 professional carers (a key health or social care professional) nominated by the patients.
Setting Primary and secondary care in Lothian, Tayside, and Forth Valley, Scotland, during 2007-9.
Results Eleven patients died during the study period. Our final dataset comprised 92 interviews (23 conducted with patient and informal carer together). Severe symptoms that caused major disruption to normal life were described, often in terms implying acceptance of the situation as a “way of life” rather than an “illness.” Patients and their informal carers adapted to and accepted the debilitating symptoms of a lifelong condition. Professional carers’ familiarity with the patients’ condition, typically over many years, and prognostic uncertainty contributed to the difficulty of recognising and actively managing end stage disease. Overall, patients told a “chaos narrative” of their illness that was indistinguishable from their life story, with no clear beginning and an unanticipated end described in terms comparable with attitudes to death in a normal elderly population.
Conclusions Our findings challenge current assumptions underpinning provision of end of life care for people with COPD. The policy focus on identifying a time point for transition to palliative care has little resonance for people with COPD or their clinicians and is counter productive if it distracts from early phased introduction of supportive care. Careful assessment of possible supportive and palliative care needs should be triggered at key disease milestones along a lifetime journey with COPD, in particular after hospital admission for an exacerbation.
doi:10.1136/bmj.d142
PMCID: PMC3025692  PMID: 21262897
9.  Misconnecting for health: (lack of) advice for professionals on the safe use of mobile phone technology 
Quality & Safety in Health Care  2007;16(3):162-163.
Ensuring that good clinical practice keeps pace with technological innovation requires that safety and medico‐legal issues are identified, and agreed nationally and internationally
doi:10.1136/qshc.2006.021345
PMCID: PMC2464991  PMID: 17545339
10.  Telephone consulting in primary care: a triangulated qualitative study of patients and providers 
The British Journal of General Practice  2009;59(563):e209-e218.
Background
Internationally, there is increasing use of telephone consultations, particularly for triaging requests for acute care. However, little is known about how this mode of consulting differs from face-to-face encounters.
Aim
To understand patient and healthcare-staff perspectives on how telephone consulting differs from face-to-face consulting in terms of content, quality, and safety, and how it can be most appropriately incorporated into routine health care.
Design of study
Focus groups triangulated by a national questionnaire.
Setting
Primary care in urban and rural Scotland.
Method
Fifteen focus groups (n = 91) were conducted with GPs, nurses, administrative staff, and patients, purposively sampled to attain a maximum-variation sample. Findings were triangulated by a national questionnaire.
Results
Telephone consulting evolved in urban areas mainly to manage demand, while in rural areas it developed to overcome geographical problems and maintain continuity of care for patients. While telephone consulting was generally seen to provide improved access, clinicians expressed strong concerns about safety potentially being compromised, largely as a result of lack of formal and informal examination. Concerns were, to an extent, allayed when clinicians and patients knew each other well.
Conclusion
Used appropriately, telephone consulting enhances access to health care, aids continuity, and saves time and travelling for patients. The current emphasis on use for acute triage, however, worried clinicians and patients. Given these findings, and until the safe use of telephone triage is fully understood and agreed upon by stakeholders, policymakers and clinicians should consider using the telephone primarily for managing follow-up appointments when diagnostic assessment has already been undertaken.
doi:10.3399/bjgp09X420941
PMCID: PMC2688070  PMID: 19520019
confidentiality; health care quality, access; physician–patient relations; telephone consulting
11.  Asthma 
BMJ : British Medical Journal  2007;334(7598):847-850.
doi:10.1136/bmj.39140.634896.BE
PMCID: PMC1853223  PMID: 17446617
12.  Is multidisciplinary teamwork the key? A qualitative study of the development of respiratory services in the UK 
Summary
Objectives
Using frameworks, such as the long-term conditions pyramid of healthcare, primary care organizations (PCOs) in England and Wales are exploring ways of developing services for people with long-term respiratory disease. We aimed to explore the current and planned respiratory services and the roles of people responsible for change.
Setting
A purposive sample of 30 PCOs in England and Wales.
Design
Semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services. Recorded interviews were transcribed and coded, and themes identified. The association of the composition of the team driving change with the breadth of services provided was explored using a matrix.
Results
All but two of the PCOs described clinical services developed to address the needs of people with respiratory conditions, usually with a focus on preventing admissions for chronic obstructive pulmonary disease (COPD). Although the majority identified the need to develop a strategic approach to service development and to meet educational needs of primary care professionals, relatively few described clearly developed plans for addressing these issues. Involvement of clinicians from both primary and secondary care was associated with a broad multifaceted approach to service development. Teamwork was often challenging, but could prove rewarding for participants and could result in a fruitful alignment of objectives. The imminent merger of PCOs and overriding financial constraints resulted in a ‘fluid’ context which challenged successful implementation of plans.
Conclusions
While the majority of PCOs are developing clinical services for people with complex needs (principally in order to reduce admissions), relatively few are addressing the broader strategic issues and providing for local educational needs. The presence of multidisciplinary teams, which integrated primary and secondary care clinicians with PCO management, was associated with more comprehensive service provision addressing the needs of all respiratory patients. Future research needs to provide insight into the structures, processes and inter-professional relationships that facilitate development of clinical, educational and policy initiatives which aim to enhance local delivery of respiratory care.
doi:10.1258/jrsm.2009.080356
PMCID: PMC2738772  PMID: 19734535
13.  Mind the gap between policy imperatives and service provision: a qualitative study of the process of respiratory service development in England and Wales 
Background
Healthcare systems globally are reconfiguring to address the needs of people with long-term conditions such as respiratory disease. Primary Care Organisations (PCOs) in England and Wales are charged with the task of developing cost-effective patient-centred local models of care. We aimed to investigate how PCOs in England and Wales are reconfiguring their workforce to develop respiratory services, and the background factors influencing service redesign.
Methods
Semi-structured qualitative telephone interviews with the person(s) responsible for driving respiratory service reconfiguration in a purposive sample of 30 PCOs. Interviews were recorded, transcribed, coded and thematically analysed.
Results
We interviewed representatives of 30 PCOs with diverse demographic profiles planning a range of models of care. Although the primary driver was consistently identified as the need to respond to a central policy to shift the delivery of care for people with long-term conditions into the community whilst achieving financial balance, the design and implementation of services were subject to a broad range of local, and at times serendipitous, influences. The focus was almost exclusively on the complex needs of patients at the top of the long-term conditions (LTC) pyramid, with the aim of reducing admissions. Whilst some PCOs seemed able to develop innovative care despite uncertainty and financial restrictions, most highlighted many barriers to progress, describing initiatives suddenly shelved for lack of money, progress impeded by reluctant clinicians, plans thwarted by conflicting policies and a PCO workforce demoralised by job insecurity.
Conclusion
For many of our interviewees there was a large gap between central policy rhetoric driving workforce change, and the practical reality of implementing change within PCOs when faced with the challenges of limited resources, diverse professional attitudes and an uncertain organisational context. Research should concentrate on understanding these complex dynamics in order to inform the policymakers, commissioners, health service managers and professionals.
doi:10.1186/1472-6963-8-248
PMCID: PMC2632662  PMID: 19055843
14.  Accessibility, clinical effectiveness, and practice costs of providing a telephone option for routine asthma reviews: phase IV controlled implementation study 
Background
Attendance for routine asthma reviews is poor. A recent randomised controlled trial found that telephone consultations can cost-effectively and safely enhance asthma review rates; however, concerns have been expressed about the generalisability and implementation of the trial's findings.
Aim
To evaluate the effectiveness of a telephone option as part of a routine structured asthma review service.
Design of study
Phase IV controlled before-and-after implementation study.
Setting
A large UK general practice.
Method
Using existing administrative groups, all patients with active asthma (n = 1809) received one of three asthma review services: structured recall with a telephone-option for reviews versus structured recall with face-to-face-only reviews, or usual-care (to assess secular trends). Main outcome measures were: proportion of patients with active asthma reviewed within the previous 15 months (Quality and Outcomes Framework target), mode of review, enablement, morbidity, and costs to the practice.
Results
A routine asthma review was provided for 397/598 (66.4%) patients in the telephone-option group compared with 352/654 (53.8%) in the face-to-face-only review group: risk difference 12.6% (95% confidence interval [CI] = 7.2 to 17.9, P<0.001). The usual-care group achieved a review rate of 282/557 (50.6%). Morbidity was equivalent in the three groups; however, enablement (P = 0.03) and confidence (P = 0.007) in asthma management were greater in the telephone-option versus face-to-face-only group. The cost per review achieved by providing the telephone-option service was lower than the face-to-face-only service (£10.03 versus £12.74, mean difference £2.71; 95% CI = 1.92 to 3.50, P<0.001); usual-care costs were £11.85 per review achieved.
Conclusion
Routinely offering telephone reviews cost-effectively increased asthma review rates, enhancing patient enablement and confidence with management, with no detriment to asthma morbidity. Practices should consider a telephone option for their asthma review service.
PMCID: PMC2151786  PMID: 17761059
access to health care; asthma; clinical trials, phase IV; consultation; intervention studies; telephone
15.  Practice organisational characteristics can impact on compliance with the BTS/SIGN asthma guideline: Qualitative comparative case study in primary care 
BMC Family Practice  2008;9:32.
Background
Although the BTS-SIGN asthma guideline is one of the most well known and widely respected guidelines in the world, implementation in UK primary care remains patchy. Building on extensive earlier descriptive work, we sought to explore the way teamwork and inter-professional relationships impact on the implementation of the BTS-SIGN guideline on asthma in general practice.
Methods
Qualitative comparative case study using nine in-depth interviews and 2 focus groups with general practitioners and practice nurses, involved in delivering asthma care. Participants were purposively recruited from practices in a Scottish health board with high and low compliance with the BTS-SIGN asthma guideline.
Results
There was a marked difference in the way respondents from practices with high compliance and respondents from practices with low compliance spoke about the value of guidelines and the challenges of implementing them. On both accounts, the former were more positive than the latter and were able to be more specific about the strategies they used to overcome barriers to implementation. We explored the reason for this difference in response and identified practice organisation, centring on delegation of work to nurses, as a factor mediating the practice's level of compliance. Effective delegation was underpinned by organisation of asthma work among practice members who have the appropriate level of skills and knowledge, know and understand each others' work and responsibilities, communicate well among themselves and trust each others' skills. It was the combination of these factors which made for successful delegation and guideline implementation, not any one factor in isolation.
Conclusion
In our sample of practices, teamwork and organisation of care within practices appeared to impact on guideline implementation and further larger studies are needed to explore this issue further. Isolated interventions such as measures to improve staff's knowledge or increased clinical resource and time, which are currently being considered, are unlikely to be effective unless practices are supported in developing their teams in a way which supports the deployment of these resources.
doi:10.1186/1471-2296-9-32
PMCID: PMC2427031  PMID: 18533013
16.  The Department of Health's research governance framework remains an impediment to multi-centre studies: findings from a national descriptive study 
Objective We describe our experience of using the standard application form, designed to streamline applications for multi-centre research, to seek approval from all primary care organizations (PCOs) in England and Wales to undertake a single telephone interview with a health service manager.
Design We sent applications (n=316), by email to each PCO, or consortium of PCOs, attaching a completed standard application form, the 15 required documents, and the approval we had been granted by the lead NHS organization. We maintained detailed records of the responses to our application, subsequent correspondence, additional paperwork requested, and time spent on the approval process.
Setting The UK Research Governance Framework, which regulates all research conducted in health and social care settings.
Participants All PCOs in England and Wales.
Interventions None.
Main outcome measures Time taken to obtain approval to undertake a telephone interview with a health service manager.
Results We were unable to establish contact with 13 (4%) PCOs. Six months after submitting our application we had received approval from 259/316 (82%) PCOs and were still awaiting a verdict from 41 (13%). The median time to approval was 56 days (IQR 42-72). Overall, an estimated 318 staff-hours were spent completing supplementary forms, providing additional information and chasing up dormant applications.
Conclusions Recent initiatives to ‘streamline’ research governance approval have failed to address the problems that face researchers undertaking multi-centre studies. There is an urgent need to develop a simpler process that allows low risk research to take place without threatening staff morale and endangering the quality of the research outputs. In the meantime, we advise researchers to allow far greater time than might reasonably be envisioned to obtain research governance approval.
PMCID: PMC1861420  PMID: 17470931
17.  Practice development plans to improve the primary care management of acute asthma: randomised controlled trial 
BMC Family Practice  2007;8:23.
Background
Our professional development plan aimed to improve the primary care management of acute asthma, which is known to be suboptimal.
Methods
We invited 59 general practices in Grampian, Scotland to participate. Consenting practices were randomised to early and delayed intervention groups. Practices undertook audits of their management of all acute attacks (excluding children under 5 years) occurring in the 3 months preceding baseline, 6-months and 12-months study time-points. The educational programme [including feedback of audit results, attendance at a multidisciplinary interactive workshop, and formulation of development plan by practice teams] was delivered to the early group at baseline and to the delayed group at 6 months. Primary outcome measure was recording of peak flow compared to best/predicted at 6 months. Analyses are presented both with, and without adjustment for clustering.
Results
23 consenting practices were randomised: 11 to early intervention. Baseline practice demography was similar. Six early intervention practices withdraw before completing the baseline audit. There was no significant improvement in our primary outcome measure (the proportion with peak flow compared to best/predicted) at either the 6 or 12 month time points after adjustment for baseline and practice effects. However, the between group difference in the adjusted combined assessment score, whilst non-significant at 6 months (Early: 2.48 (SE 0.43) vs. Delayed 2.26 (SE 0.33) p = 0.69) reached significance at 12 m (Early:3.60 (SE 0.35) vs. Delayed 2.30 (SE 0.28) p = 0.02).
Conclusion
We demonstrated no significant benefit at the a priori 6-month assessment point, though improvement in the objective assessment of attacks was shown after 12 months. Our practice development programme, incorporating audit, feedback and a workshop, successfully engaged the healthcare team of participating practices, though future randomised trials of educational interventions need to recognise that effecting change in primary care practices takes time. Monitoring of the assessment of acute attacks proved to be a feasible and responsive indicator of quality care.
doi:10.1186/1471-2296-8-23
PMCID: PMC1868738  PMID: 17456241
20.  Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK 
Background
Primary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK.
Methods
Using a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews.
Results
The 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependant on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service.
Conclusion
The introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.
doi:10.1186/1472-6963-6-62
PMCID: PMC1524758  PMID: 16734893
21.  Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial 
Background
Only about a third of people with asthma attend an annual review. Clinicians need to identify cost-effective ways to improve access and ensure regular review.
Aim
To compare the cost-effectiveness of nurse-led telephone with face-to-face asthma reviews.
Design of study
Cost-effectiveness analysis based on a 3-month randomised controlled trial.
Setting
Four general practices in England.
Methods
Adults due an asthma review were randomised to telephone or face-to-face consultations. Trial nurses recorded proportion reviewed, duration of consultation, and abortive calls/missed appointments. Data on use of healthcare resources were extracted from GP records. Cost-effectiveness was assessed from the health service perspective; sensitivity analyses were based on proportion reviewed and duration of consultation.
Results
A total of 278 people with asthma were randomised to surgery (n = 141) or telephone (n = 137) review. One-hundred-and-one (74%) of those with asthma in the telephone group were reviewed versus 68 (48%) in the surgery group (P <0.001). Telephone consultations were significantly shorter (mean duration telephone = 11.19 minutes [standard deviation {SD} = 4.79] versus surgery = 21.87 minutes [SD = 6.85], P < 0.001). Total respiratory healthcare costs per patient over 3 months were similar (telephone = 64.49 [SD = 73.33] versus surgery = 59.48 [SD = 66.02], P = 0.55). Total costs of providing 101 telephone versus 68 face-to-face asthma reviews were also similar (telephone = 725.84 versus surgery = 755.70), but mean cost per consultation achieved was lower in the telephone arm (telephone = 7.19 [SD = 2.49] versus surgery = 11.11 [SD = 3.50]; mean difference = −3.92 [95% confidence interval = −4.84 to 3.01], P < 0.001).
Conclusions
Telephone consultations enable a greater proportion of asthma patients to be reviewed at no additional cost to the health service. This mode of delivering care improves access and reduces cost per consultation achieved.
PMCID: PMC1463186  PMID: 15720933
asthma; cost-effectiveness; primary care; telephone
22.  Respiratory medicine 
The General Medical Services (GMS) contract has focused the attention of United Kingdom (UK) general practitioners (GPs) on the provision of high quality routine care for patients with chronic disease.1 The quality markers defined by the contract endorse the need for objective diagnosis and structured care recommended by the British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS–SIGN) guideline for the management of asthma and the National Institute for Clinical Excellence (NICE) guideline on the management of chronic obstructive pulmonary disease (COPD).2,3 In this paper the key recommendations of these guidelines and their implementation in the pragmatic world of general practice are discussed, with specific focus on diagnosis, monitoring, management, self-management and delivery of care.
PMCID: PMC1324808  PMID: 15239918
23.  General practitioners with a special interest in respiratory medicine: national survey of UK primary care organisations 
Background
To meet the universally recognised challenge of caring for people with long-term diseases many healthcare cultures are encouraging family physicians to develop specialist skills. We aimed to determine the major factors influencing the appointment of respiratory General Practitioners with a Special Interest (GPwSI) in the UK, and to determine the priority attached to the potential roles, perceived barriers to implementation, and monitoring planned.
Methods
We sent a piloted semi-structured questionnaire to a random sample of 50% of English and Welsh primary care organisations (PCOs) (n = 161) during winter 2003. In addition to descriptive statistics, we used hierarchical cluster analysis to classify service priorities. Free-text responses to open-ended questions were analysed qualitatively by a multidisciplinary group to identify emerging themes.
Results
Of the 111 (69%) PCOs who responded, 7 (6%) already have, and a further 35 (32%) are planning, a respiratory GPwSI service. This proportion is considerably lower than in specialities linked to National Health Service clinical priorities. Local needs and pressure on hospital beds were the main described motives for developing a service. Stated service priorities were to relieve pressure on secondary care and to improve quality of care, including the strategic planning of respiratory services within PCOs.
Conclusion
The relatively few respiratory GPwSIs currently in post reflects the lack of government prioritisation of respiratory care. However, respiratory GPwSI services are increasingly being considered as a local strategy for reducing pressure on secondary care respiratory services and raising standards of chronic disease management in primary care.
doi:10.1186/1472-6963-5-40
PMCID: PMC1166553  PMID: 15921509
25.  Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial 
BMJ : British Medical Journal  2003;326(7387):477.
Objective
To determine whether routine review by telephone of patients with asthma improves access and is a good alternative to face to face reviews in general practices.
Design
Pragmatic, randomised controlled trial.
Setting
Four general practices in England.
Participants
278 adults who had not been reviewed in the previous 11 months.
Intervention
Participants were randomised to either telephone review or face to face consultation with the asthma nurse.
Main outcome measures
Primary outcome measures were the proportion of participants who were reviewed within three months of randomisation and disease specific quality of life, as measured by the Juniper mini asthma quality of life questionnaire. Secondary outcome measures included the validated “short Q” asthma morbidity score, nursing care satisfaction questionnaire score, and length of consultation.
Results
Of 137 people randomised to telephone consultation, 101 (74%) were reviewed, compared with 68 reviewed (48%) of the 141 people in the surgery group, a difference of 26% (95% confidence interval 14% to 37%; P<0.001; number needed to treat 3.8). Three months after randomisation the two groups did not differ in the Juniper score (risk difference −0.07 (95% confidence interval −0.40 to 0.27) or in satisfaction with the consultation (risk difference −0.07 (−0.27 to 0.13)). Telephone consultations were on average 10 minutes shorter than reviews held in the surgery (mean difference 10.7 minutes (12.6 to 8.8; P<0.001)).
Conclusions
Compared with face to face consultations in the surgery, telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction. A shorter duration means that telephone consultations are likely to be an efficient option in primary care for routine review of asthma.
What is already known on the topicRegular review of patients with asthma reduces morbidity and is endorsed as good practice by UK and international guidelines, but only about a third of patients attend for their annual reviewMost studies of telephone consultation in primary care have focused on consultations requested by patients rather than their use in the routine review of chronic diseaseWhat this study addsTelephone consultations enable more people with asthma to be reviewedTelephone consultations are shorter than face to face consultations, without any apparent clinical disadvantagePatients are satisfied with telephone consultations
PMCID: PMC150181  PMID: 12609944

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