Transcranial sonography for diagnosis of Parkinson's disease

<p>Abstract</p> <p>Background</p> <p>In idiopathic Parkinson's disease (IPD) transcranial sonography (TCS) represents an alternative diagnostic method to verify clinical diagnosis. Although the phenomenon of an increased echogenicity of the Substantia nigra (SN) is well known this method is still not widly used in the diagnostic workup. Until now reliability of this method is still a matter of debate, partly because data only existed from a few laboratories using the same ultrasound machine. Therefore our study was conducted to test the reliability of this method by using a different ultrasound device and examining a large population of control and IPD subjects by two examiners to calculate interobserver reliability.</p> <p>Method</p> <p>In this study echogenicity of SN was examined in 199 IPD patients and 201 control subjects. All individuals underwent a neurological assessment including Perdue pegboard test and Webster gait test. Using a Sonos 5500 ultrasound device area of SN was measured, echogenicity of raphe, red nuclei, thalamus, caudate and lenticular nuclei, width of third and lateral ventricle were documented.</p> <p>Results</p> <p>We found a highly characteristic enlargement of the SN echogenic signal in IPD. The cut-off value for the SN area was established using a ROC curve with a sensitivity of 95% corresponding to an area of SN of 0.2 cm²and was found to be equivalent to the cut-off values of other studies using different ultrasound devices.</p> <p>Conclusions</p> <p>Our study shows that TCS is a reliable and highly sensitive tool for differentiation of IPD patients from individuals without CNS disorders.</p

General practitioners' experience and benefits from patient evaluations

<p>Abstract</p> <p>Background</p> <p>It has now for many years been recognised that patient evaluations should be undertaken as an integral part of the complex task of improving the quality of general practice care. Yet little is known about the general practitioners' (GPs') benefit from patient evaluations. Aim 1 was to study the impact on the GPs of a patient evaluation and subsequent feedback of results presented at a plenary session comprising a study guide for the results and group discussions. Aim 2 was to study possible facilitators and barriers to the implementations of the results raised by the patient evaluation process.</p> <p>Methods</p> <p>A patient evaluation survey of 597 voluntarily participating GPs was performed by means of the EUROPEP questionnaire. Evaluation results were fed back to the GPs as written reports at a single feedback meeting with group discussions of the results. Between 3 and 17 months after the feedback, the 597 GPs received a questionnaire with items addressing their experience with and perceived benefit from the evaluations.</p> <p>Results</p> <p>79.4% of the GPs responded. 33% of the responding GPs reported that the patient evaluation had raised their attention to the patient perspective on the quality of general practice care. Job satisfaction had improved among 26%, and 21% had developed a more positive attitude to patient evaluations. 77% of the GPs reported having learnt from the evaluation. 54% had made changes to improve practice, 82% would recommend a patient evaluation to a colleague and 75% would do another patient evaluation if invited. 14% of the GPs had become less positive towards patient evaluations, and job satisfaction had decreased among 3%.</p> <p>Conclusions</p> <p>We found a significant impact on the GPs regarding satisfaction with the process and attitude towards patient evaluations, GPs' attention to the patients' perspective on care quality and their job satisfaction. Being benchmarked against the average seemed to raise barriers to the concept of patient evaluations and difficulties interpreting the results may have formed a barrier to their implementation which was partly overcome by adding qualitative data to the quantitative results. The GPs' significant willingness to share and discuss the results with others may have served as a facilitator.</p

Does patient satisfaction of general practice change over a decade?

Background The Patient Participation Program (PPP) was a patient satisfaction survey endorsed by the Royal Australian College of General Practitioners and designed to assist general practitioners in continuous quality improvement (CQI). The survey was been undertaken by 3500 practices and over a million patients between 1994 and 2003. This study aimed to use pooled patient questionnaire data to investigate changes in satisfaction with primary care over time. Methods The results of 10 years of the PPP surveys were analyzed with respect to 10 variables including the year of completion, patient age, gender, practice size, attendance at other doctors, and whether the practice had previously undertaken the survey. Comparisons were made using Logistic Generalized Estimating Equations (LGEE). Results There was a very high level of satisfaction with general practice in Australia (99% of respondents). An independent indicator of satisfaction was created by pooling the results of 12 questions. This new indicator had a greater variance than the single overall satisfaction question. Participants were shown to have higher levels of satisfaction if they were male, older, did not attend other practitioners or the practice was small in size. A minimal improvement in satisfaction was detected in this pooled indicator for the second or third survey undertaken by a practice. There was however no statistically significant change in pooled satisfaction with the year of survey. Conclusion The very high level of satisfaction made it difficult to demonstrate change. It is likely that this and the presentation of results made it difficult for GPs to use the survey to improve their practices. A more useful survey would be more sensitive to detect negative patient opinions and provide integrated feedback to GPs. At present, there are concerns about the usefulness of the PPP in continuous quality improvement in general practice.James Allan, Peter Schattner, Nigel Stocks and Emmae Ramsa

Does patient satisfaction of general practice change over a decade?

Background The Patient Participation Program (PPP) was a patient satisfaction survey endorsed by the Royal Australian College of General Practitioners and designed to assist general practitioners in continuous quality improvement (CQI). The survey was been undertaken by 3500 practices and over a million patients between 1994 and 2003. This study aimed to use pooled patient questionnaire data to investigate changes in satisfaction with primary care over time. Methods The results of 10 years of the PPP surveys were analyzed with respect to 10 variables including the year of completion, patient age, gender, practice size, attendance at other doctors, and whether the practice had previously undertaken the survey. Comparisons were made using Logistic Generalized Estimating Equations (LGEE). Results There was a very high level of satisfaction with general practice in Australia (99% of respondents). An independent indicator of satisfaction was created by pooling the results of 12 questions. This new indicator had a greater variance than the single overall satisfaction question. Participants were shown to have higher levels of satisfaction if they were male, older, did not attend other practitioners or the practice was small in size. A minimal improvement in satisfaction was detected in this pooled indicator for the second or third survey undertaken by a practice. There was however no statistically significant change in pooled satisfaction with the year of survey. Conclusion The very high level of satisfaction made it difficult to demonstrate change. It is likely that this and the presentation of results made it difficult for GPs to use the survey to improve their practices. A more useful survey would be more sensitive to detect negative patient opinions and provide integrated feedback to GPs. At present, there are concerns about the usefulness of the PPP in continuous quality improvement in general practice.James Allan, Peter Schattner, Nigel Stocks and Emmae Ramsa

Disrupting the rhythm of depression: design and protocol of a randomized controlled trial on preventing relapse using brief cognitive therapy with or without antidepressants

Background: Maintenance treatment with antidepressants is the leading strategy to prevent relapse and recurrence in patients with recurrent major depressive disorder (MDD) who have responded to acute treatment with antidepressants (AD). However, in clinical practice most patients (up to 70-80%) are not willing to take this medication after remission or take too low dosages. Moreover, as patients need to take medication for several years, it may not be the most cost-effective strategy. The best established effective and available alternative is brief cognitive therapy (CT). However, it is unclear whether brief CT while tapering antidepressants (AD) is an effective alternative for long term use of AD in recurrent depression. In addition, it is unclear whether the combination of AD to brief CT is beneficial.Methods/design: Therefore, we will compare the effectiveness and cost-effectiveness of brief CT while tapering AD to maintenance AD and the combination of CT with maintenance AD. In addition, we examine whether the prophylactic effect of CT was due to CT tackling illness related risk factors for recurrence such as residual symptoms or to its efficacy to modify presumed vulnerability factors of recurrence (e.g. rigid explicit and/or implicit dysfunctional attitudes). This is a multicenter RCT comparing the above treatment scenarios. Remitted patients on AD with at least two previous depressive episodes in the past five years (n = 276) will be recruited. The primary outcome is time related proportion of depression relapse/recurrence during minimal 15 months using DSM-IV-R criteria as assessed by the Structural Clinical Interview for Depression. Secondary outcome: economic evaluation (using a societal perspective) and number, duration and severity of relapses/recurrences.Discussion: This will be the first trial to investigate whether CT is effective in preventing relapse to depression in recurrent depression while tapering antidepressant treatment compared to antidepressant treatment alone and the combination of both. In addition, we explore explicit and implicit mediators of CT.Trial registration: Netherlands Trial Register (NTR): NTR1907

The General Practice Assessment Questionnaire (GPAQ) – Development and psychometric characteristics

<p>Abstract</p> <p>Background</p> <p>Continual quality improvement in primary care is an international priority. In the United Kingdom, the major initiative for improving quality of care is the Quality and Outcomes Framework (QoF) of the 2004 GP contract. Although the primary focus of the QoF is on clinical care, it is acknowledged that a comprehensive assessment of quality also requires valid and reliable measurement of the patient perspective, so financial incentives are included in the contract for general practices to survey patients' views. One questionnaire specified for use in the QoF is the General Practice Assessment Questionnaire (GPAQ). This paper describes the development of the GPAQ (with post-consultation and postal versions) and presents a preliminary examination of the psychometric properties of the questionnaire.</p> <p>Methods</p> <p>Description of scale development and preliminary analysis of psychometric characteristics (internal reliability, factor structure), based on a large dataset of routinely collected GPAQ surveys (n = 190,038 responses to the consultation version of GPAQ and 20,309 responses to the postal version) from practices in the United Kingdom during the 2005–6 contract year.</p> <p>Results</p> <p>Respondents tend to report generally favourable ratings. Responses were particularly skewed on the GP communication scale, though no more so than for other questionnaires in current use in the UK for which data were available. Factor analysis identified 2 factors that clearly relate to core concepts in primary care quality ('access' and 'interpersonal care') that were common to both version of the GPAQ. The other factors related to 'enablement' in the post-consultation version and 'nursing care' in the postal version.</p> <p>Conclusion</p> <p>This preliminary evaluation indicates that the scales of the GPAQ are internally reliable and that the items demonstrate an interpretable factor structure. Issues concerning the distributions of GPAQ responses are discussed. Potential further developments of the item content for the GPAQ are also outlined.</p

Can the feedback of patient assessments, brief training, or their combination, improve the interpersonal skills of primary care physicians? A systematic review

<p>Abstract</p> <p>Background</p> <p>Improving quality of primary care is a key focus of international health policy. Current quality improvement efforts place a large focus on technical, clinical aspects of quality, but a comprehensive approach to quality improvement should also include interpersonal care. Two methods of improving the quality of interpersonal care in primary care have been proposed. One involves the feedback of patient assessments of interpersonal care to physicians, and the other involves brief training and education programmes. This study therefore reviewed the efficacy of (i) feedback of real patient assessments of interpersonal care skills, (ii) brief training focused on the improvement of interpersonal care (iii) interventions combining both (i) and (ii)</p> <p>Methods</p> <p>Systematic review of randomised controlled trials. Three electronic databases were searched (CENTRAL, Medline and Embase) and augmented by searches of the bibliographies of retrieved articles. The quality of studies was appraised and results summarised in narrative form.</p> <p>Results</p> <p>Nine studies were included (two patient based feedback studies and seven brief training studies). Of the two feedback studies, one reported a significant positive effect. Only one training study reported a significant positive effect.</p> <p>Conclusion</p> <p>There is limited evidence concerning the effects of patient based feedback. There is reasonable evidence that brief training as currently delivered is not effective, although the evidence is not definitive, due to the small number of trials and the variation in the training methods and goals. The lack of effectiveness of these methods may reflect a number of issues, such as differences in the effectiveness of the interventions in experienced practitioners and those in training, the lack of theory linking feedback to behaviour change, failure to provide sufficient training or to use a comprehensive range of behaviour change techniques. Further research into both feedback and brief training interventions is required before these interventions are routinely introduced to improve patient satisfaction with interpersonal care in primary care. The interventions to be tested in future research should consider using insights from the wider literature on communication outside primary care, might benefit from a clearer theoretical basis, and should examine the use of combined brief training and feedback.</p