Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial.

BACKGROUND: Studies have shown the benign to malignant ratio of excised pigmented skin lesions is suboptimal in primary care. OBJECTIVES: To assess the impact of dermoscopy and short-term sequential digital dermoscopy imaging (SDDI) on the management of suspicious pigmented skin lesions by primary care physicians. METHODS: A total of 63 primary care physicians were trained in the use of dermoscopy and SDDI (interventions) and then recruited pigmented lesions requiring biopsy or referral in routine care by naked eye examination. They were then given a dermatoscope and the option of a SDDI instrument, and change of diagnosis and management was assessed. RESULTS: Following the use of the interventions on 374 lesions a total of 163 lesions (43.6%) were excised or referred, representing a reduction of 56.4%. Of the 323 lesions confirmed to be benign, 118 (36.5%) were excised or referred, leading to a reduction of 63.5% (P < 0.0005) in those requiring excision or referral. The baseline naked eye examination benign to melanoma ratio was 9.5 : 1 which decreased to 3.5 : 1 after the diagnostic interventions (P < 0.0005). Of the 42 malignant lesions included in the study (34 melanoma, six pigmented basal cell carcinoma and two Bowen disease) only one in situ melanoma was incorrectly managed (patient to return if changes occur) resulting in the correct management of 97.6% and 97.1% of malignant pigmented lesions and melanoma, respectively. CONCLUSIONS: In a primary care setting the combination of dermoscopy and short-term SDDI reduces the excision or referral of benign pigmented lesions by more than half while nearly doubling the sensitivity for the diagnosis of melanoma.

Patient and practitioner characteristics predict brief alcohol intervention in primary care.

BACKGROUND: The effectiveness of an evidence-based health care intervention depends on it being delivered consistently to appropriate patients. Brief alcohol intervention is known to be effective at reducing excessive drinking and its concomitant health and social problems. However, a recent implementation trial reported partial delivery of brief alcohol intervention by general practitioners (GPs) which is likely to have reduced its impact. AIM: To investigate patient-practitioner characteristics influencing brief alcohol intervention in primary care. DESIGN OF STUDY: Cross-sectional analysis of 12,814 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires. SETTING: Eighty-four GPs who had implemented a brief alcohol intervention programme in a previous trial based in the Northeast of England. METHOD: GPs were requested to screen all adults (aged over 16 years) presenting to their surgery and follow a structured protocol to give a brief intervention (five minutes of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of the screening questionnaire were collected from all practices after a three-month implementation period. RESULTS: Although AUDIT identified 4080 'risk' drinkers, only 2043 (50%) received brief intervention. Risk drinkers that were most likely to receive brief intervention were males (58%), unemployed (61%), and technically-trained patients (55%). Risk drinkers that were least likely to receive brief intervention were females (44%), students (38%), and university educated patients (46%). Logistic regression modelling showed that patients' risk status was the most influential predictor of brief intervention. Also, GPs' experience of relevant training and longer average practice consultations predicted brief intervention. However, personal characteristics relating to patients and GPs also predicted brief intervention in routine practice. CONCLUSION: Interpersonal factors relating to patients and practitioners contributed to the selective provision of brief alcohol intervention in primary care. Ways should be found to remedy this situation or the impact of this evidence-based intervention may be reduced when implemented in routine practice.

General practice reform in the United Kingdom: moving into the new millennium.

Radical reform of general practice is under way in the United Kingdom, driven by a National Health Service "modernisation" agenda and the promise of additional resources from the Blair Government. Australian GPs can not afford to ignore these changes and should ensure that through their representative bodies they influence any similar changes in Australia.

Alcohol education for general practitioners in the United Kingdom - a window of opportunity?

Alcohol misuse is a major public health problem. In the UK, general practitioners are perceived as key players in prevention and management of alcohol problems, but may not be prepared sufficiently to undertake this work. A systematic review of the literature by computerized search of the Medline database, hand search of review article citations and a survey of relevant educational and training organizations and agencies were undertaken. Although there is no shortage of educational materials, there has been little evaluation of their effectiveness. A need for more training and support has been identified, but this requires better co-ordination and a more multidisciplinary approach. Forthcoming changes in the National Health Service and the organization of continuing professional development offer a unique opportunity to advance this agenda.

Changes in receptionists' attitudes towards involvement in a general practice-based trial of screening and brief alcohol intervention.

BACKGROUND: Primary health care receptionists are increasingly expected to be involved in research. However, little is known about receptionists' attitudes to research or health programmes. AIM: To examine changes in receptionists' attitudes, with different levels of training and support, towards involvement in a general practice-based trial of screening and brief alcohol intervention. METHOD: Subjects were 84 receptionists, one per practice, who assisted in the implementation of a screening and brief alcohol intervention programme. Receptionists were randomly assigned to one of three conditions: control (no training or support), training alone, and training plus ongoing telephone support. Baseline and follow-up questionnaires were used to assess changes in receptionists' attitudes. RESULTS: Of 40 items that measured receptionists' attitudes to involvement in the programme, 70% had deteriorated after three months, 20% significantly so. There was no effect of training and support condition. Receptionists' and GPs' attitudes to research and health programmes conflicted. CONCLUSION: Receptionists developed more negative views about involvement in research and health programmes over the three-month study period, regardless of level of training and support.

Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners.

General practitioners' (GPs') recognition of, attitudes towards, and intervention for, excessive drinking and alcohol problems among their patients were assessed in a postal questionnaire survey. Levels of recognition of, and intervention for, excessive drinking by GPs were low. GPs did not routinely enquire about alcohol and had managed only small numbers of patients specifically for excessive drinking or alcohol problems in the previous year. Enquiry about alcohol issues was elicited mainly by physical symptoms or by new patient registrations. Although 83% of GPs felt prepared to counsel excessive drinkers, only 21% felt effective in helping patients reduce consumption. Over the past 10 years, there appears to have been an increase in numbers of GPs who feel that they should be working with alcohol issues, but fewer GPs perceive themselves as being effective in this work. The main barriers to brief alcohol intervention were given as insufficient time and training, and lack of help from government policy; the main incentives related to availability of appropriate support services and proven efficacy of brief interventions.

Our Healthier Nation: are general practitioners willing and able to deliver? A survey of attitudes to and involvement in health promotion and lifestyle counselling.

BACKGROUND: The recent Green Paper, Our Healthier Nation, identifies professional advice on healthier living as a key component of its national contract for health. General practitioners (GPs) are ideally placed for this work. However, previous research has reported a discrepancy between patients' expectations of lifestyle advice from GPs and their receipt of such advice. AIMS: To describe GPs' current attitudes to and involvement in health promotion and lifestyle counselling, and to track changes in these areas over recent years. METHOD: A postal questionnaire survey of a random sample of 430 GPs, one per practice, from all general practices in Leicestershire, Derbyshire, and Nottinghamshire. GPs who had not responded after two weeks received a reminder telephone call plus two follow-up questionnaires. RESULTS: Four hundred and eleven GPs were eligible for the survey, which yielded a response rate of 68% (n = 279). GPs reported spending an average 16% of practice time on prevention and 79% reported educating patients about lifestyle risk 'most' or 'all of the time'. Solo GPs spent more time on prevention than GPs from group practices. Most enquiries and interventions related to smoking behaviour. GPs felt most effective in changing patients' use of prescription drugs, and the largest reported difference between current and potential effectiveness in helping patient change lifestyle behaviour, after information and training, related to reducing alcohol consumption. CONCLUSIONS: Despite an increasing workload, GPs remain positive about health promotion and lifestyle counselling. Over the past 10 years, there has been an increase in routine enquiries about lifestyle behaviour, but confidence about effectiveness in helping patients changes lifestyle behaviour remains low. More training and support concerning lifestyle intervention is required by GPs in order for them to contribute effectively to the Government's health promotion programme.

Practice nurses in the Waikato, 1991-1992, I: Occupational profile.

AIMS: To describe the personal characteristics, working conditions, clinical activities and professional development of a representative sample of practice nurses in the Waikato during the period 1991-1992. METHODS: The data are from a survey of practice nurses drawn from a larger study of general practice carried out in the Waikato (the WaiMedCa Study). Eighty-nine percent of the 107 practices in the region participated in the study. The practice nurse survey was carried out on the 189 nurses working in these practices. Of these 149 replied, representing a response rate of 79%. RESULTS: On average, there was one nurse for each solo practice and two in most other practices. Only two practices--both solo--did not employ a nurse. Practice nurses were female and aged between 30 and 50. While only one-third had received a postgraduate qualification, two-thirds had been to recent professional development courses. The majority had worked as a practice nurse for between one and ten years. Nurses averaged just under 15 telephone contacts a day and 28 face-to-face contacts a week. Nurses' workload comprised general measurements and assessments, monitoring and surveillance procedures (such as diabetes, asthma and child development), and counselling and women's health activities. CONCLUSION: Practice nurses are an accepted and essential part of primary health care in New Zealand. However, their potential is probably underdeveloped and they could be more fully utilised for a wider range of nursing functions.

A randomized trial of three marketing strategies to disseminate a screening and brief alcohol intervention programme to general practitioners.

BACKGROUND: Research findings are of little benefit to patients or society if they do not reach the audience they are intended to influence. A dissemination strategy is needed to target new findings at its user group and encourage a process of consideration and adoption or rejection. AIM: To evaluate the effectiveness and cost-effectiveness of different marketing strategies for the dissemination of a screening and brief alcohol intervention (SBI) programme to general practitioners (GPs). METHOD: Seven hundred and twenty-nine GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority were randomly assigned to one of three marketing strategies: postal marketing (mailing a promotional brochure to GPs), telemarketing (following a script to market the programme over the telephone), and personal marketing (following the same script during face-to-face marketing at GPs' practices). GPs who took up the programme were asked if they would agree to use it. Outcome measures included the proportions of GPs who took up the programme and agreement to use it. RESULTS: Of the 614 GPs eligible for the study, 321 (52%) took the programme. There was a significant difference in the proportions of GPs from the three marketing strategies who took the programme (82% telemarketing, 68% personal marketing, and 22% postal marketing). Of the 315 GPs who took the programme and were eligible to use it, 128 (41%) agreed to use the programme for three months. GPs in the postal marketing group were more likely to agree to use the programme (55% postal marketing, 44% personal marketing, and 34% telemarketing). Personal marketing was the most effective overall dissemination strategy; however, economic analysis revealed that telemarketing was the most cost-effective strategy. Costs for dissemination per GP were: 13 Pounds telemarketing, 15 Pounds postal marketing, and 88 Pounds personal marketing. CONCLUSION: Telemarketing appeared to be the most cost-effective strategy for dissemination of SBI to GPs.

A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners.

BACKGROUND: Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice. An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines. AIM: To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention (SBI) by general practitioners (GPs). METHOD: Subjects were 128 GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority, who agreed to use the 'Drink-Less' SBI programme in an earlier dissemination trial. GPs were stratified by previous marketing conditions and randomly allocated to three intensities of training and support: controls (n = 43) received the programme with written guidelines only, trained GPs (n = 43) received the programme plus practice-based training in programme usage, trained and supported GPs (n = 42) received the programme plus practice-based training and a support telephone call every two weeks. GPs were requested to use the programme for three months. Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with. RESULTS: Seventy-three (57%) GPs implemented the programme and screened 11,007 patients for risk drinking. Trained and supported GPs were significantly more likely to implement the programme (71%) than controls (44%) or trained GPs (56%); they also screened, and intervened with, significantly more patients. Costs per patient screened were: trained and supported GPs, 1.05 Pounds; trained GPs, 1.08 Pounds; and controls, 1.47 Pounds. Costs per patient intervened with were: trained and supported GPs, 5.43 Pounds; trained GPs, 6.02 Pounds; and controls, 8.19 Pounds. CONCLUSION: Practice-based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs.

'So much post, so busy with practice--so, no time!': a telephone survey of general practitioners' reasons for not participating in postal questionnaire surveys.

BACKGROUND: Response rates by general practitioners (GPs) to postal surveys have consistently fallen, compromising the validity of this type of research. If postal survey work is to continue we need to understand GPs' reasons for not participating and respond appropriately. AIM: To investigate GPs' reasons for not responding to postal surveys. METHOD: A qualitative study was carried out to determine GPs reasons for not participating in postal surveys, which were drawn from a telephone survey of 276 non-responders to a postal questionnaire survey. Practitioners' comments were recorded and reasons for their non-response quantified using content analysis. RESULTS: Primary reasons for GPs not replying to the postal survey were that questionnaires had got lost in paperwork (34%), that GPs were too busy for the extra work involved (21%), and that questionnaires were routinely 'binned' (16%). Higher practice workloads, including increased administration, meant that participation in research had become a low priority. GPs provided some suggestions for researchers that would increase their chances of questionnaires being returned. CONCLUSIONS: Researchers need to be aware of the pressures of service general practice and to rationalize the amount of research material sent to GPs. GPs were most likely to respond to postal surveys that had a high interest factor, that involved localized research relevant to general practice, and that incorporated a personalized approach by researchers, including good-quality explanatory information.

Training general practitioners.

Nationally there is no standardized system for the education and training of general practitioners (GPs) within the UK in relation to prevention, early detection and management of alcohol problems. A number of surveys over the past 20 years have confirmed GPs' role legitimacy concerning working with excessive drinkers, but identified a lack of role adequacy and role support for this work. However, there are considerable constraints present in current UK general practice which limit opportunities for education and training of GPs. A possible way ahead may be to encourage general practitioners to utilize a screening and early intervention programme, coupled with ongoing support and imaginative use of other primary health care workers, community workers and the secondary services.

General practice postal surveys: a questionnaire too far?

A primary care led NHS, driven by evidence based practice, needs to build on a firm foundation of research in primary care. As researchers are making increasing use of questionnaire surveys to assess general practitioners' views and attitudes, so response rates to questionnaire surveys among general practitioners are dropping. The reasons include lack of perceived relevance of the research and lack of information and feedback about it, and researchers need to be more aware of the realities of everyday practice. Approaches that might reverse this trend include monitoring all research activities going on in an area to ensure that practices are not overused, giving general practitioners incentives to participate, and improving the relevance of research and the quality of questionnaires.

Geographical variations in the organisation of general practice.

AIMS: To describe organisational characteristics of New Zealand general practice and to investigate inter-regional variations in these characteristics. METHODS: Data were collected by standardised questionnaires from general practitioners in Auckland, Waikato and Taranaki. The Waikato data were collected in July-August 1991 by postal survey, the Taranaki data were collected May-June 1992 by postal survey and the Auckland data were collected December 1990 to January 1991 by face-to-face interview. RESULTS: The response rates were Auckland 98% (167/171), Waikato 84% (185/220) and Taranaki 79% (79/100). There were significantly more overseas trained graduates in rural areas than in urban areas. Average practice size was 2.3 full time equivalent doctors, with each 100 doctors employing 71 nurses and 77 receptionists. The number of patients seen per week ranged from 109-141. Almost all (95%) general practitioners operated appointment systems. One in five general practitioners had patients in private hospitals, and more than half (58%) had patients in rest homes. At the time of interview, 29% of Auckland general practitioners used computers in their practices compared with over 50% in Waikato and Taranaki (p < 0.05). A smaller proportion of Auckland general practitioners had access to age/sex registers and fewer Auckland general practitioners had a recall system. Of Auckland general practitioners with recall systems, a greater proportion used them for mammograms, blood pressure and lipid measurements compared with elsewhere. CONCLUSIONS: There are some significant regional variations in the functional characteristics of general practice in New Zealand which should be taken into account when planning primary care services in different regions. Should budget holding and managed care be introduced, computerised practices will be required. This will have significant resource implications.

Adolescent health--a descriptive study of a school doctor clinic.

AIM: To describe a school doctor clinic at a New Zealand secondary school. METHODS: A three phase study was designed and conducted at a coeducational secondary school in Auckland. Firstly, a health questionnaire was developed to assess adolescents' perceptions of their health status and use of primary health care services. The second phase was descriptive study of a newly established school doctor clinic. The doctor clinic was run twice weekly over a 3 month period in 1993. The third phase of the study was a clinic-based satisfaction survey. RESULTS: A 75% response rate was achieved, with a total of 221 health questionnaires completed from 292. Although the majority of students (n = 184, 84%) considered themselves healthy, 16% (n = 36) described their health as only 'fair' or 'poor'. Seventy one percent (n = 157) of students had seen their general practitioner in the preceeding twelve months. Thirteen percent (n = 142) of the school population consulted the school doctor clinic. Significantly more female, Maori and European students attended the school doctor clinic compared with the school demography. The commonest diagnoses for the doctor clinic were respiratory, skin and musculoskeletal problems. Thirty one percent of the diagnoses related to recognised adolescent health needs such as contraception, sexual health, nutrition, and psychosocial problems. Over two thirds of students at the first consultation had not seen another health provider. Students perceived that the doctor clinic overcame barriers such as access, cost and confidentiality. CONCLUSION: The school doctor clinic was well utilised, overcame some barriers to access and addressed many recognised adolescent health needs.