Cluster randomized trial of a multifaceted primary care decision-support intervention for inherited breast cancer risk.

BACKGROUND: GPs are increasingly expected to meet the needs of patients concerned about their risk of inherited breast cancer, but may lack skills or confidence to use complex management guidelines. We developed an evidence-based, multifaceted intervention intended to promote confidence and skills in this area. OBJECTIVE: To evaluate the effectiveness of the intervention in improving GP confidence in managing patients concerned about genetic risk of breast cancer. DESIGN: Cluster randomized controlled trial. SETTING: General practices in the Grampian region of Scotland. SUBJECTS: GPs and the patients they referred for genetic counselling for risk of breast cancer. MAIN OUTCOME MEASURES: GPs' self-reported confidence in four activities related to genetics; rates of referral of patients at elevated genetic risk; and referred patients' understanding of cancer risk factors. RESULTS: No statistically significant differences were observed between intervention and control arms in the primary or secondary outcomes. A possible effect of the intervention on the proportion of referred patients who were at elevated risk could not be discounted. Only a small proportion of intervention GPs attended the educational session, were aware or the software, or made use of it in practice. CONCLUSIONS: No convincing evidence of the effectiveness of the intervention was found, probably reflecting barriers to its use in routine practice.

Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study.

OBJECTIVE: To examine the association between hypertensive diseases of pregnancy (gestational hypertension and pre-eclampsia) and the development of circulatory diseases in later life. DESIGN: Cohort study of women who had pre-eclampsia during their first singleton pregnancy. Two comparison groups were matched for age and year of delivery, one with gestational hypertension and one with no history of raised blood pressure. SETTING: Maternity services in the Grampian region of Scotland. PARTICIPANTS: Women selected from the Aberdeen maternity and neonatal databank who were resident in Aberdeen and who delivered a first, live singleton from 1951 to 1970. MAIN OUTCOME MEASURES: Current vital and cardiovascular health status ascertained through postal questionnaire survey, clinical examination, linkage to hospital discharge, and mortality data. RESULTS: There were significant positive associations between pre-eclampsia/eclampsia or gestational hypertension and later hypertension in all measures. The adjusted relative risks varied from 1.13-3.72 for gestational hypertension and 1.40-3.98 for pre-eclampsia or eclampsia. The adjusted incident rate ratio for death from stroke for the pre-eclampsia/eclampsia group was 3.59 (95% confidence interval 1.04 to 12.4). CONCLUSIONS: Hypertensive diseases of pregnancy seem to be associated in later life with diseases related to hypertension. If greater awareness of this association leads to earlier diagnosis and improved management, there may be scope for reducing a proportion of the morbidity and mortality from such diseases.

Eliciting preferences of the community for out of hours care provided by general practitioners: a stated preference discrete choice experiment.

Access to primary care services is a major issue as new models of delivering primary care continue develop in many countries. Major changes to out of hours care provided by general practitioners (GPs) were made in the UK in 1995. These were designed in response to low morale and job dissatisfaction of GPs, rather than in response to patients' preferences. The aim of this study is to elicit the preferences of patients and the community for different models of GP out of hours care. A questionnaire was sent to parents of children in Aberdeen and Glasgow in Scotland who had received a home visit or attended a primary care emergency centre, or were registered with a GP. The questionnaire used a discrete choice experiment that asked parents to imagine their child had respiratory symptoms. Parents were then asked to choose between a series of pairs of scenarios, with each scenario describing a different model of out of hours care. Each model varied by waiting time, who was seen, location, and whether the doctor listened. The response rate was 68% (3,893/5,718). The most important attribute was whether the doctor seemed to listen, suggesting that policies aimed at improving doctor-patient communication will lead to the largest improvements in utility. The most preferred location of care was a hospital accident and emergency department. This suggests that new models of primary care emergency centres may not reduce the demand for accident and emergency visits from this group of patients in urban areas. Preferences also differed across sub-groups of patients. Those who had never used out of hours care before had stronger preferences for waiting time and the doctor listening, suggesting higher expectations of non-users. Further research is required into the demand for out of hours care as new models of care become established.