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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Review of computerized decision support systems for oral anticoagulation management
Computerized decision: support systems (CDSS) are available to assist clinicians in the therapeutic management of oral anticoagulation. We report the findings relating to CDSS for oral anticoagulation management of a primary-care-based systematic review which largely focused on near-patient testing. Seven papers were reviewed which covered four different systems. The methodology of these papers was generally poor, although one randomized controlled trial showed improved therapeutic control associated with computerized management compared with human performance.
Survey of research activity, training needs, departmental support, and career intentions of junior academic general practitioners
Background. Recent changes in the organization of the National Health Service have created new roles and responsibilities for academic general practice. Previous work on the constraints and opportunities of a career in academic general practice is largely anecdotal and is often based on the views of more senior members of the profession. Aim. To survey the research activity, perceived level of training, support needs, and career intentions of junior academic general practitioners (GPs). Method. A postal, validated, semistructured questionnaire was sent to the 121 eligible junior academic GPs in the academic departments of general practice in the United Kingdom and Dublin. Main outcome measures were 'research activity score', as measured by publications in peer-reviewed journals and involvement in research projects, 'training score' devised from 13 skills required for both research and teaching, and perceived level of departmental support assessed by six different support mechanisms. Results. Response rate was 89% (n = 108). Forty-six responders (43% had no publications. Twenty-five responders (23%) had no principal project. Thirty-nine responders (37%) had a mentor. Research activity appeared to be dependent on sex, having a predominantly research role rather than a full-time teaching role, and a positive perception of academic training (P < 0.05). Increasing departmental 'support scores' and length of time in the department were both significantly associated with more positive perceptions of academic training (P < 0.05). Only 29 (27%) responders wanted to progress to senior positions within academic general practice. Conclusion. Training and departmental support and guidance available to junior academics in primary care are perceived as variable and often inadequate. If academic general practice is to thrive, improved academic training is required, such as taught Master's degrees, supervised personal projects or 'apprenticeship' as a co-investigator, and improved methods of departmental support.
Varying efficacy of Helicobacter pylori eradication regimens: Cost effectiveness study using a decision analysis model
Objective: To determine how small differences in the efficacy and cost of two antibiotic regimens to eradicate Helicobacter pylori can affect the overall cost effectiveness of H pylori eradication in duodenal ulcer disease. Design: A decision analysis to examine the cost effectiveness of eight H pylori eradication strategies for duodenal ulcer disease with and without 13C-urea breath testing to confirm eradication. Main outcome measures: Cumulative direct treatment costs per 100 patients with duodenal ulcer disease who were positive for H pylori. Results: In model 1 the strategy of omeprazole, clarithromycin, and metronidazole alone was the most cost effective of the four strategies assessed. The addition of the 13C-urea breath test and a second course of omeprazole, clarithromycin, and metronidazole achieved the highest eradication rate (97%) but was the most expensive (£62.63 per patient). The cost of each additional effective eradication was £589.00 (incremental cost per case) when compared with the cost of treating once only with omeprazole, clarithromycin, and metronidazole; equivalent to the cost of a patient receiving ranitidine for duodenal ulcer relapse for more than 15 years. Eradication strategies of omeprazole, amoxycillin, and metronidazole were less cost effective than omeprazole, clarithromycin, and metronidazole alone. In model 2 the addition of the 13C-urea breath test after treatment, and maintenance treatment, increased the cost of all the strategies and reduced the cost advantage of omeprazole, clarithromycin, and metronidazole alone. Conclusion: Small differences in efficacy can influence the comparative cost effectiveness of strategies for eradicating H pylori. Of the strategies tested the most cost effective (omeprazole, clarithromycin, and metronidazole alone) was neither the least expensive (omeprazole, amoxycillin, and metronidazole alone) nor the most effective (omeprazole, clarithromycin, and metronidazole with further treatment for patients found positive for H pylori on 13C-urea breath testing). Cost effectiveness should be an important part of choosing an eradication strategy for H pylori. © 1998, BMJ Publishing Group Ltd. All rights reserved.
Prevalence of atrial fibrillation in the general population and in high-risk groups
Atrial fibrillation (AF) is the commonest cardiac arrhythmia and is associated with high risk of embolic stroke, which can be reduced by anticoagulation. To have an impact on the population as a whole, patients must first be identified, and screening would be most cost-effective if targeted on patients at high risk of the condition. We have investigated the prevalence of AF in different age groups in the general population, and in those in high risk groups. Methods: We have analysed the prevalence of AF and associated echocardiographic risk actors in patients in the following groups: Random population sample, aged 45+; existing clinical diagnosis of heart failure (made by GP); previous MI; hypertension; angina; and diabetes. Patients were assessed clinically and with ECG and echocardiography, as part of a large heart failure epidemiology study. Results: The table details the prevalence of AF in the patient groups. Other associated risk factors for embolic stroke (mitral valve disease, left atrial enlargement or impaired LV function) are also listed, and the proportion anticoagulated at the time of screening. AF Abnormal echo in pts with AF On warfarin Population aged 45+ 43/2552 (1.7%) 29/43 (67%) 9/43 (21%) of which: 45-54 1/858 (0.1%) 1/1 (100%) 1/1 (100%) 55-64 7/785 (0.9%) 2/7 (29%) 1/7 (14%) 65-74 9/615 (1.5%) 6/9 (67%) 4/9 (44%) 75+ 26/294 (8.8%) 20/26 (77%) 3/26 (12%) Clinical heart failure 69/279 (24.7%) 61/69 (88%) 24/69 (35%) Previous MI 8/117 (6.8%) 6/8 (75%) 3/8 (37%) Hypertension 5/192 (2.6%) 2/5 (40%) 1/5 (20%) Angina 4/120 (3.3%) 3/4 (75%) 2/4 (50%) Diabetes 3/58 (5.2%) 3/3 (100%) 2/3 (67%) Conclusions: AF prevalence in the population sample was 1.7%, and in the high-risk groups overall was 11.6%; these patients had other embolic risk factors more frequently also. Targeting screening on such patients would identify many patients at high stroke risk.
Primary care oral anticoagulant management utilising computerised Decision Support (DSS) and Near Patient Testing (NPT)
Introduction: Increased numbers of patients receiving warfarin, particularly for non-rheumatic atrial fibrillation has increased pressure on GPs to undertake therapeutic articoagulation monitoring. This MRC sponsored study tested the effectiveness of utilising a combination of DSS and NPT in general practice to provide an effective warfarin management service in primary care. Method: 9 intervention and 3 control practices recruited from Birmingham run practice nurse anticoagulation clinics, using DSS and NPT (Thrombotrak). Patients were randomised to attend the practice based clinic or continue to attend hosptial clinics. Patients attending the practice clinic had a venous blood sample taken. INR estimation was tested using NPT and the result entered onto the DSS which recommends warfarin dosage and recall date. Patients were given hand held record containing this information. The venous sample was sent to the laboratory for quality control and results recorded centrally. Results: 368 patients were recruited (121 intervention, 103 intra-controls, 144 inter-controls). Improved INR control was seen win 85% of intervention patients in range compared with 62% and 67% for the intra and inter-controls (chi-squared p<0.05). There was also a reduction in the incidence of stroke in the intervention group (n.s.). The capital costs of the DSS and NPT were offset by the savings from patients not attending hospital clinics. Discussion: This study has shown that warfarin management can be undertaken efficiently, effectively and with overall cost savings for Health Services, in primary care, utilising DSS and NPT. With the increasing use of warfarin for stroke prophylaxis in atrial fibrillation this model of care represents a cost-effective method of ensuring maximum benefit, with minimum risk.
General practitioner perceptions of treatment benefits and costs in patients with hyperlipidaemia
This study explored general practitioner (GP) perceptions of use of treatments to manage hyperlipidaemia and their cost implications. GPs recognized different levels of coronary heart disease (CHD) risk, but were not always aware of which were major factors. Most were unfamiliar with published guidelines on managing hyperlipidaemia, and were likely to initiate drug therapies even in low-risk patients with mild hyperlipidaemia. Clearer advice is needed on whom to treat and on dietary intervention with high-fibre as well as low-fat diets.
Primary care anticoagulant clinic management using computerized decision support and near patient International Normalized Ratio (INR) testing: Routine data from a practice nurse-led clinic
Background. Increasing indications for warfarin therapy has led to increased pressure on primary care to undertake therapeutic monitoring. Objective. This study evaluates a primary care model of oral anticoagulation monitoring which utilises computerized decision support (CDSS) and near patient testing (NPT) within a practice nurse-led clinic. Whilst this has been shown to be a successful model under trial conditions, this paper reports the first data from a long-standing clinic, outside a formal study. Method. A prospective evaluation of therapeutic and clinical control of all patients taking warfarin within one inner city general practice. Data were collected via CDSS. Results. 29 patients were seen in 208 appointments. The mean percentage of patients within therapeutic range was 72%. The costs to the practice were £1751. The costs the practice would have incurred had these patients been seen at the hospital with the same frequency would have been £2290. Conclusions. The use of CDSS and NPT for nurse-delivered oral anticoagulation monitoring could enable the safe transfer of the majority of patients from secondary to primary care. Funding mechanisms to support the transfer of costs will be essential for most practices, as will be the maintenance of adequate staff training and quality assurance.
Risk of and prophylaxis for venous thromboembolism in hospital patients
Objective: To review the published clinical data on prophylaxis for thromboembolism in order to develop general guidelines to encourage the establishment of local protocols for management. Data sources: Published papers on thromboembolism over the period 1991-1997 were identified by Medline search and/or from the authors' personal literature collections and reviewed. Study selection: A total of 981 studies were identified. Only those papers reporting randomized studies with clearly defined diagnostic methods and clear end-points were included in this review. Data extraction: The available evidence for each specialty was summarized and reviewed by the authors responsible for each specialty, prior to presentation and discussion of their findings within the group. Where a consensus opinion was achieved in a speciality, general guidelines for thromboprophylaxis were summarized. Where a consensus could not be agreed, recommendations for further work were made. Data synthesis: There is evidence to support the preferred use of low-molecular-weight heparins (LMWHs) over unfractionated heparin (UFH) in orthopaedic surgery, major trauma and general surgery. However, the ideal duration of thromboprophylaxis has yet to be defined. The use of once daily subcutaneous administration of LMWH offers major practical advantages and may have significant cost saving implications. Further work is required to investigate the use of thromboprophylaxis in minimal access surgery, trauma, elective lower limb surgery, hip fracture and pregnancy; to compare the efficacy of LMWH and mechanical prophylaxis; and to investigate extended prophylaxis after discharge. Conclusions: There is overwhelming evidence that thromboembolic prophylaxis reduces the incidence of postoperative deep vein thrombosis and pulmonary embolism. Recommendations concerning the management of these patients when stratified into low, moderate and high risk are made with the suggestion that hospitals develop their own guidelines for the treatment of these patients.
Patient and GP factors associated with emergency medical admissions to one UK district general hospital
Objectives: Despite international debate over growing pressures on hospital beds, particularly from rises in emergency admissions, there are few published data on the characteristics of patients admitted to hospital. Most research has attempted to explore the appropriateness of general practitioner (GP) admissions, yet even the proportion of emergency admissions made via the GP is not known. This study aimed to investigate GP and patient factors associated with acute medical admissions to one hospital in Birmingham, UK. Methods: A study was performed on all acute medical admissions made over one week to a district general hospital in Birmingham and local general practices referring acutely to it. Admissions were identified from routine hospital dataset and the information validated. Factors perceived as linked to admission were explored by semi-structured interview or postal questionnaire with the admitting doctors and with a proportion of patients. The subjects were 158 patients and the 84 GPs involved in a proportion of the admissions. Outcome measures were admission routes, diagnoses, linked medical and social factors. Results: Only 84 (53%) patients were admitted via their GP (or deputy). 47% were self-referrals or admitted via outpatients. Data on 16% patients could not be validated because of GP refusal (3 doctors, 15 patients) or untraceable doctor (10 patients). Most admissions were for respiratory problems (47, 30%), mainly cases of infective illness (13% all admissions, 43% respiratory). Cardiovascular disease involved 16% cases, principally myocardial infarction or angina. Drug overdose was the most frequent single diagnosis, almost 1 in 10 acute admissions. 69% of the GP admissions were over 65 years old (30% over 75) against 36% of the non-GP (p<0.01). Additional influences on GP admissions included: exacerbations of long-standing medical problems (29%); clarification of uncertain diagnoses (61%); and requests for advice (5%). Some admissions also resulted from social pressures including: pressure from carers (15%); visit occurred at night (4%); and even pressure from patients to avoid admission (8%). In 11% of cases, GP admission was stated as solely related to non-acute medical problems. The average length of stay was 10.6 days (range 1 to 120 days). Mean length of stay for patients admitted by a doctor was 13 days compared to 8 days for non-GP admissions (p=0.025). 13% of patients died during or shortly after admission. Conclusions: Most patients sent in by the GPs or selfreferring, in this small sample of urban emergency admissions, were admitted with serious medical problems, on the basis of the coded discharge diagnoses, and required extended hospital stays. GP admissions in this sample appeared a sicker, or less coping, cohort. There was evidence that GPs were attempting to maintain patients at home and felt that around 15% of their admissions might have been managed in some alternative low technology environment. © 1997 Informa UK Ltd All rights reserved.
A comparison of two models of general practice care of patients with diabetes
The presumption that diabetes is a disease treated in hospital that cannot be trusted to primary care has shifted in favour of a view that diabetes care should be shared between hospital specialists and general practice. Greenhalgh concedes that there may be some patients for whom the specialist has only a limited role to play. Pereira Gray, however, identifies structured versus unstructured care in general practice as the key issue. This study compares these two approaches in terms of process measures, clinical outcomes, service utilisation and costs. Methods. A retrospective review of general practice and hospital records of patients with type II diabetes (n = 709) was conducted in ten urban practices. In 5 practices care of diabetes was structured around the concept of an identified period of "protected time" - a 'mini-clinic'. In the other 5 the style of care was more traditional. Practices were compared in terms of frequency of measurement of various parameters including body mass index, random blood glucose, blood pressure, glycosylated haemoglobin (HbA1) or fructosamine, and fundoscopy. The extent of hospital involvement in care and the economic implications of the two modes of care delivery were also assessed. Results. In terms of metabolic parameters the two models of care were broadly comparable. Measures of process of care indicated that required monitoring was more likely to have been carried out in patients under the care of mini-clinic practices and that within other practices there was both under and over recording of disease parameters. The most striking difference, however, was in the extent of hospital utilisation with the 353 patients in mini-clinic practices generating only 75 hospital visits over a 2 year period versus 288 visits generated by 356 patients looked after in non-mini-clinic practices. This difference was statistically significant (p < 0.05) and was associated with (and the main cause of) an estimated £ 46 (£ 163 versus £ 116) greater cost over 2 years for the care of patients not being care for under the mini-clinic model. Conclusions. This study suggests that the bulk of diabetes care can be managed in primary care and, if properly structured, can achieve comparable metabolic outcomes at a greatly reduced cost.
Accuracy of routinely collected clinical data on acute medical admissions to one hospital
Despite the rapid growth in routine computerized data collection within the National Health Service (NHS), and the increased use of such data for generating hospital statistics and doctor activity rates, few validation studies exist. During a study of 158 acute medical admissions, an examination of hospital data revealed numerous and systematic inaccuracies. If general practitioner (GP) performance statistics are to be reliably based on such sources, data validation, staff training, and protocols for data entry should form a routine part of NHS practice.