NHS health checks: a cross- sectional observational study on equity of uptake and outcomes.

BACKGROUND: The National Health Checks programme aims to reduce the incidence of cardiovascular diseases and health inequalities in England. We assessed equity of uptake and outcomes from NHS Health Checks in general practices in Bristol, UK. METHODS: A cross-sectional study using patient-level data, from 38 general practices. We descriptively analysed the socioeconomic status (SES) of patients invited and the SES and ethnicity of those attending. Logistic regression was used to test associations between invitation and attendance, with population characteristics. RESULTS: Between June 2010 to October 2014, 31,881 patients were invited, and 13,733 NHS Health Checks completed. 47% of patients invited from the three least and 39% from the two most-deprived index of multiple deprivation quintiles, completed a Check. Proportions of invited patients, by ethnicity were 64% non-black and Asian and 31% black and Asian. Men were less likely to attend than women (OR 0.73, 95% confidence interval 0.67 to 0.80), as were patients ≤ 49 compared to ≥ 70 years (OR 0.40, 95% confidence interval 0.65 to 0.83). After controlling for SES and population characteristics, compared to patients with low CVD risk, high risk patients were more likely to be prescribed cardiovascular drugs (OR 6.2, 95% confidence interval 4.51 to 8.40). Compared to men, women (OR 01.18, 95% confidence interval 1.03 to 1.35) were more likely to be prescribed cardiovascular drugs, as were those ≤ 49 years (50-59 years, OR 1.42, 95% confidence intervals 1.13-1.79, 60-69 years, OR 1.60, 95% confidence intervals, 1.22-2.10, ≥ 70 years, OR 1.64, 95% confidence intervals, 1.14 to 2.35). Controlling for population characteristics, the following groups were most likely to be referred to lifestyle services: younger women (OR 2.22, 95% CI 1.69 to 2.94), those in the most deprived IMD quintile (OR 3.22, 95% CI 1.63 to 6.36) and those at highest risk of CVD (OR, 2.77, 95% CI 1.91 to 4.02). CONCLUSIONS: We found no statistically significant evidence of inequity in attendance for an NHS Health Check by SES. Being older or a woman were associated with better attendance. Targeting men, younger patients and ethnic minority groups may improve equity in uptake for NHS Health Checks.

Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study.

BACKGROUND: NHS Health Checks are a national cardiovascular risk assessment and management programme in England and Wales. We examined the experiences of patients attending and healthcare professionals (HCPs) conducting NHS Health Checks. METHODS: Interviews were conducted with a purposive sample of 28 patients and 16 HCPs recruited from eight general practices across a range of socio-economic localities. Interviews were audio recorded, transcribed, anonymized and analysed thematically. RESULTS: Patients were motivated to attend an NHS Health Check because of health beliefs, the perceived value of the programme, a family history of cardiovascular and other diseases and expectations of receiving a general health assessment. Some patients reported benefits including reassurance and reinforcement of healthy lifestyles. Others experienced confusion and frustration about how results and advice were communicated, some having a poor understanding of the implications of their results. HCPs raised concerns about the skill set of some staff to competently communicate risk and lifestyle information. CONCLUSIONS: To improve the satisfaction of patients attending and improve facilitation of lifestyle change, HCPs conducting the NHS Health Checks require sufficient training to equip them with appropriate skills and knowledge to deliver the service effectively.

Prevalence of experiences of domestic violence among psychiatric patients: systematic review.

BACKGROUND: Domestic violence has been linked with many mental disorders, including anxiety, depression, post-traumatic stress disorder, eating disorders and psychosis. AIMS: To estimate the prevalence (adult lifetime and past year) of different types of domestic violence experienced by men and women receiving psychiatric treatment. METHOD: In a systematic review, a search of 18 electronic databases was supplemented by hand searching, citation tracking and updating a recent systematic review of criminal victimisation in psychiatric populations. Two reviewers independently extracted data and appraised study quality. RESULTS: Forty-two studies were included. The median prevalence of lifetime partner violence reported in high-quality papers was 30% (interquartile range (IQR) 26-39) among female in-patients and 33% (IQR 21-53) among female out-patients. Among male patients, one high-quality study reported a lifetime prevalence of 32% across mixed psychiatric settings. No study included a control group. CONCLUSIONS: Psychiatric patients experience a high prevalence of domestic violence but there is limited information on family (non-partner) domestic violence, the prevalence of emotional abuse and the extent of risk compared with non-psychiatric controls.

Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study.

OBJECTIVE: To investigate the long-term impact of antenatal domestic violence on maternal psychiatric morbidity and child behaviour. DESIGN: Cohort study. SETTING: Avon, UK. POPULATION OR SAMPLE: A birth cohort of 13,617 children and mother dyads were followed to 42 months of age. METHODS: Experiences of domestic violence and depressive symptoms were gathered at 18 weeks of gestation and up to 33 months after birth, together with maternal, paternal and child characteristics. MAIN OUTCOME MEASURES: Child behavioural problems were assessed at 42 months using the Revised Rutter Questionnaire. ANALYSIS: Logistic regression with the use of multiple imputation employing chained equations for missing data. RESULTS: Antenatal domestic violence was associated with high levels of maternal antenatal (odds ratio [OR], 4.02; 95% confidence interval [CI], 3.4-4.8) and postnatal (OR, 1.29; 95% CI, 1.02-1.63) depressive symptoms after adjustment for potential confounders. Antenatal domestic violence predicted future behavioural problems at 42 months in the child before adjustment for possible confounding and mediating factors (OR, 1.87; 95% CI, 1.45-2.40); this association was not significant after adjustment for high levels of maternal antenatal depressive symptoms, postnatal depressive symptoms or domestic violence since birth. CONCLUSIONS: Antenatal domestic violence is associated with high levels of both maternal antenatal and postnatal depressive symptoms. It is also associated with postnatal violence, and both are associated with future behavioural problems in the child at 42 months. This is partly mediated by maternal depressive symptoms in the ante- or postnatal period.

Validation of the State Version Questionnaire on Autonomic Regulation (State-aR) for cancer patients.

OBJECTIVES: Current quality of life inventories used in oncology mainly measure the effects of chemo- or radiotherapy alongside functional and role scales. A new approach is to measure the autonomic state of regulation with the trait-inventory of autonomic regulation (Trait-aR). Loss of Trait-aR has been shown in different medical conditions such as breast cancer (BC) but not in colorectal cancer patients (CRC). In this paper we report the validation of a new state autonomic regulation scale (State-aR) of the last week. METHODS: Study 1 included 114 participants: (41 women/16 men with cancer and 57 age- and gender-matched healthy people) to conduct a reliability-, factor- and validity-analysis. Concurrent and convergent validity was evaluated with Trait-aR, Fatigue-Numerical-Scale, Hospital Anxiety and Depression Scale (HADS-D) and the self-regulation scale, 65 participants were retested. Study 2 completed 42 participants: 17 with BC and 25 with CRC receiving chemotherapy. The State-aR was administered prior, during and after chemotherapy for measuring responsiveness. RESULTS: The factor analysis loaded to four subscales of State-aR (rest-activity, orthostatic-circulatory, thermo-sweating and digestive regulation) with a: Cronbach-α r(α) = 0.77?0.83 and a test-retest-reliability r(rt) = 0.60?0.80. The sum- and subscales correlated with their concurrent subscales in the Trait-aR (0.48?0.74) and with the sum-scale moderately with all convergent criteria (r = 0.41?-0.44; p <0.001). During chemotherapy the State-aR-sum and rest-activity-scale decreased significantly compared to the change in the Trait-aR (p <0.05). CONCLUSIONS: These findings support that the state autonomic regulation scale has satisfactory to good reliability, good validity and acceptable responsiveness in the context of chemotherapy treatment.

Domestic violence and severe psychiatric disorders: prevalence and interventions.

BACKGROUND: The lifetime prevalence of domestic violence in women is 20-25%. There is increasing recognition of the increased vulnerability of psychiatric populations to domestic violence. We therefore aimed to review studies on the prevalence of, and the evidence for the effectiveness of interventions in, psychiatric patients experiencing domestic violence. METHOD: Literature search using Medline, PsycINFO and EMBASE applying the following inclusion criteria: English-language papers, data provided on the prevalence of or interventions for domestic violence, adults in contact with mental health services. RESULTS: Reported lifetime prevalence of severe domestic violence among psychiatric in-patients ranged from 30% to 60%. Lower rates are reported for men when prevalence is reported by gender. No controlled studies were identified. Low rates of detection of domestic violence occur in routine clinical practice and there is some evidence that, when routine enquiry is introduced into services, detection rates improve, but identification of domestic violence is rarely used in treatment planning. There is a lack of evidence on the effectiveness of routine enquiry in terms of morbidity and mortality, and there have been no studies investigating specific domestic violence interventions for psychiatric patients. CONCLUSIONS: There is a high prevalence of domestic violence in psychiatric populations but the extent of the increased risk in psychiatric patients compared with other populations is not clear because of the limitations of the methodology used in the studies identified. There is also very limited evidence on how to address domestic violence with respect to the identification and provision of evidence-based interventions in mental health services.

A cluster-randomised controlled trial of a brief training session to facilitate general practitioner referral to smoking cessation treatment.

OBJECTIVES: General practitioners (GPs) are the main source of referrals to specialist smoking cessation services (SSCS), but the referral rates are low. We evaluated effects of a brief GP training session on the number of referrals received by their local SSCS. METHODS: A cluster-randomised controlled trial was undertaken across three East London primary care trusts. A total of 91 GPs were randomly allocated to a training session or usual care. Participants in the intervention arm were offered a 40-min training session addressing the rationale and skills for referral of smokers for treatment. Participants in the usual care arm received referral guidance by post. The main outcome measure was the number of referrals recorded by the SSCS over 3 months after the intervention. RESULTS: Over the 3-month baseline period the average number of referrals per GP was 1.0 and 0.6 in the intervention and usual care arms, respectively. During the post-intervention period the mean number of referrals was 6.4 and 1.8 per GP. When adjusting for baseline variables the incidence rate ratio for the referrals from the intervention arm compared to usual care was 4.9 (p<0.001; 95% CI 1.7 to 14.7). CONCLUSION: A brief training session can significantly increase GP referral to smoking cessation services. TRIAL REGISTRATION: National Research Register, Department of Health, UK N0261148824 (available online at: http://www.nrr.nhs.uk/ViewDocument.asp?ID = N0261148824).

Validation of a questionnaire measuring the regulation of autonomic function.

BACKGROUND: To broaden the range of outcomes that we can measure for patients undergoing treatment for oncological and other chronic conditions, we aimed to validate a questionnaire measuring self-reported autonomic regulation (aR), i.e. to characterise a subject's autonomic functioning by questions on sleeping and waking, vertigo, morningness-eveningness, thermoregulation, perspiration, bowel movements and digestion. METHODS: We administered the questionnaire to 440 participants (female symbol: N = 316, male symbol: N = 124): 95 patients with breast cancer, 49 with colorectal cancer, 60 with diabetes mellitus, 39 with coronary heart disease, 28 with rheumatological conditions, 32 with Hashimoto's disease, 22 with multiple morbidities and 115 healthy people. We administered the questionnaire a second time to 50.2% of the participants. External convergence criteria included the German version of the Hospital Anxiety and Depression Scale (HADS-D), a short questionnaire on morningness-eveningness, the Herdecke Quality of Life Questionnaire (HLQ) and a short version questionnaire on self-regulation. RESULTS: A principal component analysis yielded a three dimensional 18-item inventory of aR. The subscales orthostatic-circulatory, rest/activity and digestive regulation had internal consistency (Cronbach-alpha: ralpha = 0.65 - 0.75) and test-retest reliability (rrt = 0.70 - 85). AR was negatively associated with anxiety, depression, and dysmenorrhoea but positively correlated to HLQ, self-regulation and in part to morningness (except digestive aR) (0.49 - 0.13, all p < 0.05). CONCLUSION: An internal validation of the long-version scale of aR yielded consistent relationships with health versus illness, quality of life and personality. Further studies are required to clarify the issues of external validity, clinical and physiological relevance.

Occurrence and impact of domestic violence and abuse in gay and bisexual men: A cross sectional survey.

This cross-sectional survey measured adult experience and perpetration of negative and potentially abusive behaviours with partners and its associations with mental and sexual health problems, drug and alcohol abuse in gay and bisexual men attending a UK sexual health service. Of 532 men, 33.9% (95% CI: 29.4-37.9) experienced and 16.3% (95% CI: 13.0-19.8) reported carrying out negative behaviour. Ever being frightened of a partner (aOR 2.5; 95% CI: 2.0-3.1) and having to ask a partner's permission (aOR 2.7; 95% CI: 1.6-4.7) were associated with increased odds of being anxious. There were increased odds of cannabis use in the last 12 months amongst men who reported ever being physically hurt (aOR 2.4; 95% CI: 1.7-3.6). Being frightened (aOR 2.2; 95% CI: 1.5-3.2), being physically hurt (aOR 2.3; 95% CI: 1.4-3.8), being forced to have sex (aOR 2.5; 95% CI: 1.3-4.9) and experiencing negative behaviour in the last 12 months (aOR 1.7; 95% CI: 1.2-2.5) were associated with increased odds of using a Class A drugs in the last 12 months. Sexual health practitioners should be trained with regards to the risk indicators associated with domestic violence and abuse, how to ask about domestic violence and abuse and refer to support.

Rapid-access chest pain clinics and the traditional cardiology out-patient clinic.

BACKGROUND: The National Service Framework for coronary heart disease recommends rapid-access chest pain clinics (RACPCs) for cardiological assessment of new-onset chest pain within 2 weeks of referral. AIM: To measure the extent to which an RACPC successfully substituted for an out-patient cardiology clinic (OPCC) at a general hospital, in assessing new-onset chest pain referrals. METHODS: Prospective measurement of attendance and waiting times for consecutive patients at the RACPC and OPCC, and multivariate analysis of factors associated with referral for angiography. RESULTS: From September 2002 to August 2004, 1382 patients with chest pain attended the RACPC, and 228 patients, the OPCC. All RACPC patients were seen within 24 h of referral, except those referred on Friday afternoons, or the day before national holidays. The mean +/- SD waiting time for OPCC appointments was 97 +/- 43 days. Of 208 OPCC patients, 30 (14%) fulfilled the RACPC referral criterion of recent onset chest pain (<4 weeks duration) vs. 926/1382 (67%) RACPC patients. Thus the RACPC substituted for the OPCC in 926/956 (97%) new chest pain referrals. Patients from the OPCC were 3.82 (95%CI 1.85-7.90) more likely to be referred for a coronary angiogram. compared to those attending the RACPC. DISCUSSION: The RACPC has provided efficient and effective substitution for the OPCC in the assessment of new chest pain referrals according to pre-defined referral criteria. Broadening the referral criterion of the RACPC to patients with chest pain of >4 weeks duration would result in more referrals.

Occurrence and impact of negative behaviour, including domestic violence and abuse, in men attending UK primary care health clinics: a cross-sectional survey.

OBJECTIVE: To measure the experience and perpetration of negative behaviour, including domestic violence and abuse (DVA), and investigate its associations with health conditions and behaviours in men attending general practice. DESIGN: Cross-sectional questionnaire-based study conducted between September 2010 and June 2011. SETTING: 16 general practices in the south west of England. PARTICIPANTS: Male patients aged 18 or older, attending alone, who could read and write English. A total of 1403 of eligible patients (58%) participated in the survey and 1368 (56%) completed the questions relevant to this paper. 97% of respondents reported they were heterosexual. MAIN OUTCOME MEASURES: Lifetime occurrence of negative behaviour consistent with DVA, perceived health impact of negative behaviours, associations with anxiety and depression symptoms, and cannabis use in the past 12 months and binge drinking. RESULTS: 22.7% (95% CI 20.2% to 24.9%) of men reported ever experiencing negative behaviour (feeling frightened, physically hurt, forced sex, ask permission) from a partner. All negative behaviours were associated with a twofold to threefold increased odds of anxiety and depression symptoms in men experiencing or perpetrating negative behaviours or both. 34.9% (95% CI 28.7% to 41.7%) of men who reported experiencing negative behaviour from a partner, and 30.8% (95% CI 23.7% to 37.8%) of men who perpetrated negative behaviours said they had been in a domestically violent or abusive relationship. No associations with problematic drinking were found; there was a weak association with cannabis use. CONCLUSIONS: DVA is experienced or perpetrated by a large minority of men presenting to general practice, and these men were more likely to have current symptoms of depression and anxiety. Presentation of anxiety or depression to clinicians may be an indicator of male experience or perpetration of DVA victimisation.

The etiology of Balkan endemic nephropathy: still more questions than answers.

Balkan endemic nephropathy (BEN) has attracted increasing attention as a possible environmental disease, and a significant amount of research from complementary scientific fields has been dedicated to its etiology. There are two actual competing theories attempting to explain the cause of this kidney disease: 1) the mycotoxin hypothesis, which considers that BEN is produced by ochratoxin A ingested intermittently in small amounts by the individuals in the endemic regions, and 2) the Pliocene lignite hypothesis, which proposes that the disease is caused by long-term exposure to polycyclic aromatic hydrocarbons and other toxic organic compounds leaching into the well drinking water from low rank coals underlying or proximal to the endemic settlements. We outline the current developments and future prospects in the study of BEN and differentiate possible factors and cofactors in disease etiology.

Relationship between weathered coal deposits and the etiology of Balkan endemic nephropathy.

Field studies in epidemiology and environmental geochemistry in areas in Yugoslavia containing villages with a high incidence of Balkan endemic nephropathy (BEN), indicate a possible relationship between the presence of low-rank coal deposits and the etiology of BEN. Preliminary results from qualitative chemical analyses of drinking water from shallow farm wells indicate the presence of soluble polar aromatic and polynuclear aromatic hydrocarbons. These compounds may be derived from weathering of low-rank coals occurring in the vicinity of the endemic villages. All of the endemic villages are in alluvial valleys of tributaries to the Danube River. All except one of the clusters of endemic villages are located in the vicinity of known Pliocene age coals. Detailed sampling of the drinking waters and the nearby coals are being undertaken to identify a possible etiologic factor.

Feasibility of spirometry and reversibility testing for the identification of patients with chronic obstructive pulmonary disease on asthma registers in general practice.

There is renewed interest in the diagnosis of chronic obstructive pulmonary disease (COPD) within primary care. Primary care physicians have difficulty distinguishing asthma from COPD. We tested the feasibility of using spirometry and if appropriate, reversibility testing, to identify patients with COPD on asthma registers in primary care. We carried out a cross-sectional study in three inner-city group practices in east London. Three hundred and twenty-eight patients aged 50 years and over on practice asthma registers were invited to attend for spirometry and, if appropriate, a trial of oral corticosteroids. The main outcome measures were: feasibility of carrying out spirometry; lung function; severity of COPD; prior diagnosis of COPD; response to a corticosteroid trial; quality of life. One hundred and sixty-eight of 328 (51%) patients attended for spirometry. According to British Thoracic Society criteria, 58 (34%) patients had normal spirometry at the time of assessment; 40 (24%) had active asthma and 57 (34%) had COPD. Thirteen patients (8%) were unable to perform spirometry. Of 57 patients with COPD 30 (53%) had mild, 15 (26%) had moderate and 12 (21%) had severe disease. Twenty-three of 57 (40%) patients with COPD on spirometry had this diagnosis recorded prior to the study. New diagnoses of COPD were more likely in those with mild or moderate disease (P<0.05). Twenty-three of 57 (40%) patients with COPD completed a corticosteroid trial: one showed significant reversibility of lung function. Spirometry was feasible and helped identify patients with COPD on asthma registers in these inner-city practices. Patients aged 50 years and over on asthma registers had a wide spectrum of lung function with considerable diagnostic misclassification. Some patients with normal lung function when tested may have had well controlled asthma. New diagnoses of COPD were mainly in those with mild or moderate disease.

Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study.

Although the prevalence of angina in women is increasing, women are less likely than men to undergo invasive management of coronary disease. Gender differences in language use may contribute to disparities in management, since the diagnosis of angina relies on a patient's description of their symptoms. This study set out to investigate whether gender differences exist in the language used when describing angina symptoms and perceived health problems at the time of angiography, which might influence the rate of subsequent revascularisation. Content analysis was used to analyse written accounts of 'symptoms and health problems' in 200 (96 female) patients randomly selected within age strata who were undergoing coronary angiography for chronic stable angina in the Appropriateness of Coronary Revascularisation (ACRE) study. Written free text was coded into seven categories: pain location (chest or arm and throat, neck or jaw); pain character; breathlessness; other symptoms; effects on lifestyle; symptom attributions; and patient discourses ('story' or 'factual'). Women described more throat, neck or jaw pain than men among those with low physical functioning ( p=0.06), in the presence of coronary artery disease (p = 0.04) and in those who were not subsequently revascularised (p =0.05). Women also gave more accounts than men of breathlessness and other symptoms, but there was little evidence for gender differences in the use of 'factual' discourses. We conclude that from the time of angiography, gender differences in language use do exist and description of angina pain may influence subsequent revascularisation. Further research is necessary to investigate the nature and consequences of gender differences in language use at this and earlier stages in the referral process.

Domestic violence: a hidden problem for general practice.

Domestic violence is a common problem that may affect more than a quarter of women. It is a complex area in which to undertake research. Studies often focus on selected populations and exhibit a diversity of design, making comparison difficult. This review focuses on physical violence by men against women partners or ex-partners, and exemplifies important issues for general practitioners. Domestic violence frequently goes undetected. This may be the result of doctor's fears of exploring an area perceived as time-consuming, where knowledge is lacking and where they feel powerless to 'fix' the situation. Women may not reveal that they are experiencing violence, sometimes because doctors are unsympathetic or hostile. Nevertheless, women wish to be asked routinely about physical abuse and want to receive immediate advice and information about their options if necessary. Women experience a range of health and social problems in association with domestic violence, including depression, anxiety, substance abuse and pregnancy complications. However, none of these features is specific enough to be useful as an indicator of violence. Therefore, doctors should routinely ask all women direct questions about abuse. This recommendation can be incorporated into guidelines, which should be implemented widely in the UK, to improve the care of women experiencing domestic violence. In parallel with this, the educational needs of general practitioners should be addressed. Further research is needed to establish the prevalence of domestic violence in women presenting to general practice and to investigate how the problem is currently being addressed. If progress is to be made in tackling domestic violence, action within primary care is just one part of this: a fundamental change in the attitudes of men towards women is required.

Systematic reviews of bed rest and advice to stay active for acute low back pain.

BACKGROUND: In the United Kingdom (UK), 9% of adults consult their doctor annually with back pain. The treatment recommendations are based on orthopaedic teaching, but the current management is causing increasing dissatisfaction. Many general practitioners (GPs) are confused about what constitutes effective advice. AIM: To review all randomized controlled trials of bed rest and of medical advice to stay active for acute back pain. METHOD: A systematic review based on a search of MEDLINE and EMBASE from 1966 to April 1996 with complete citation tracking for randomized controlled trials of bed rest or medical advice to stay active and continue ordinary daily activities. The inclusion criteria were: primary care setting, patients with low back pain of up to 3 months duration, and patient-centred outcomes (rate of recovery from the acute attack, relief of pain, restoration of function, satisfaction with treatment, days off work and return to work, development of chronic pain and disability, recurrent attacks, and further health care use). RESULTS: Ten trials of bed rest and eight trials of advice to stay active were identified. Consistent findings showed that bed rest is not an effective treatment for acute low back pain but may delay recovery. Advice to stay active and to continue ordinary activities results in a faster return to work, less chronic disability, and fewer recurrent problems. CONCLUSION: A simple but fundamental change from the traditional prescription of bed rest to positive advice about staying active could improve clinical outcomes and reduce the personal and social impact of back pain.

Traveller Gypsies and childhood immunization: a study in east London.

The immunization status of the children of Traveller Gypsies presenting to two general practices and a paediatric accident and emergency department in east London between July 1988 and February 1990 was compared with that of a control group presenting to the same services. Study of parental reports and other records for 72 Traveller Gypsy children and 106 control children aged 10 months to six years revealed that Traveller Gypsy children had significantly lower completion rates for pertussis, measles, diphtheria/tetanus and poliomyelitis vaccines than the control group. The difference between the uptake of the first and third diphtheria/tetanus, pertussis and poliomyelitis vaccines was significantly greater among the Traveller Gypsy children than among the control group. The low immunization rates are due to poor access to services as well as rejection of certain vaccines by Traveller Gypsies. The 1990 general practitioner contract and reforms to the health service may result in decreased access for Traveller Gypsies unless steps are taken by family health services and district health authorities to meet the health care needs of this group. Possible solutions to this problem include outreach services to caravan sites, opportunistic immunization, better records and targeted health education.

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK.

BACKGROUND: Despite research evidence that guidelines can improve patient care, concerns remain over their cost-effectiveness. This is particularly so when there is a proliferation of guidelines for the same condition. Faced with differing recommendations, users will wish to make informed decisions on which guideline to follow. In creating a guideline appraisal instrument we have assessed guidelines developed in the United Kingdom (UK) for the management of a range of disorders including depression in primary care. AIM: To identify the number of UK clinical guidelines for the management of depression in primary care and to describe their quality and clinical content. METHOD: A survey was undertaken to identify all depression guidelines developed in the UK between January 1991 and January 1996. All guidelines produced by national organizations and a random sample of local guidelines were appraised using a validated instrument by six assessors: a national expert in the disease area, a general practitioner, a public health physician, a hospital consultant, a nurse specializing in the disease area, and a researcher on guideline methodology. The clinical content of each guideline was then assessed by one of the researchers (RB) according to a defined framework. RESULTS: Forty-five depression guidelines were identified. While there was a considerable range in the quality of the six national and three local guidelines appraised, at a group level their performance was similar to guidelines for other diseases. Clinical recommendations tended to reflect the joint consensus statement produced by the Royal College of General Practitioners and Royal College of Psychiatrists in 1992. The most obvious difference was in the style in which the guidelines were written and presented. CONCLUSION: A 'national template' was the starting place for most guidelines. Steps need to be taken to ensure that these templates are based on the best possible research evidence and professional opinion. Local clinicians should concentrate on effective dissemination and implementation strategies, rather than creating new guidelines.