Community asthma clinics: 1993 survey of primary care by the National Asthma Task Force. (1/23)

OBJECTIVES: To establish a baseline of work done in primary care asthma clinics in the United Kingdom and to assess the degree of clinical delegation to nurses and the appropriateness of their training. DESIGN: Prospective questionnaire survey of asthma care in general practices and a subsidiary survey of all family health services authorities (FHSAs) of the number of asthma clinics in their area. SETTING: All 14,251 general practices in the United Kingdom and 117 FHSAs or health boards (Scotland and Northern Ireland). RESULTS: Questionnaires were returned by 4327 (30.4%) general practices, 54% being completed by practice nurses and 22% by general practitioners; in 24% profession was not stated. In all, 77.2% (3339/4327) of respondents ran an asthma clinic. 60 FHSAs state the number of asthma clinics at the time of the general practice survey (total 3653 clinics); within responding FHSAs 1702 (46.6%) practices running an asthma clinic replied to the general practice survey. Clinics exclusive for patients with asthma mostly occurred in practices with five or more general practitioners (70.2%), compared with single-handed practices (31.7%). The average number of asthma clinics run per practice was five a month; the average duration was 2 hours and 20 minutes. 1131 (48.8%) nurses ran clinics by themselves, 1180 (47.9%) with the doctor, and 39 (1.7%) had no medical input. Comprehensive questioning occurred other than for nasal (872, 26.1%) or oesophageal (335, 10.0%) symptoms and use of aspirin and non-steroidal drugs (1161, 33.4%). Growth in children was measured by only a third of respondents. Of the 1131 nurses who ran clinics alone, 251 (22.2%) did so without formal training entailing assessment. CONCLUSION: Asthma clinics are now common in general practice and much of their work is done by nurses, a significant minority of whom may not have had sufficient training. IMPLICATIONS: As this survey is probably biased toward the more asthma aware practices, greater deficiencies in training and standards may exist in other practices. Further evaluation of the effectiveness of asthma clinics is needed.  (+info)

Clinical interventions and outcomes of One-to-One midwifery practice. (2/23)

BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation.  (+info)

A survey of diabetes care in general practice in England and Wales. (3/23)

BACKGROUND: The focus of care for people with diabetes has shifted from hospital to general practice. Many practices now offer diabetes care via dedicated mini-clinics, shared care schemes or opportunistically. There has never been a national survey of the organisation of diabetes care in general practice. AIM: To describe some key features of diabetes care in primary care in England and Wales. METHOD: Descriptive postal questionnaire survey to one in five (1873) randomly sampled general practices. RESULTS: Seventy per cent (1320) of practices responded. Of these, 96% had diabetes registers identifying 1.9% of their population as having diabetes; 71% held clinics run by a general practitioner (GP) and a nurse (64%) or a nurse alone (34%); 80% felt adequately supported; and 54% shared patient management protocols with the local secondary care team. Overall, practices provided most of the routine diabetes care for 75% of their diabetic patients. The majority of GPs and practice nurses had received some recent, albeit brief, diabetes education. CONCLUSION: A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for delivering good care is in place. Many practices have a special interest in diabetes with the majority feeling adequately supported by secondary care. However, there are concerns about the educational needs of those providing care. More work needs to be done to ensure seamless care across the primary-secondary care interface.  (+info)

A cost consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis. (4/23)

BACKGROUND: The practice nurse is central to the development of a primary care-led National Health Service. Skin diseases can have a major impact on patients' lives but general practitioners (GPs) lack many of the skills of practical dermatology care and support. AIM: To determine whether a primary care dermatology liaison nurse should be introduced by our health authority. We identified the resources consumed and the benefits that accrued from a practice nurse who had received training in practical dermatology care. METHOD: A cost consequence study in parallel with a randomised controlled trial was undertaken in a group of nine GPs and 109 patients between the ages of 18 and 65 years who had a diagnosis of psoriasis or eczema. RESULTS: Although there was a significant improvement in our primary outcome measure within group, when compared with the control group significance was not achieved. There was no significant change in the Euroqol measure but the clinical instrument showed a significant change when compared with control. On entry, our qualitative data identified three main themes--the embarrassment caused by these skin conditions, the wish for a cure rather than treatment, and concern over the long-term effects of steroids. On completion, 20% of patients expressed that they had received a positive benefit from the clinic. CONCLUSION: This study demonstrates the difficulties of obtaining relevant information to facilitate decisions on how resources should be allocated in primary care. Not all questions can be answered by large multi-centred trials and studies themselves have an opportunity cost consuming resources that could otherwise be spent on direct health care. Often, local resource decisions will be based on partial evidence-yielding solutions that are satisfactory rather than optimum but which are, nevertheless, better than decisions taken with no evidence at all.  (+info)

Is there a role for nurse-led blood pressure management in primary care? (5/23)

Adequate treatment of high blood pressure reduces the risk of strokes and other cardiovascular events, but current treatment in UK general practice is often inadequate. Nurse-led management of people with high blood pressure could lead to improvements due to strict adherence to protocols, agreed target blood pressure, better prescribing and compliance, and regular follow-up. However, a review of the literature shows a lack of robust evidence of the effectiveness of nurse-led hypertension management in primary care. There is a clear need for randomized controlled trials to see if nurse-led management is associated with better blood pressure control than routine care.  (+info)

The medical care of patients with primary care home nursing is complex and influenced by non-medical factors: a comprehensive retrospective study from a suburban area in Sweden. (6/23)

BACKGROUND: The reduced number of hospital beds and an ageing population have resulted in growing demands for home nursing. We know very little about the comprehensive care of these patients. The objectives were to identify the care, in addition to primary health care, of patients with primary-care home nursing to give a comprehensive view of their care and to investigate how personal, social and functional factors influence the use of specialised medical care. METHODS: One-third (158) of all patients receiving primary-care home nursing in an area were sampled, and 73 % (116) were included. Their care from October 1995 until October 1996 was investigated by sending questionnaires to district nurses and home-help providers and by collecting retrospective data from primary-care records and official statistics. We used non-parametric statistical methods, i.e. medians and minimum - maximum, chi2, and the Mann-Whitney test, since the data were not normally distributed. Conditional logistic regression was used to study whether personal, social or functional factors influenced the chance (expressed as odds ratio) that study patients had made visits to or had received inpatient care from specialised medical care during the study year. RESULTS: 56 % of the patients had been hospitalised. 73 % had made outpatient visits to specialised medical care. The care took place at 14 different hospitals, and more than 22 specialities were involved, but local care predominated. Almost all patients visited doctors, usually in both primary and specialised medical care. Patients who saw doctors in specialised care had more help from all other categories of care. Patients who received help from their families made more visits to specialised medical care and patients with severe ADL dependence made fewer visits. CONCLUSIONS: The care of patients with primary-care home nursing is complex. Apart from home nursing, all patients also made outpatient visits to doctors, usually in both primary and specialised medical care. Many different caregivers and professions were involved. Reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care. This raises questions concerning the medical care for patients with both medical and functional problems.  (+info)

Secondary prevention of stroke--results from the Southern Africa Stroke Prevention Initiative (SASPI) study. (7/23)

OBJECTIVE: To describe the prevalence of risk factors and experience of preventive interventions in stroke survivors, and identilfy barriers to secondary prevention in rural South Africa. METHODS: A clinician visited individuals in the Agincourt field site (in South Africa's rural north east) who were identified in a census as possible stroke victims to confirm the diagnosis of stroke. We explored the impact of stroke on the individual's family, and health-seeking behaviour following stroke by conducting in-depth interviews in the households of 35 stroke survivors. We held two workshops to understand the knowledge, experience, and views of primary care nurses, who provide the bulk of professional health care. FINDINGS: We identified 103 stroke survivors (37 men), 73 (71%) of whom had hypertension, but only 8 (8%) were taking anti-hypertensive treatment. Smoking was uncommon; 8 men and 1 woman smoked a maximum of ten cigarettes daily. 94 (91%) stroke survivors had sought help, which involved allopathic health care for most of them (81; 79%). 42 had also sought help from traditional healers and churches, while another 13 people had sought help only from those sources. Of the 35 survivors who were interviewed, 29 reported having been prescribed anti-hypertensive pills after their stroke. Barriers to secondary prevention included cost of treatment, reluctance to use pills, difficulties with access to drugs, and lack of equipment to measure blood pressure. A negative attitude to allopathic care was not an important factor. CONCLUSION: In this rural area hypertension is the most important modifiable risk factor in stroke survivors. Effective secondary prevention may reduce the incidence of recurrent strokes, but there is no system to deliver such care. New strategies for care are needed involving both allopathic and non-allopathic-health care providers.  (+info)

Staff training and ambulatory tuberculosis treatment outcomes: a cluster randomized controlled trial in South Africa. (8/23)

OBJECTIVE: To assess whether adding a training intervention for clinic staff to the usual DOTS strategy (the internationally recommended control strategy for tuberculosis (TB)) would affect the outcomes of TB treatment in primary care clinics with treatment success rates below 70%. METHODS: A cluster randomized controlled trial was conducted from July 1996 to July 2000 in nurse-managed ambulatory primary care clinics in Cape Town, South Africa. Clinics with successful TB treatment completion rates of less than 70% and annual adult pulmonary TB loads of more than 40 patients per year were randomly assigned to either the intervention (n = 12) or control (n = 12) groups. All clinics completed follow-up. Treatment outcomes were measured in cohorts of adult, pulmonary TB patients before the intervention (n = 1200) and 9 months following the training (n = 1177). The intervention comprised an 18-hour experiential, participatory in-service training programme for clinic staff delivered by nurse facilitators and focusing on patient centredness, critical reflection on practice, and quality improvement. The main outcome measure was successful treatment, defined as patients who were cured and those who had completed tuberculosis treatment. FINDINGS: The estimated effect of the intervention was an increase in successful treatment rates of 4.8% (95% confidence interval (CI): -5.5% to 15.2%) and in bacteriological cure rates of 10.4% (CI: -1.2% to 22%). A treatment effect of 10% was envisaged, based on the views of policy-makers on the minimum effect size for large-scale implementation. CONCLUSION: This is the first evidence from a randomized controlled trial on the effects of experiential, participatory training on TB outcomes in primary care facilities in a developing country. Such training did not appear to improve TB outcomes. However, the results were inconclusive and further studies are required.  (+info)