Use of the NHS Choices website for primary care consultations: results from online and general practice surveys

OBJECTIVES: To determine the effect of using the NHS Choices website on primary care consultations in England and Wales. We examined the hypothesis that using NHS Choices may reduce the frequency of primary care consultations among young, healthy users. DESIGN: Two cross-sectional surveys of NHS Choices users. SETTING: Survey of NHS Choices users using an online pop-up questionnaire on the NHS Choices website and a snapshot survey of patients in six general practices in London. PARTICIPANTS: NHS Choices website users and general practice patients. MAIN OUTCOME MEASURES: For both surveys, we measured the proportion of people using NHS Choices when considering whether to consult their GP practice and on subsequent frequency of primary care consultations. RESULTS: Around 59% (n = 1559) of online and 8% (n = 125) of general practice survey respondents reported using NHS Choices in relation to their use of primary care services. Among these, 33% (n = 515) of online and 18% (n = 23) of general practice respondents reported reduced primary care consultations as a result of using NHS Choices. We estimated the equivalent capacity savings in primary care from reduced consultations as a result of using NHS Choices to be approximately £94 million per year. CONCLUSIONS: NHS Choices has been shown to alter healthcare-seeking behaviour, attitudes and knowledge among its users. Using NHS Choices results in reduced demand for primary care consultations among young, healthy users for whom reduced health service use is likely to be appropriate. Reducing potentially avoidable consultations can result in considerable capacity savings in UK primary care

It's not what you do it's the way that it's measured: quality assessment of minor ailment management in community pharmacies:Quality assessment of minor ailment management in community pharmacies

Background: Effective management of minor ailments in community pharmacies could reduce the burden on alternative high-cost services (general practices, Emergency Departments). Evidence is needed regarding the appropriateness of management of these conditions in community pharmacies. Objective: To explore the appropriateness of minor ailment management in community pharmacies. Setting: Prospective, observational study of simulated patient (SP) visits to community pharmacies in Grampian (Scotland) and East Anglia (England). Method: Eighteen pharmacies (nine per centre) were recruited within a 25-mile radius of Aberdeen or Norwich. Consultations for four minor ailments were evaluated: back pain; vomiting/diarrhoea; sore throat; and eye discomfort. Each pharmacy received one SP visit per ailment (four visits/pharmacy; 72 visits total). Visits were audio-recorded and SPs completed a data collection form immediately after each visit. Primary Outcome Measure: Each SP consultation was assessed for appropriateness against product licence, practice guidelines and study-specific consensus standards developed by a multi-disciplinary consensus panel. Results: Evaluable data were available for 68/72 (94.4%) visits. Most (96%) visits resulted in the sale of a product; advice alone was the outcome of three visits. All product sales complied with the product licence, 52 (76%) visits complied with practice guidelines and seven visits achieved a ‘basic’ standard according to the consensus standard. Conclusion: Appropriateness of care varied according to the standard used. Pharmacy-specific quality standards are needed which are realistic and relevant to the pharmacy context and which reflect legal and clinical guidelines to promote the safe and effective management of minor ailments in this setting

Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial

Background Negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions. Objective To establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia. Design A multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up Setting Adult psychiatric services, treating people with schizophrenia. Participants Inpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity. Interventions Eligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study. Main Outcome Measures The primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich’s Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale. Results No therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference –1.3, 95% confidence interval–2.5 to–0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation. Limitations The trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. Conclusion Although adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies. Future Work Further studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge.</p

Respiratory Self-Care:Identifying Current Challenges and Future Potentials for Digital Technology to Support People with Chronic Respiratory Conditions

Chronic respiratory conditions (CRCs) are life-long diseases affecting millions of people worldwide. They have a huge impact on individuals’ everyday lives, resulting in a number of physical and emotional challenges. Self-management interventions for CRCs are thought to provide empowerment and improve quality of life. However, despite the number of people living with CRCs, most self-management tools in previous HCI work have been designed without the insight of those affected by the conditions. In this paper, we contribute to the literature by investigating the experiences and everyday challenges faced by those with CRCs, through the involvement of 156 participants via interviews and an anonymous survey. Our findings reveal the self-care challenges of CRCs and the reactive management approaches taken by participants. We conclude by providing a set of design implications that support the design of future self-management tools for CRCs

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings. Objectives Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community. Review methods We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. Results We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed. Conclusions In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control. Limitations We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers. Future work There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme

Optimism measured pre-operatively is associated with reduced pain intensity and physical symptom reporting after coronary artery bypass graft surgery.

OBJECTIVE: Optimism is thought to be associated with long-term favourable outcomes for patients undergoing coronary artery bypass graft (CABG) surgery. Our objective was to examine the association between optimism and post-operative pain and physical symptoms in CABG patients. METHODS: We assessed optimism pre-operatively in 197 adults undergoing CABG surgery, and then followed them up 6-8 weeks after the procedure to measure affective pain, pain intensity, and physical symptom reporting directly pertaining to CABG surgery. RESULTS: Greater optimism measured pre-operatively was significantly associated with lower pain intensity (β=-0.150, CI=-0.196 to -0.004, p=.042) and fewer physical symptoms following surgery (β=-0.287, CI=-0.537 to -0.036, p=.025), but not with affective pain, after controlling for demographic, clinical and behavioural covariates, including negative affectivity. CONCLUSIONS: Optimism is a modest, yet significant, predictor of pain intensity and physical symptom reporting after CABG surgery. Having positive expectations may promote better recovery