Primary Care

Background: Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting. Methods: A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use. Results: Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group.

Background Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. Objectives To assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. Methods We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. Results Of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17Á15 AE 8Á51, with small regional differences [lower in England compared with Scotland (P = 0Á001) and Wales (P < 0Á001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cutoffs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. Conclusions Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.

he goals of cost-effective medical care in the perioper- ative period are to maximize beneficial patient out- comes while avoiding excessive use of medical tests and procedures that are unlikely to contribute to improved outcomes. This article will review some general principles of cost-effective perioperative care for the primary care physi- cian with a focus on preoperative cardiac risk assessment.

Approximately 20% of deaths from adverse events are related to medication incidents, costing the NHS an additional £500 million annually. Less than 5% of adverse events are reported. This study aims to assess the reporting rate of medication incidents in NHS facilities in the north east of Scotland, and to describe the types and outcomes of reported incidents among different services. Furthermore, we wished to quantify the proportion of reported incidents according to the reporters&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; profession. A retrospective description was made of medication incidents reported to an online reporting system (DATIX) over a 46-month-period (July 2005 to April 2009). Reports originated from acute and community hospitals, mental health, and primary care facilities. Over the study period there were 2,666 incidents reported with a mean monthly reporting rate of 78.2/month (SD±16.9). 6.1% of all incidents resulted in harm, with insulin being the most commonly implicated medication. Nearly three-quarters (74.2%, n=1,978) of total incidents originated from acute hospitals. Administration incidents were implicated in the majority of the reported medication incidents (59%), followed by prescribing (10.8%) and dispensing (9.9%), while the nondescript &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;other medication incidents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; accounted for 20.3% of total incidents. The majority of reports were made by nursing and midwifery staff (80%), with medical and dental professionals reporting the lowest number of incidents (n=56, 2%). The majority of medication incidents in this study were reported by nursing and midwifery staff, and were due to administration incidents. There is a clear need to elucidate the reasons for the limited contribution of the medical and dental professionals to reporting medication incidents.

The majority of leg ulcer patients in Sweden are managed by primary health care personnel. To compare, in a primary care setting, the healing results and the expenses of two commonly used wound dressings for leg ulcers. Thirty patients with leg ulcers of venous or mixed venous/arterial aetiology were randomized to treatment with saline-soaked gauze or with the hydrocolloidal dressing [HCD: DuoDERM (ConvaTec, A Bristol-Myers Squibb Company, Princeton)]. All patients were bandaged with the same compression of low-stretch-type [Comprilan (Beiersdorf AG, Hamburg)]. Vårdcentralen Marieberg, Primary Health Care Centre, Motala, Sweden. Healing/reduction of ulcer area, pain, costs for material, nursing time, kilometres driven were registered during a six-week period. Two patients dropped out of the study, one in the gauze-group due to erysipelas, and one in the HCD-group for social reasons. A total of 1234 dressing changes were analysed. Costs for material were similar in the two groups. When the total care including nursing- and travelling time and kilometres driven were analysed, the mean cost for treatment with gauze dressings was 4126 Swedish Kronor (SEK), and with HCD, 1565 SEK. Seven patients in the HCD-group and two in the gauze-group healed during the study. The reduction of the ulcer area was 19% in the gauze-group and 51% in the HCD-group (p &amp;lt; 0.16). The total care, analysed in an authentic clinical setting, must be considered when different wound-care methods are discussed. In this study the use of HCD showed lower costs than use of gauze-dressings. As regards healing there was a tendency to improved healing with HCD, but no significant difference. Patients in the HCD-group reported significantly less pain at dressing changes (p &amp;lt; 0.003) than patients in the gauze-group.

The majority of leg ulcer patients in Sweden are managed by primary health care personnel. To compare, in a primary care setting, the healing results and the expenses of two commonly used wound dressings for leg ulcers. Thirty patients with leg ulcers of venous or mixed venous/arterial aetiology were randomized to treatment with saline-soaked gauze or with the hydrocolloidal dressing [HCD: DuoDERM (ConvaTec, A Bristol-Myers Squibb Company, Princeton)]. All patients were bandaged with the same compression of low-stretch-type [Comprilan (Beiersdorf AG, Hamburg)]. Vårdcentralen Marieberg, Primary Health Care Centre, Motala, Sweden. Healing/reduction of ulcer area, pain, costs for material, nursing time, kilometres driven were registered during a six-week period. Two patients dropped out of the study, one in the gauze-group due to erysipelas, and one in the HCD-group for social reasons. A total of 1234 dressing changes were analysed. Costs for material were similar in the two groups. When the total care including nursing- and travelling time and kilometres driven were analysed, the mean cost for treatment with gauze dressings was 4126 Swedish Kronor (SEK), and with HCD, 1565 SEK. Seven patients in the HCD-group and two in the gauze-group healed during the study. The reduction of the ulcer area was 19% in the gauze-group and 51% in the HCD-group (p &amp;lt; 0.16). The total care, analysed in an authentic clinical setting, must be considered when different wound-care methods are discussed. In this study the use of HCD showed lower costs than use of gauze-dressings. As regards healing there was a tendency to improved healing with HCD, but no significant difference. Patients in the HCD-group reported significantly less pain at dressing changes (p &amp;lt; 0.003) than patients in the gauze-group.

It is widely recommended that sphygmomanometers are maintained and calibrated regularly to ensure that the pressure scale remains accurate to within the European Standard specification of +/-3 mmHg. In primary care, however, such checks are reported to be only rarely performed. This paper describes a survey of the accuracy of the absolute static pressure scale of aneroid, mercury and automated sphygmomanometers in clinical use in primary care. On-site measurements of sphygmomanometer pressure scale accuracy were carried out in 45 general practices within Lambeth, Southwark and Lewisham. A total of 279 sphygmomanometers from these practices were included in the study. The device pressure scales were calibrated using an accurate electronic reference pressure sensor. The key finding of this study is that 17.9% (50 out of 279) of all surveyed devices gave errors exceeding the +/-3 mmHg threshold. Of these, 53.2% (33 out of 62) of aneroid devices were found to be reading in error by more than +/-3 mmHg compared with 7.8% (16 out of 217) of the combined population of mercury and automated devices. The difference between these groups is statistically significant (P=0.002). Significant differences in the performance of specific models of aneroid, mercury and automated devices were also identified. A service model for improving the accuracy of blood pressure monitoring in primary care needs to take into account the current proliferation of pressure scale errors in these devices, the lack of uptake of regular checks and the poor quality of some of the devices currently in use.

Depression guidelines in the UK recommended a policy of watchful waiting for mild depression due to a lack of evidence for the effectiveness of antidepressant treatment for mild cases. However there has been relatively little research carried out in primary care to help establish the severity threshold at which antidepressant treatment is effective and cost-effective. The THREAD (THREshold for AntiDepressants) study is a multi-centre randomised controlled trial designed to determine the clinical and cost effectiveness of a selective serotonin reuptake inhibitor (SSRI) plus general practitioner (GP) supportive care, versus supportive care alone, for mild to moderate depression in primary care. The aim is to recruit 300 patients from three centres (Southampton, London and Liverpool). Depressive symptoms will be assessed at baseline, 12 weeks and 26 weeks, using the 17-item Hamilton Depression Rating Scale (HDRS). Two severity sub-groups of patients will be recruited, with HDRS scores of 12-15, and 16-19. Possible predictors of response will be explored including life events and difficulties and alcohol consumption. Analysis of covariance, controlling for baseline value, severity group and centre will be used to estimate the overall treatment effectiveness (difference in HDRS score) at final follow up. The primary analysis will be by &amp;amp;amp;amp;amp;#39;intention to treat&amp;amp;amp;amp;amp;#39; using double sided tests. The interaction between severity sub-group and treatment will be tested, and if appropriate, effects within separate severity sub-groups estimated. The economic analysis will compare the two treatment groups in terms of mean costs and cost-effectiveness. The results of this study will give GPs important information to help them determine the severity of depression at which antidepressant treatment is likely to be cost-effective.

To compare the volume and quality of original research in primary care published by researchers from primary care in the United Kingdom against five countries with well established academic primary care. Bibliometric analysis. United Kingdom, United States, Australia, Canada, Germany, and the Netherlands. Studies reviewed Research publications relevant to comprehensive primary care and authored by researchers from primary care, recorded in Medline and Embase, with publication dates 2001-7 inclusive. Volume of published activity of generalist primary care researchers and the quality of the research output by those publishing the most using citation metrics: numbers of cited papers, proportion of cited papers, and mean citation scores. 82,169 papers published between 2001 and 2007 in the six countries were classified as research on primary care. In a 15% pragmatic random sample of these records, 40% of research on primary care from the United Kingdom and 46% from the Netherlands was authored by researchers employed in a primary care setting or employed in academic departments of primary care. The 141 researchers with the highest volume of publications reporting research findings published between 2001 and 2007 (inclusive) authored or part authored 8.3% of the total sample of papers. For authors with the highest proportion of publications cited at least five times, the best performers came from the United States (n=5), United Kingdom (n=4), and the Netherlands (n=2). In the top 10 of authors with the highest proportions of publications achieving 20 or more citations, six were from the United Kingdom and four from the United States. The mean Hirsch index (measure of a researcher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s productivity and impact of the published work) was 14 for the Netherlands, 13 for the United Kingdom, 12 for the United States, 7 for Canada, 4 for Australia, and 3 for Germany. This international comparison of the volume and citation rates of papers by researchers from primary care consistently placed UK researchers among the best performers internationally.