Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour

Background. In the United Kingdom little is known about general practitioners' attitudes to and behaviour concerning clinical guidelines. Aim. A study was performed to investigate these two under-researched areas. Method. In 1994 a postal questionnaire on clinical guidelines was sent to all 326 general practitioner principals on the list of Lincolnshire Family Health Services Authority. The questionnaire consisted of 20 attitude statements and an open question on clinical guidelines, as well as surveying characteristics and behaviour of respondents. Results. Of the 326 general practitioners sent questionnaires, 213 (65%) replied. Most respondents (78%) reported having been involved in writing inhouse guidelines. An even greater proportion (92%) reported having participated in clinical audit. Respondents were generally in favour of clinical guidelines, with mean response scores indicating a positive attitude to guidelines in 15 of the 20 statements, a negative attitude in four and equivocation in one. The majority of respondents felt that guidelines were effective in improving patient care (69%). Members (or fellows) of the Royal College of General Practitioners had a more positive attitude than non-members towards guidelines. They were also significantly more likely than non-members to have written inhouse guidelines, as were those who had participated in audit compared with those who had not participated in audit. A substantial minority (over a quarter) of general practitioners were concerned that guidelines may be used for setting performance-related pay, or that they may lead to 'cookbook' medicine, reduce clinical freedom or stifle innovation. There was also concern that guidelines should be scientifically valid. Conclusion. This study suggests that many general practitioners in the Lincolnshire Family Health Services Authority area have produced written inhouse guidelines. This is largely sustained by positive attitudes about the effectiveness and benefits of clinical guidelines. The positive attitude of RCGP members supports it in its continuing role in developing, implementing and evaluating guidelines in primary care. The question of whether incorporation of guidelines into clinical audit is an effective means to disseminate systematic research-based guidelines warrants further study

Guidelines in primary care: an investigation of general practitioners’ attitudes and behaviour towards clinical guidelines

Background. Little is known about the attitudes and behaviour of British general practitioners towards clinical guidelines. Aim. To investigate the beliefs, attitudes and behaviour of general practitioners towards clinical guidelines. Method. A postal questionnaire sent to all 326 general practitioner principals on the list of Lincolnshire Family Health Services Authority in 1994. Results. Of the 326 general practitioners sent questionnaires 213 (65.3%) replied. Most respondents (78.4%) had written, or participated in writing, practice-based guidelines. An even greater proportion (92.0%) had participated in clinical audit. The majority of respondents felt that guidelines were effective in improving care (68.5%). Members (and fellows) of the Royal College of General Practitioners had a more positive attitude towards guidelines. They were significantly more likely to have written in-house guidelines as were those who had participated in audit. There was no evidence of change in attitude after participating in an inter-practice audit. Conclusions. Practice-based guidelines are widely used in Lincolnshire. This use is largely sustained by positive beliefs about their effectiveness and benefits. Practitioners were ambivalent about the use of guidelines for setting performance-related pay and their effect on professional status. They were concerned that guidelines should be scientifically valid and valued local “ownership” of guidelines. The positive attitude of its members supports the college in its continuing role in developing guidelines in primary care. Incorporation into clinical audit may also be an effective way of disseminating systematic research-based guidelines

Effect on hypnotic prescribing of a quality improvement collaborative for primary care of insomnia: segmented regression analysis

Introduction Patients with insomnia commonly present to general practice. Hypnotic misuse and underuse of psychological treatments demonstrates scope for improved care. To explore this, we undertook a feasibility study using a Quality Improvement Collaborative (QIC) across 8 general practices, investigating the effect of implementing sleep assessment and psychological interventions on hypnotic prescribing. Methods We used a before-after analysis of the time series of prescribing of benzodiazepines (e.g. diazepam, temazepam, lorazepam) and Z-drugs (e.g. zopiclone, zolpidem, zaleplon) across intervention practices. We contrasted results with those for 8 control practices not subject to the QIC. Data were constructed as average daily quantity of hypnotic prescribed per Specific Therapeutic group Age-sex weightings Related Prescribing Unit (STAR–PU) for the period October 2005 to March 2010. Modelling was by 2-segment intercept-trend regression performed on the 24 month periods either side of the 6-month operation of the QIC (October 2007 to March 2008). Estimation was by either least squares or corrected using the Prais-Winsten method if error serial correlation was present in the errors. We then jointly re-estimated across all intervention practices (repeated on all control practices) using seemingly unrelated regressions to allow for any potential correlations in the models’ errors. Testing whether the intervention had been successful in inducing a structural break such that post-QIC prescribing of either drug was reduced, we constructed a bespoke test S based on the mean prediction error in the post-QIC period for aggregated intervention practices. Results Comparing the two prescribing periods, there was a noteworthy and significant reduction in benzodiazepine prescribing in intervention practices over the shorter post-QIC term of 12 months (S=-2.46, p=0.007), but this was not sustained for the full 24 months post-QIC (S=-0.72, p=0.236). However, for Z-drugs prescribing reductions in intervention practices were sustained into the longer post-QIC period (12 months: S=-1.98, p=0.024; 24 months, S=-1.90, p=0.029). The before-after comparison to control practices showed no significant reduction in prescribing of either drug. Conclusion Efficacy of the QIC in reducing hypnotic prescribing was shown, giving support to the need for a full scale trial. Varying length of persistence of outcomes warrants attention

Prehospital management of suspected seizures: cross-sectional study in a regional ambulance service

Introduction, Suspected convulsions and seizures are a common reason for emergency calls to ambulance services. Pre-hospital care is a key element of good quality care for these patients and it is a key determinant of downstream health service activity but there is very little research in this area. Epilepsy is an ambulatory care sensitive condition (ACSC) and the incidence of convulsions and seizures is an important indicator of failed scheduled care. The prevalence of active epilepsy in the UK is 1% and 20-30% of people with epilepsy have more than one seizure per month. Convulsions and seizures result in a large number of emergency calls to ambulance services, the majority of these patients are conveyed to emergency departments (ED), which accounts for much of the health costs of uncontrolled epilepsy. Methods, We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected convulsions and seizures over a one year period (August 2011 to July 2012) extracted from a single regional ambulance service (EMAS). Our aims were firstly to generate descriptive statistics (including incidence) for patients over the age of 18 years treated by EMAS for seizures over a period of a year, and secondly to use regression analysis to identify predictors of transport to hospital in this sample. Results & Conclusion There were 6208 patients with chief complaint recorded as suspected convulsions and seizures (suspected Epileptics). There were 3218 (54.4%) male epileptics and 2697 (45.6%) female epileptics. Suspected epileptics are the sixth most common reason for emergency calls to the East Midlands Ambulance Service

Qualitative interview study of patients', ambulance practitioners' and emergency department clinicians' perceptions of prehospital pain management

Introduction Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain and 20% of patients reporting inadequate pain relief. Improving prehospital pain management is important for service quality. Our aim was to investigate perceptions of pain management from patients, ambulance and emergency care staff. Methods Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital in pain, ambulance staff and emergency department clinicians. Interviews were audiotaped and transcribed using thematic analysis to iteratively develop themes supported by data analysis software, MAXQDA. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (f) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal of or inadequate analgesia were not uncommon because patients were concerned about drug side effects or, did not want to be transported. Pain was commonly assessed using a verbal pain score; clinical observation was often discordant with subjective experience. Communication difficulties, non-cooperation or influence of alcohol or drugs were found as barriers to pain assessment. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing agreed multi-organisational pain management protocols supported by training for staff. Discussion Patients and practitioners expected pain to be relieved in the ambulance. Suggestions to improve prehospital pain management included addressing identified barriers, modifying the available drugs, using non-drug measures and developing agreed multi-organisational pain management protocols supported by appropriate training for staff. Our findings will inform development of protocols and quality improvement programmes along the pathway of prehospital pain management

Informing use of QCancer in the primary care consultation - perspectives of service users and practitioners

Introduction: Earlier detection of cancer may help reduce the current high level of cancer mortality in the UK. Cancer risk assessment tools such as QCancer, which predict the absolute risk of cancer in symptomatic individuals, may help identify those at high risk needing investigation for possible cancer. Little is known about the views of service users and primary care practitioners on the use of QCancer in primary care consultations. The aim of this study was to explore the perspectives of service users and primary care practitioners on use of QCancer and how communication with patients might be enhanced when using QCancer in primary care consultations. Methods: The study was conducted in Lincolnshire, a large rural county in the East Midlands, using a qualitative research design. This involved individual interviews with service users recruited from the general public, and both individual and focus group interviews with primary care practitioners including general practitioners and practice nurses. Data were recorded, transcribed verbatim and analysed using the framework approach. Ethics approval was granted by the University of Lincoln School of Health and Social Care Ethics Committee. Results: We interviewed 36 participants (19 service users and 17 practitioners) until data saturation was achieved. Four main themes emerged: the implications of quantifying cancer risk; usefulness of QCancer; communicating cancer risk and barriers to implementation in primary care consultations. Participants expressed a range of views about the implications of quantifying cancer risk using QCancer. These included: potential conflict with current cancer risk guidelines and the need to refer patients with symptoms suggestive of cancer whatever their quantified risk. Participants agreed that QCancer would help to: quantify cancer risk; support clinical decision making; inform efforts to modify health behaviours; improve processes and speed of assessments, diagnosis and treatment; and, enable practitioners to personalise patient care. To enhance patient-practitioner communication of cancer risk, both service users and primary care practitioners suggested the following: tailoring a visual representation of risk; being honest and open with patients; involving patients in the use of QCancer; and allowing time for listening, explaining, informing and reassuring patients. Potential challenges to the uptake of QCancer were also identified including: the additional time required for its use and communication; unnecessary worry caused by investigation of false positives; potential for over-referral; and practitioner scepticism with the need to establish the effectiveness of QCancer against current practice before introducing it more widely. Conclusion: Participants perceived the potential usefulness of QCancer but felt that communication needs of users and potential barriers should be considered when planning to implement QCancer. Before rolling out the tool, further research is needed to pilot and evaluate the impact of QCancer on outcomes such as rates of investigations, referrals, diagnoses as well as patient and practitioner experiences of using the tool

Reliability and validity of an Ambulance Patient Reported Experience Measure (A-PREM): pilot study

Background There are no prehospital ambulance Patient Reported Experience Measures (A-PREMs) routinely used to support service comparisons and improvement. We developed an A-PREM, generating items through secondary analysis of ambulance patient interview data, and refining the instrument using expert assessment and cognitive interviews of service users. We aimed to pilot the A-PREM (48 experience and 12 attribute items) investigating user acceptability, reliability and construct validity. Methods Ambulance users attended by a UK regional ambulance service within the previous six months, excluding those suffering cardiac arrest, were sent a self-administered A-PREM. Returned questionnaires were entered into Microsoft Excel and imported into SPSS v22 for analysis. Experience items were recoded to range from 0 (don’t know/can’t remember) to 3 (best recorded experience). Descriptive analysis for item frequencies and missing values, reliability analyses for potential scales and tests of correlation and association were conducted. Results In all, 111 A-PREMs (22.2%) were returned. Missing data were highest for call-taking items. There was a significant association with a shorter wait for first response for four items measuring overall experience of call-taking (χ, p=0.05), ambulance staff (p<0.001), ambulance overall (p=0.001) and A&E (p=0.023). Four separate experience scales encompassing call taking (AmbCallScore, α=0.91), care at scene (AmbCareScore, α=0.90), care on leaving the patient (AmbLeaveScore, α=0.69), and care on transport (AmbTranScore α=0.71), showed satisfactory to high internal consistencies and distributions indicating generally positive experiences. AmbCallScore, AmbCareScore and AmbLeaveScore showed significantly higher scores (ANOVA) with shorter wait to first response. There were no significant differences for overall measures or scales by sex or age of participant, whether they were transported to hospital or not and whether it was their first experience of the ambulance service. Conclusion Our findings show that the A-PREM should be tested more widely for evidence of reliability, validity and sensitivity to different care and settings

Investigating the potential role of ICT to support older people with multi-morbidity to navigate the care network

Tools are available to help people navigate when they are not quite sure where they should be going (e.g. GPS). In the care system there is (as yet) no available map to guide patients, users or carers to particular health and care services. This poster displays the mixed method research protocol in which we will investigate the potential role of ICT to support older people with multi morbidities to navigate through the care system. Three distinct work streams are set up to explore and analyse the current literature, patients’ perspective about their care network and patients’ experience about problems in their care system. A fourth work stream will bring these analyses together to generate design requirements for engineers in order to prototype an electronic tool. This will support patients to appropriately and successfully navigate through health and social care services

A systematic scoping review of the use of cancer risk assessment tools for early detection of cancer risk in primary care

Introduction Cancer risk assessment tools are designed to predict cancer risk using risk factors and symptoms of individuals. These tools could prompt investigations and referral for specialist attention, leading to early diagnosis and treatment and a potential reduction in the high mortality of cancer in the UK. While cancer risk assessment tools are thought to accurately predict the risk of specific cancers, this is based on statistical testing of data from databases rather than using the tools on actual patients. More needs to be known about the use and implementation in practice of cancer risk assessment tools to aid primary care detection of cancer. We aimed to scope the evidence relating to the use of cancer risk assessment tools for early detection of cancer in primary care. Methods Using the framework proposed by Arksey and O’Malley, we conducted a systematic scoping review of the literature published in the English language from 2004 to 2015 to ensure relevance to current practice. Our search strategy included specific search terms which were used to search six electronic databases: Medline; CINAHL; Scopus; Cochrane; Science Direct and Psych INFO. A narrative synthesis was used to analyse the papers identified. Results We retrieved 481 papers from the initial database search. After sifting titles and abstracts, 72 full text papers remained, of which 48 studies were excluded because these did not meet the inclusion criteria. The remaining 24 studies were included in the review. These included: randomised controlled trials (2); cohorts (11), survey (2); case control (3); qualitative (3), critical reviews (1) and other unspecific designs (2). This review found limited evidence on: novel cancer risk assessment tools being used; perceptions of users and outcomes of using the tools. While there was also some evidence pointing to the usefulness of cancer risk assessment tools, there was limited evidence on how best to communicate cancer risk to patients when using a cancer risk assessment tool. Conclusion The evidence available on the use of cancer risk assessment tools in primary care was limited. Further research is needed to explore how best cancer risk can be communicated to patients when using a cancer risk assessment tool in primary care consultations