Factors associated with the consultation of GPs among adults aged ≥16 years: an analysis of data from the Health Survey for England 2019.

BACKGROUND: Understanding the factors associated with demands for general practice care is crucial for policy decision makers to appropriately allocate healthcare resources. AIM: To investigate factors associated with the frequency of GP consultations. DESIGN & SETTING: Data on 8086 adults aged ≥16 years was obtained from cross-sectional Health Survey for England (HSE) 2019. METHOD: The primary outcome was the frequency of consultations of a GP in the last 12 months. Multivariable ordered logistic regression analysis was used to evaluate associations between GP consultations and a range of sociodemographic and health-related factors. RESULTS: Frequency of GP consultations for all reasons was higher among females (odds ratio [OR] 1.81, 95% confidence interval [CI] = 1.64 to 2.01), those aged ≥75 years (OR 1.48, 95% CI = 1.15 to 1.92), ethnic minority populations (Black: OR 1.42, 95% CI = 1.09 to 1.84; Asian: OR 1.53, 95% CI = 1.25 to 1.87), lowest household income (OR 1.53, 95% CI = 1.29 to 1.83), adults with long-lasting illnesses (OR 3.78, 95% CI = 3.38 to 4.22), former smokers (OR 1.17, 95% CI = 1.04 to 1.22), being overweight (OR 1.14, 95% CI = 1.01 to 1.29), and being obese (OR 1.32, 95% CI = 1.16 to 1.50). Predictors of consultations for physical health problems were similar to predictors of consultations for any health problems. However, younger age was associated with more consultations for mental health problems, or a combination of mental and physical health problems. CONCLUSION: The higher frequency of consultation of GPs is associated with female sex, older age, ethnic minority populations, being socioeconomically disadvantaged, existence of lasting illnesses, smoking, being overweight, and being obese. Older age is associated with increased consultations for physical health problems, but associated with reduced consultations for mental health or a combination of mental and physical health problems.

Intervention fidelity assessment: A sub-study of the Norfolk Diabetes Prevention Study (NDPS).

BACKGROUND: Previous research has shown that lifestyle modification can delay or prevent the onset of type 2 diabetes in high-risk individuals. The Norfolk Diabetes Prevention Study (NDPS) was a parallel, three-arm, randomized controlled trial with up to 46 months follow-up that tested a group-delivered, theory-based lifestyle intervention to reduce the incidence of type 2 diabetes in high-risk groups. The current study aimed to evaluate if the NDPS intervention was delivered to an acceptable standard and if any part(s) of the delivery required improvement. METHODS: A sub-sample of 30, 25 for inter-rater reliability and audio-recordings of the NDPS intervention education sessions were assessed independently by two reviewers (CT, TW) using a 12-item checklist. Each item was scored on a 0-5 scale, with a score of 3 being defined as 'adequate delivery'. Inter-rater reliability was assessed. Analysis of covariance (ANCOVA) was used to assess changes in intervention fidelity as the facilitators gained experience. RESULTS: Inter-rater agreement was acceptable (86%). A mean score of 3.47 (SD = .38) was achieved across all items of the fidelity checklist and across all intervention facilitators (n = 6). There was an apparent trend for intervention fidelity scores to decrease with experience; however, this trend was non-significant (p > .05) across all domains in this small sample. CONCLUSION: The NDPS was delivered to an acceptable standard by all Diabetes Prevention Facilitators. Further research is needed to better understand how the intervention's delivery characteristics can be optimized and how they might vary over time.

Primary care financing: a systematic assessment of research priorities in low- and middle-income countries.

INTRODUCTION: Financing of primary healthcare (PHC) is the key to the provision of equitable universal care. We aimed to identify and prioritise the perceived needs of PHC practitioners and researchers for new research in low- and middle-income countries (LMIC) about financing of PHC. METHODS: Three-round expert panel consultation using web-based surveys of LMIC PHC practitioners, academics and policy-makers sampled from global networks. Iterative literature review conducted in parallel. First round (Pre-Delphi survey) elicited possible research questions to address knowledge gaps about financing. Responses were independently coded, collapsed and synthesised to two lists of questions. Round 2 (Delphi Round 1) invited panellists to rate importance of each question. In Round 3 (Delphi Round 2), panellists ranked questions in order of importance. RESULTS: A diverse range of PHC practitioners, academics and policy-makers in LMIC representing all global regions identified 479 knowledge gaps as potentially critical to improving PHC financing. Round 2 provided 31 synthesised questions on financing for rating. The top 16 were ranked in Round 3e to produce four prioritised research questions. CONCLUSIONS: This novel exercise created an expansive and prioritised list of critical knowledge gaps in PHC financing research questions. This offers valuable guidance to global supporters of primary care evaluation and implementation, including research funders and academics seeking research priorities. The source and context specificity of this research, informed by LMIC practitioners and academics on a global and local basis, should increase the likelihood of local relevance and eventual success in implementing the findings.

Valuing health-related quality of life in heart failure: a systematic review of methods to derive quality-adjusted life years (QALYs) in trial-based cost-utility analyses.

The accurate measurement of health-related quality of life (HRQoL) and the value of improving it for patients are essential for deriving quality-adjusted life years (QALYs) to inform treatment choice and resource allocation. The objective of this review was to identify and describe the approaches used to measure and value change in HRQoL in trial-based economic evaluations of heart failure interventions which derive QALYs as an outcome. Three databases (PubMed, CINAHL, Cochrane) were systematically searched. Twenty studies reporting economic evaluations based on 18 individual trials were identified. Most studies (n = 17) utilised generic preference-based measures to describe HRQoL and derive QALYs, commonly the EQ-5D-3L. Of these, three studies (from the same trial) also used mapping from a condition-specific to a generic measure. The remaining three studies used patients' direct valuation of their own health or physician-reported outcomes to derive QALYs. Only 7 of the 20 studies reported significant incremental QALY gains. Most interventions were reported as being likely to be cost-effective at specified willingness to pay thresholds. The substantial variation in the approach applied to derive QALYs in the measurement of and value attributed to HRQoL in heart failure requires further investigation.

Primary Care Research Priorities in Low-and Middle-Income Countries.

PURPOSE: To identify and prioritize the needs for new research evidence for primary health care (PHC) in low-and middle-income countries (LMICs) about organization, models of care, and financing of PHC. METHODS: Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre-Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking. RESULTS: One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC. CONCLUSIONS: This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings.

Core Principles to Improve Primary Care Quality Management.

Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim.

How embedded is public involvement in mainstream health research in England a decade after policy implementation? A realist evaluation.

Objectives To explore how embedded patient and public involvement is within mainstream health research following two decades of policy-driven work to underpin health research with patient and public involvement in England. Methods Realist evaluation using Normalization Process Theory as a programme theory to understand what enabled patient and public involvement to be embedded as normal practice. Data were collected through a national scoping and survey, and qualitative methods to track patient and public involvement processes and impact over time within 22 nationally funded research projects. Results In research studies that were able to create reciprocal working relationships and to embed patient and public involvement this was contingent on: the purpose of patient and public involvement being clear; public contributors reflecting research end-beneficiaries; researchers understanding the value of patient and public involvement; patient and public involvement opportunities being provided throughout the research and ongoing evaluation of patient and public involvement. Key contested areas included: whether to measure patient and public involvement impact; seeking public contributors to maintain a balance between being research-aware and an outsider standpoint seen as 'authentically' lay; scaling-up patient and public involvement embedded within a research infrastructure rather than risk token presence and whether patient and public involvement can have a place within basic science. Conclusions While patient and public involvement can be well-integrated within all types of research, policy makers should take account of tensions that must be navigated in balancing moral and methodological imperatives.

The Cost-Effectiveness of Screening in the Community to Reduce Osteoporotic Fractures in Older Women in the UK: Economic Evaluation of the SCOOP Study.

The SCOOP study was a two-arm randomized controlled trial conducted in the UK in 12,483 eligible women aged 70 to 85 years. It compared a screening program using the FRAX® risk assessment tool in addition to bone mineral density (BMD) measures versus usual management. The SCOOP study found a reduction in the incidence of hip fractures in the screening arm, but there was no evidence of a reduction in the incidence of all osteoporosis-related fractures. To make decisions about whether to implement any screening program, we should also consider whether the program is likely to be a good use of health care resources, ie, is it cost-effective? The cost per gained quality adjusted life year of screening for fracture risk has not previously been demonstrated in an economic evaluation alongside a clinical trial. We conducted a "within trial" economic analysis alongside the SCOOP study from the perspective of a national health payer, the UK National Health Service (NHS). The main outcome measure in the economic analysis was the cost per quality adjusted life year (QALY) gained over a 5-year time period. We also estimated cost per osteoporosis-related fracture prevented and the cost per hip fracture prevented. The screening arm had an average incremental QALY gain of 0.0237 (95% confidence interval -0.0034 to 0.0508) for the 5-year follow-up. The incremental cost per QALY gained was £2772 compared with the control arm. Cost-effectiveness acceptability curves indicated a 93% probability of the intervention being cost-effective at values of a QALY greater than £20,000. The intervention arm prevented fractures at a cost of £4478 and £7694 per fracture for osteoporosis-related and hip fractures, respectively. The current study demonstrates that a systematic, community-based screening program of fracture risk in older women in the UK represents a highly cost-effective intervention. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.

Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries.

BACKGROUND: Primary healthcare (PHC) is essential for equitable access and cost-effective healthcare. This makes PHC a key factor in the global strategy for universal health coverage (UHC). Implementing PHC requires an understanding of the health system under prevailing circumstances, but for most countries, no data are available. OBJECTIVES: This paper describes and analyses the health systems of Bahrain, Egypt, Lebanon, Qatar, Sudan and the United Arab Emirates, in relation to PHC. METHODS: Data were collected during a workshop at the WONCA East Mediterranean Regional Conference in 2017. Academic family physicians (FP) presented their country, using the WONCA framework of 11 PowerPoint slides with queries of the country demographics, main health challenges, and the position of PHC in the health system. RESULTS: All six countries have improved the health of their populations, but currently face challenges of non-communicable diseases, aging populations and increasing costs. Main concerns were a lack of trained FPs in community settings, underuse of prevention and of equitable access to care. Countries differed in the extent to which this had resulted in coherent policy. CONCLUSION: Priorities were (i) advocacy for community-based PHC to policymakers, including the importance of coordination of healthcare at the community level, and UHC to respond to the needs of populations; (ii) collaboration with universities to include PHC as a core component of every medical curriculum; (iii) collaboration with communities to improve public understanding of PHC; (iv) engagement with the private sector to focus on PHC and UHC.

Primary care evidence in clinical guidelines: a mixed methods study of practitioners' views.

BACKGROUND: Clinical practice guidelines are widely used in primary care, yet are not always based on applicable research. AIM: To explore primary care practitioners' views on the applicability to primary care patients of evidence underpinning National Institute for Health and Care Excellence (NICE) guideline recommendations. DESIGN AND SETTING: Delphi survey and focus groups in primary care, England, UK. METHOD: Delphi survey of the perceived applicability of 14 guideline recommendations rated before and after a description of their evidence base, followed by two focus groups. RESULTS: GPs significantly reduced scores for their perceived likelihood of pursuing recommendations after finding these were based on studies with low applicability to primary care, but maintained their scores for recommendations based on highly applicable research. GPs reported they were more likely to use guidelines where evidence was applicable to primary care, and less likely if the evidence base came from a secondary care population. Practitioners in the focus groups accepted that guideline developers would use the most relevant evidence available, but wanted clearer signposting of those recommendations particularly relevant for primary care patients. Their main need was for brief, clear, and accessible guidelines. CONCLUSION: Guidelines should specify the extent to which the research evidence underpinning each recommendation is applicable to primary care. The relevance of guideline recommendations to primary care populations could be more explicitly considered at all three stages of guideline development: scoping and evidence synthesis, recommendation development, and publication. The relevant evidence base needs to be presented clearly and concisely, and in an easy to identify way.

A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients.

OBJECTIVES: Primary care patients typically have less severe illness than those in hospital and may be overtreated if clinical guideline evidence is inappropriately generalized. We aimed to assess whether guideline recommendations for primary care were based on relevant research. STUDY DESIGN AND SETTING: Literature review of all publications cited in support of National Institute for Health and Care Excellence (NICE) recommendations for primary care. The relevance to primary care of all 45 NICE clinical guidelines published in 2010 and 2011, and their recommendations, was assessed by an expert panel. RESULTS: Twenty-two of 45 NICE clinical guidelines published in 2010 and 2011 were relevant to primary care. These 22 guidelines contained 1,185 recommendations, of which 495 were relevant to primary care, and cited evidence from 1,573 research publications. Of these cited publications, 590 (38%, range by guideline 6-74%) were based on patients typical of primary care. CONCLUSION: Nearly two-third (62%) of publications cited to support primary care recommendations were of uncertain relevance to patients in primary care. Guideline development groups should more clearly identify which recommendations are intended for primary care and uncertainties about the relevance of the supporting evidence to primary care patients, to avoid potential overtreatment.

Declaração de Gramado pela Saúde Rural nos países em desenvolvimento / Gramado Statement for Rural Health in developing countries / Declaración de Gramado para la Salud Rural en los países en desarrollo

Nós, aqui reunidos na XII Conferência Mundial de Saúde Rural da Wonca / IV Congresso Sulbrasileiro de Medicina de Família e Comunidade, declaramos como reflexão e recomendação para a saúde das populações rurais, em particular para os países em desenvolvimento, o que segue. Sistemas de saúde para uma melhor saúde rural A saúde rural não pode ser pensada separadamente do desenvolvimento do sistema de saúde. Pessoas de países em desenvolvimento merecem um uso racional e eficiente dos recursos disponíveis para gastos de saúde a fim de se otimizarem os resultados e a satisfação com os serviços. O aprimoramento da saúde rural deve estar associado a uma forte orientação do sistema de saúde para atenção primária à saúde1 e orientação para as reais necessidades das comunidades. Cobertura de saúde universal com equidade nos sistemas de saúde deve ser uma prioridade global2,3 Longitudinalidade e atenção integral devem ser constantemente alvo das políticas de saúde. Cuidado centrado na comunidade com competência cultural deve ser o princípio de todas as políticas de sistema de saúde. Hospitais e unidades de saúde rurais devem estar adequadamente vinculados a uma rede de saúde constantemente avaliada, e esta rede vinculada aos serviços mais especializados por meio de fluxos estabelecidos de comunicação, regulação e transporte. Envolvimento com a comunidade em todos os níveis das decisões deve ser encorajado para todos os sistemas de saúde. "Rural Proofing" implica "pensar no rural", consultar as comunidades rurais com a revisão de evidências rurais, desenvolver soluções rurais que são postas em prática, assim como monitorar, reavaliando continuamente e agindo em resposta a um ambiente em mudança.4 "Rural Proofing" deve ser centrado na pessoa e derivado por meio da lente do conhecimento contextualizado rural. É declaração do Wonca Working Party on Rural Practice (WWPRP) que Rural Proofing deve ser um aspecto rotineiro da aprovação e implementação das políticas. O WWPRP vai procurar desenvolver uma abordagem para ferramentas de Rural Proofing que abranja os princípios de melhoria da saúde para todas as pessoas rurais com uma apresentação do progresso dos resultados em 2015, na 13a Conferência Mundial de Saúde Rural da WONCA. Estratégias para o desenvolvimento profissional contínuo devem envolver tecnologias de suporte remoto e formação. As iniciativas de sucesso de treinamento em serviços de medicina de família já existentes devem ser exploradas. Competências desejáveis para a prática rural devem ser definidas e adicionadas de forma adaptada às diferentes realidades locais e necessidades. Devem-se qualificar e corresponsabilizar os gestores de saúde para a adoção de políticas orientadas pelo uso culturalmente apropriado das melhores evidências disponíveis. A necessidade de discussão das particularidades da saúde rural e da prática profissional é essencial. No entanto, a busca excessiva de definições muito estritas pode não ser útil para a implementação de políticas que realmente impactem a saúde dessas populações.5 Categorias intermediárias geradas pelo conceito de rururbano6,7 são fundamentais para estimular o intercâmbio de conhecimentos de medicina rural diante da enorme complexidade das situações sociais contemporâneas. Entende-se aqui rururbano como "um processo de desenvolvimento socioeconômico que combina, em termos de forma e conteúdo, uma única vivência regional e nacional. Ela representa uma rejeição à absoluta urbanização e, ao mesmo tempo, à idealização de camponeses vivendo arcaicamente em espaço rurais."6 O conceito também é utilizado para discutir a complexidade da definição de rural/urbano na legislação brasileira por outros autores, ao constatar-se que quase 15% da população nacional não se encaixam claramente em nenhuma das categorias isoladamente.7 O estabelecimento de um sistema de saúde, o que especificamente inclui a preocupação com a saúde das populações rurais, implica estabelecer redes de cooperação eficazes entre comunidades, educação e instituições de pesquisa, serviços de saúde e de gestão. Reconhecemos o trabalho realizado anteriormente nos fóruns rurais de Cartagena, Santa Fé e Montevidéu como importantes para o desenvolvimento da saúde rural na América Latina. Recursos humanos para a Saúde Rural A má distribuição e escassez de recursos humanos são muitas vezes maiores e mais graves nos países em desenvolvimento, e as soluções para este problema devem ser idealmente trabalhadas de forma conjunta por políticas de retenção e de qualidade, respeitando-se as recomendações internacionais8 e acordos para a migração internacional ética.9,10 O melhor perfil a ser alcançado por meio de políticas de alta prioridade para otimizar a saúde rural é o de pós-graduado em medicina de família. Em países em desenvolvimento, muitas vezes serão exigidos tempo e recursos para estimular a formação deste perfil, mas no médio e longo prazo, isto é custo-efetivo.1 Programas de residência devem ser a estratégia de padrão-ouro para este objetivo. Condições devem ser criadas para aumentar o número de vagas, sua descentralização e a garantia de uma quantidade adequada de bolsas de estudos para que os profissionais de saúde não sejam desviados para outras áreas nem entrem diretamente no mercado de trabalho. Outras maneiras de alcançar mais rapidamente o número necessário de profissionais devem preservar as diferenças entre esses modelos e valorar diferentemente profissionais com uma formação mais completa. Um escopo mais amplo de habilidades e conhecimentos deve ser incluído em uma formação estendida para esses profissionais. Em locais onde já há programas de medicina de família, períodos adicionais com conteúdo rural devem ser criados, ou seja, com conteúdos especiais ligados à realidade local, podendo incluir cirurgia, habilidades e conhecimentos de obstetrícia, atendimento de emergência, pediatria, etc. Políticas de migração, serviços obrigatórios, recrutamentos temporários sem estratégias de retenção devem ser estratégias excepcionais e não devem ser as principais políticas de nenhum país. Descentralização rural da formação, políticas para estimular os alunos advindos de áreas rurais, melhoramentos na qualidade do trabalho, de vida e de pagamento, incluindo programas de carreira profissional devem ser parte de políticas multifatoriais para retenção. Migração de profissionais internacionais deve sempre respeitar as legislações nacionais e as recomendações internacionais. Trabalhadores de saúde rural que vivem e trabalham em zonas rurais devem ser valorizados e sua situação sempre deve ser comparada com as novas políticas para evitar prejuízo destes. A exposição dos alunos de todas profissões da área da saúde deve incluir todos os possíveis cenários de prática profissional, incluindo rural e rururbanas, e deve ser planejada longitudinalmente sempre que possível. A formação necessariamente deve ser direcionada para as necessidades locais. As competências (conhecimentos, habilidades e atitudes) de medicina de família rural devem ser parte da formação de graduação. Unidades de cuidados de ensino nas áreas rurais são o cenário adequado para a formação de saúde rural e capacitação.

Developing generalism in the South African context.

The largest impact on the South African burden of disease will be made in community-based and primary healthcare (PHC) settings and not in referral hospitals. Medical generalism is an approach to the delivery of healthcare that routinely applies a broad and holistic perspective to the patient's problems and is a feature of PHC. A multi-professional team of generalists, who share similar values and principles, is needed to make this a reality. Ward-based outreach teams include community health workers and nurses with essential support from doctors. Expert generalists - family physicians - are required to support PHC as well as provide care at the district hospital. All require sufficient training, at scale, with greater collaboration and integration between training programmes. District clinical specialist teams are both an opportunity and a threat. The value of medical generalism needs to be explained, advocated and communicated more actively. 

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

OBJECTIVES: Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. DESIGN: Qualitative study in General Practice. SETTING: UK primary care. MAIN OUTCOME MEASURES: A qualitative study - interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. DESIGN AND SETTING: Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. PARTICIPANTS: UK based GPs (interview and surveys); European GP trainees (focus groups). RESULTS: Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. CONCLUSIONS: WE DESCRIBE FOUR AREAS FOR CHANGE: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

The at-risk registers in severe asthma (ARRISA) study: a cluster-randomised controlled trial examining effectiveness and costs in primary care.

BACKGROUND: Patients at risk of severe exacerbations contribute disproportionally to asthma mortality, morbidity and costs. We evaluated the effectiveness and costs of using 'asthma risk registers' for these patients in primary care. METHODS: In a cluster-randomised trial, 29 primary care practices identified 911 at-risk asthma patients using British asthma guideline criteria (severe asthma plus adverse psychosocial characteristics). Intervention practices added electronic alerts to identified patients' records to flag their at-risk status and received practice-based training about using the alerts to improve patient access and opportunistic management. Control practices continued routine care. Numbers of patients experiencing the primary outcome of a moderate-severe exacerbation (resulting in death, hospitalisation, accident and emergency attendance, out-of-hours contact, or a course/boost in oral prednisolone for asthma), other healthcare and medication usage, and costs over 1 year were derived from practice-based records. RESULTS: There was no significant effect on exacerbations (control: 46.5%; intervention: 53.6%, OR, 95% CI 1.30, 0.93 to 1.80). However, this composite outcome masked relative reductions in intervention patients experiencing hospitalisations (OR 0.50, 95% CI 0.26 to 0.94), accident and emergency (OR 0.74, 95% CI 0.42 to 1.31) and out-of-hours contacts (OR 0.79, 95% CI 0.45 to 1.37); and a relative increase in prednisolone prescription for exacerbations (OR 1.31, 95% CI 0.92 to 1.85). Furthermore, prescription of nebulised short-acting ß-agonists reduced and long-acting ß-agonists increased for intervention relative to control patients. The adjusted mean per patient healthcare cost was £138.21 lower (p=0.837) among intervention practices. CONCLUSION: Using asthma risk registers in primary care did not reduce treated exacerbations, but reduced hospitalisations and increased prescriptions of recommended preventative therapies without increasing costs.

Computerised therapy for depression with clinician vs. assistant and brief vs. extended phone support: study protocol for a randomised controlled trial.

BACKGROUND: Computerised cognitive behaviour therapy (cCBT) involves standardised, automated, interactive self-help programmes delivered via a computer. Randomised controlled trials (RCTs) and observational studies have shown than cCBT reduces depressive symptoms as much as face-to-face therapy and more than waiting lists or treatment as usual. cCBT's efficacy and acceptability may be influenced by the "human" support offered as an adjunct to it, which can vary in duration and can be offered by people with different levels of training and expertise. METHODS/DESIGN: This is a two-by-two factorial RCT investigating the effectiveness, cost-effectiveness and acceptability of cCBT supplemented with 12 weekly phone support sessions are either brief (5-10 min) or extended (20-30 min) and are offered by either an expert clinician or an assistant with no clinical training. Adults with non-suicidal depression in primary care can self-refer into the study by completing and posting to the research team a standardised questionnaire. Following an assessment interview, eligible referrals have access to an 8-session cCBT programme called Beating the Blues and are randomised to one of four types of support: brief-assistant, extended-assistant, brief-clinician or extended-clinician.A sample size of 35 per group (total 140) is sufficient to detect a moderate effect size with 90% power on our primary outcome measure (Work and Social Adjustment Scale); assuming a 30% attrition rate, 200 patients will be randomised. Secondary outcome measures include the Beck Depression and Anxiety Inventories and the PHQ-9 and GAD-7. Data on clinical outcomes, treatment usage and patient experiences are collected in three ways: by post via self-report questionnaires at week 0 (randomisation) and at weeks 12 and 24 post-randomisation; electronically by the cCBT system every time patients log-in; by phone during assessments, support sessions and exit interviews. DISCUSSION: The study's factorial design increases its efficiency by allowing the concurrent investigation of two types of adjunct support for cCBT with a single sample of participants. Difficulties in recruitment, uptake and retention of participants are anticipated because of the nature of the targeted clinical problem (depression impairs motivation) and of the studied interventions (lack of face-to-face contact because referrals, assessments, interventions and data collection are completed by phone, computer or post). TRIAL REGISTRATION: Current Controlled Trials ISRCTN98677176.