The development of a training pack on the management of aggression and violence in primary care

The objective of this study was to develop an appropriate model of training for primary health care team members in the management of aggression and violence at work. A qualitative analysis of the videotaped interviews of primary health care team members was used to develop the content of a teaching package. The subjects comprised 44 interviewees working in primary care in 2 districts within the largest health region of the United Kingdom. The main outcome measures were the themes identified from the modified content analysis of interviews. Violence was perceived as occurring principally in connection with unmet demands for such things as prescriptions and referrals. Predisposing factors for aggression and violence include drink and drugs. Only patients are perceived as violent: health care workers use other terms to describe their feelings and responses. Staff have had little opportunity to train for the management of violence at work. What little tuition occurred was during basic training. It is important to identify the extent of aggression and violence in individual practices. However, such exploration will identify staff needs in terms of reducing the risks of aggressive events or responding to the consequence of episodes suffered. Qualitative examination of videotaped interviews in this way has facilitated the assessment of training needs in primary care. A tailored educational programme has been developed to respond to these needs

Effect of Helicobacter pylori eradication therapy on dyspeptic symptoms in primary care.

OBJECTIVE: The aim was to explore the effect of eradication therapy on dyspeptic symptoms in patients with known peptic ulcer disease (PUD). METHOD: A total of 164 known dyspeptics and 147 non-dyspeptic attenders at six UK general practices were recruited. The Helisal Rapid Blood test was performed in the practices and eradication therapy left to the preference of the general practitioner. Patients were followed prospectively by a Likert scaled symptom questionnaire and record review. The symptom questionnaire distinguished between patients known to have dyspepsia and those not. RESULTS: There was a statistically significant decrease in dyspeptic symptoms in patients with known PUD who received eradication therapy (n = 43, Z = -2.63, P = 0.009). CONCLUSIONS: Eradication of Helicobacter pylori in primary care can lead to a reduction in consumption of H2 receptor antagonists and hence cost savings. This study demonstrates that dyspeptic symptoms also decrease. The questionnaire could be used in further studies to evaluate the effect of management on dyspeptic symptoms in the primary care setting

A prospective controlled trial of computerized decision support for lipid management in primary care.

OBJECTIVES: This study aimed to assess the uptake and effect in primary care of a computerized decision support system (DSS) for the management of hyperlipidaemia. METHOD: A prospective controlled trial was conducted in 25 practices covering a population of 150,000 in the city of Birmingham. The Primed system, a specialist developed, rule based DSS for general practice, was introduced prospectively after a 3-month baseline data collection. The main outcome measures were nine months' data on prescribing of lipid lowering agents; use of laboratory tests; and referrals to secondary care for the investigation of hyperlipidaemia. RESULTS: System use was lower than expected. A shift was observed towards requests for appropriate follow-up of previously abnormal lipid results and a greater emphasis on full lipid profiles, in line with the DSS guidelines. Referrals showed a 55% decrease on those expected (NS). The prescribing evaluation revealed a large variation between practices, but no significant alteration following system use. Views of users favoured decision support as a concept, but criticised technical problems with the system. CONCLUSIONS: Greater integration of DSS software and practice based data handling systems is needed. The mode of data capture, and hence both the content and form of knowledge representation, in DSS must take greater account of the primary care consultation process if such systems are to be of use to practitioners

Analysis of primary care staff language about aggression at work using concordancing techniques to identify themes.

OBJECTIVE: We aimed to describe features of language used during interviews about the extent of aggression and violence at work and their effect on primary care staff. METHOD: Forty-four primary health care team members in the West Midlands were interviewed, and interviews were recorded on videotape. The language content of these interviews was analysed using Cobuild concordancing software. Outcome measures used were word frequency, collocation and mutual information (MI) scores for language use. RESULTS: A total of 17517 words spoken by interviewees were analysed. Violence in this sample was perceived as occurring principally in connection with unmet demands for such things as prescriptions and referrals. Only patients were perceived as violent; health care workers used other terms to describe their own feelings and responses. Sixty-eight specific incidents of violence were recounted, features perceived as salient being drink, youth and to a lesser extent mental illness. CONCLUSIONS: Concordancing software can be successfully used in the qualitative examination of videotaped interviews. In this study, the technique rapidly identified a number of perceived training needs among a variety of primary care staff

Comparison of the use of four desktop analysers in six urban general practices.

There is little data on the advantages and disadvantages of using desktop analysers in general practice. This prospective trial compared four of the analysers available in the United Kingdom, in six urban general practices, over a six month period. Of the 2619 tests where the time was noted, 55.8% were performed outside the hours when routine transport to a hospital laboratory was possible (after 12.00 hours). Of the 3530 tests performed the commonest were measurements of cholesterol (14.4 tests per 5000 patients per 30 days), glucose (6.0 tests) and haemoglobin (5.6 tests). Less than 5% of the tests were performed as an emergency despite the speed at which results are available. The main reasons for requesting the tests were screening or case finding (56.9%), with the remainder for monitoring chronic disease, especially diabetes and hypercholesterolaemia. There was evidence that the use of the machines in the four practices reduced requests for hospital laboratory blood tests by 24-40% of pre-study levels. However, there was a considerable increase in testing for cholesterol (three fold) and haemoglobin (eight fold) on the desktop analysers, compared with the number of laboratory tests requested before the study. The cost per test of using such machines is closely related to the level of activity and probably does not compete favourably with hospital testing unless several tests are performed each day. Quality control tests were within the specified limits on at least 98% of occasions, however these tests also identified the need for laboratory back up where a problem was found

A comparison of Bayesian and maximum likelihood methods to determine the performance of a point of care test for Helicobacter pylori in the office setting.

OBJECTIVE: Evaluations of point of care tests (PCT) are often hampered by a lack of appropriate gold standards. This study aimed to compare the results of a Bayesian statistical analysis and a maximum likelihood method to evaluate the performance of a PCT for Helicobacter pylori in primary care. METHODS: The Helisal Rapid Blood Test (Cortecs Diagnostics) was performed in 311 patients from 6 primary care centers, and a concurrent venous sample was taken for 2 enzyme-linked immunosorbent assays (ELISA) performed at the laboratory, blind to the PCT result. The Bayesian analysis was conducted using Markov Chain Monte Carlo methods (WinBUGS). The performance characteristics of the PCT and the 2 ELISA tests were estimated together with 95% credible intervals (95% CIs). RESULTS: The estimate of prevalence of H. pylori in this population was 64% (95% CI, 59% to 70%), the sensitivity and specificity of the PCT were 89% (84% to 94%) and 84% (77% to 91%), respectively (likelihood ratios positive 5.6, negative 0.13). The equivalent maximum likelihood results were prevalence, 65%; sensitivity, 90%; and specificity, 83%. CONCLUSIONS: The Helisal Rapid Blood Test performed as well as laboratory-based ELISA tests in this cohort of patients. The Bayesian analysis and the maximum likelihood method gave similar results, the Bayesian method also simultaneously estimating 95% CIs

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration.

OBJECTIVE: The aim was to establish the potential efficacy, tolerability and side-effect profile of electromagnetic therapy as an adjunct to conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinical trial was carried out in a dedicated leg ulcer clinic based in one urban general practice. Nineteen patients with leg ulcers of confirmed venous aetiology were assessed. The main outcome measures were rate and scale of venous leg ulcer healing, changes in patient-reported pain levels, quality of life, degree of mobility, side effect profile and acceptability to patients and staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinic achieved improvements in the size of their ulcer (4, 21%, healed fully) and in reduced pain levels (P < 0.05) during the trial, despite the chronicity of ulcer histories. Patients treated with electromagnetic therapy at 800 Hz were found at day 50 to have significantly greater healing (P < 0.05) and pain control (P < 0.05) than placebo therapy or treatment with 600 Hz. All patients reported improved mobility at the end of the study. The electromagnetic therapy was well tolerated by patients, with no differences between groups in reporting adverse events, and proved acceptable to staff. CONCLUSIONS: Despite the small numbers in this pilot study, electromagnetic therapy provided significant gains in the healing of venous leg ulcers and reduction in pain

Comparison of the use of four desktop analysers in six urban general practices.

There is little data on the advantages and disadvantages of using desktop analysers in general practice. This prospective trial compared four of the analysers available in the United Kingdom, in six urban general practices, over a six month period. Of the 2619 tests where the time was noted, 55.8% were performed outside the hours when routine transport to a hospital laboratory was possible (after 12.00 hours). Of the 3530 tests performed the commonest were measurements of cholesterol (14.4 tests per 5000 patients per 30 days), glucose (6.0 tests) and haemoglobin (5.6 tests). Less than 5% of the tests were performed as an emergency despite the speed at which results are available. The main reasons for requesting the tests were screening or case finding (56.9%), with the remainder for monitoring chronic disease, especially diabetes and hypercholesterolaemia. There was evidence that the use of the machines in the four practices reduced requests for hospital laboratory blood tests by 24-40% of pre-study levels. However, there was a considerable increase in testing for cholesterol (three fold) and haemoglobin (eight fold) on the desktop analysers, compared with the number of laboratory tests requested before the study. The cost per test of using such machines is closely related to the level of activity and probably does not compete favourably with hospital testing unless several tests are performed each day. Quality control tests were within the specified limits on at least 98% of occasions, however these tests also identified the need for laboratory back up where a problem was found