Preliminary codesign and testing of a feedback tool to improve the quality of peer appraiser documentation for medical revalidation.

Medical appraisal and associated revalidation are mandatory for doctors in the United Kingdom. However, the quality of appraisal documentation, which informs the revalidation process on a doctor's fitness-to-practise, is known to be variable. This preliminary study aimed to develop and test a formative educational tool that could be used, as part of routine appraiser training in the general practice setting, to review and provide evidence and feedback on the quality of documentation completion. A mixed-methods study was undertaken based on codesign principles, which elicited the views and opinions of medical appraisers, appraisal leads and medical managers on the content of an educational tool designed to reduce variation in appraisal paperwork completion. The study team created a 24-item educational tool covering six domains of the appraisal process. Domains included 'reflection on practice', 'knowledge, skills and performance' and 'quality and safety'. The tool was piloted amongst appraisers and received positive feedback. This study contributes practical knowledge to help reduce variation in appraisal documentation. The tool can be used to streamline the completion of appraisal documentation by appraisers. It may provide a level of quality assurance and contribute to providing fair, objective and measurable grounds for revalidation.

Sub-acute cutaneous lupus erythematosus following nitrofurantoin: causative or coincidental?

A 70-year-old woman presented with progressive skin lesions on the face, limbs and trunk in the absence of systemic illness. Three months earlier, she had been prescribed six months prophylactic nitrofurantoin for recurrent urinary tract infections, treated with nitrofurantoin and trimethoprim. Positive immunology and histological inflammatory changes in a skin biopsy were consistent with a diagnosis of sub-acute cutaneous lupus erythematosus. Following treatment with topical steroids, the skin lesions regressed, but alopecia followed and required hydroxychloroquine. One year later, there are no new skin lesions and no evidence of systemic lupus erythematosus. Nitrofurantoin is associated with many side effects and hypersensitivity reactions. Possible drug-induced lupus reactions due to nitrofurantoin include pneumonitis, blood disorders and hepatotoxicity. This is the only published case of isolated sub-acute cutaneous lupus following maintenance nitrofurantoin.

Feasibility of screening for and treating vitamin D deficiency in forensic psychiatric inpatients.

Neuroleptic and anti-epileptic medication, inadequate vitamin D intake and limited solar exposure increase the risk of vitamin D deficiency in high security psychiatric environments. Of the 33 inpatients (40% selected; 21% of hospital population) completing this cross-sectional study, 36% had insufficient and 58% deficient vitamin D. Five patients with vitamin D deficiency had secondary hyperparathyroidism, two of whom had osteopenia on dual-emission X-ray absorptiometry. At 1-year follow up, of the 31 patients eligible, 15 had accepted and continued supplements. Systematic screening is therefore necessary due to mental health and consent issues. Implications of supplementation and grounds access are discussed.

Glad you brought it up: a patient-centred programme to reduce proton-pump inhibitor prescribing in general medical practice.

BACKGROUND: Many patients unnecessarily receive proton-pump inhibitor (PPI) drugs long term with significant financial and safety implications. Educating, empowering and supporting patients to self-manage their symptoms can lead to significant and sustained reductions in PPI prescribing. We aimed to implement a programme to reduce inappropriate PPI prescribing. METHOD: Eligible patients in one general medical practice in rural Scotland were invited for participation between November 2008 and February 2010. Patients attended special nurse advisor clinics, completed dyspepsia questionnaires, received information, formulated self-management plans and were offered flexible support. RESULTS: Of the study population, 437/2883 (15%) were prescribed PPIs. Of these, 166 (38%) were judged eligible for participation. After 12 months, 138/157 (83%) had reduced or stopped their PPIs, while 19/157 (11%) had reverted. The estimated annual net saving in the prescribing budget was ?3180.67. Self-reported understanding of symptom self-management increased from 6/20 (30%) to 18/20 (90%) patients after participation in the programme. CONCLUSION: A patient-centred programme delivered by a specialist nurse significantly reduced PPI prescribing with financial and potential therapeutic benefits. The vast majority of eligible patients were able to 'step down and off' or 'step off' PPI use after 12 months without any complications or deteriorating symptom control. Further research with larger cohorts of practices and patients is needed to develop a feasible, acceptable and effective programme if similar benefits are to be achieved for primary care in general.

Lamb pays lip service: two cases of ecthyma contagiosum (orf).

Ecthyma contagiosum (orf) is caused by a parapox virus, which results in ulcerative stomatitis of mainly sheep and goats. The disease may be transmitted to humans through direct contact. Complications are rare in healthy individuals, who rarely report the disease. Two married, recreational sheep farmers, were bitten on their index fingers by an affected lamb. While the husband made an uneventful recovery after oral flucloxacillin, his wife was admitted to hospital with necrosis of her finger, cellulitis and lymphangitis requiring intravenous clindamycin. She subsequently developed a generalized maculo-papular rash, which was initially thought to be an adverse drug reaction, but, on hindsight, may have been erythema multiforme associated with orf. Orf is a common zoonosis, rarely reported in general practice. The disease is usually self-limiting and resolves in 6-8 weeks, but complications may occur. The diagnosis should be considered in at-risk occupational and religious groups.

Verification of 'learning credits' by GP appraisers.

BACKGROUND: The RCGP CPD Learning Credits system aims to enable GPs to demonstrate knowledge and skills relevant to their daily practice. Credits are self-assessed and will form part of the 'evidence' necessary for successful revalidation. At an appraisal, GP appraisers verify the credits in terms of the time spent on the CPD activity and its impact on the GP's practice. The purpose of this study was to examine the extent to which GPs (as appraisees) are able to self-assess their own learning and, as appraisers, verify credits in a standardised way. METHOD: All 17 GP appraisers in NHS Lanarkshire were invited to participate in a study, which triangulated three sources of evidence on credits: self-rating, peer-assessment and workshop discussion. The resultant data were analysed on an Excel spreadsheet. Outcomes included self-assessed credit value, peer-assessed mean score (range) and free text. RESULTS: Of the 17 appraisers, 15 completed the paperwork and 13 attended the workshop. GPs' self-assessed learning credits were equivalent to peer-assessed score in 5/15 cases, but considered overestimates in 4/15 and underestimates in 6/15 cases. The most extreme variance was for an oncology module, where the variance ranged from 28% to 200% of the self-assessed score. CONCLUSIONS: GPs have a variable understanding of how to award themselves learning credits and of how to judge the credits of potential appraisees. Without adequate resources for appraisal training, validated instruments, calibration and reliability, verification of the learning credit system will be flawed by its subjective and arbitrary nature.

Practice nurse appraisal: evaluation report.

BACKGROUND: As general practice nurses (GPNs) now perform many activities formerly undertaken by general practitioners (GPs), the paperwork and process of the Scottish GP appraisal scheme may be usefully replicated for GPN appraisal. METHOD: Eight GPNs adapted paperwork. Ten GP appraisers in NHS Lanarkshire were invited to interview their GPN(s) using the adapted paperwork. Both groups evaluated the project from 'descriptive' (participation and process) and 'reflective' or qualitative perspectives. RESULTS: Eight GPs appraised 11 GPNs using a ten-page document. GPNs reported that the documentation was helpful in preparing for and participating in the interview, as well as the planning of future objectives and development. GPs reported that the appraisal interview incorporated GPNs' views, the content was relevant, and their approach nonjudgemental and developmental. Some expressed concern that their participation had not helped them identify ways of addressing GPN learning needs. There was clear indication from GPNs that trained colleagues rather than GP employers are preferred appraisers. Improvements in the paperwork would be required. DISCUSSION: There is potential to replicate the paperwork and processes used in GP appraisal to GPNs, subject to refinement of the paperwork and engagement of trained nurse colleagues in the process. This may reduce the effect of collusion, inhibition or conflict of interest. However, GPN personal development still must be reconciled with practice priorities and development. CONCLUSION: The results of this pilot indicate a positive response in terms of participation and process. Further research should examine GPN appraisal using an external nurse appraiser, training issues and resource implications.

The peer review pilot project: a potential system to support GP appraisal in NHS Scotland?

GP appraisal may, in future, have to include objective and verifiable elements. This condition could be achieved by developing peer review of core areas of clinical practice. The setting for the study was two regions of NHS Education for Scotland (NES) without existing peer review systems (Figure 1). The South East region was further divided into South and East areas. A triangulation methodology was adopted to reflect the perspectives of peer reviewers, GPs submitting materials and the GPs appraising them (Figure 2). Outcomes measures included peer reviewers' feedback, learning needs identified by peer review, feedback from contributors and appraisers' perception of making judgements within GP appraisal. 1 Peer reviewers were recruited, trained and allocated to provide feedback on significant event analysis (SEA), criterion audit or video consultation submitted by professional colleagues. 2 GP appraisers voluntarily submitted materials for peer review then commented on feedback provided by peer reviewers. 3 A focus group of appraisers examined issues relating to professional judgement and national standards within appraisal. 4 All 15 peer reviewers recruited considered the project successful. Peer reviewers thought the model piloted could be delivered nationally if adequately resourced and supported by GPs. 5 Twenty six items (14 SEAs, nine audits and three videos) were submitted for peer review, which demonstrated moderate or high levels of learning need among GP participants. 6 In the focus group, most appraisers expressed difficulty making 'professional judgements' within appraisal but demonstrated a clear willingness to accept peer-reviewed material as evidence for discussion and development. Appraisers identified a range of educational material with the potential to conform to a national standard. There is potential for peer review to contribute to the development of objective and verifiable elements in GP appraisal, encouraging GPs to achieve agreed educational standards independent of the appraisal process. This small study suggests that a national system of peer review to support GP appraisal may be desirable among relevant stakeholders and should be explored further. Additional resources would clearly be required. A comparative review of different systems in other countries suggests further research is necessary to provide greater evidence of feasibility, acceptability and educational benefit of such a system in the UK.