Does the design of the NHS Diabetes Prevention Programme intervention have fidelity to the programme specification? A document analysis.

AIMS: To assess fidelity of the Healthier You: NHS Diabetes Prevention Programme (NHS-DPP), a behavioural intervention for people in England at high risk of developing type 2 diabetes, to the specified programme features. METHODS: Document analysis of the NHS-DPP programme specification, including National Institute for Health and Care Excellence (NICE) PH38 diabetes prevention guidance. This was compared with the intervention design (framework response documents and programme manuals) from all four independent providers delivering the NHS-DPP. Documents were coded using the Template for Intervention Description and Replication framework (describing service parameters) and the Behaviour Change Technique Taxonomy v1. RESULTS: Providers demonstrated good fidelity to service parameters of the NHS-DPP. The NHS-DPP specification indicated 19 unique behaviour change techniques. Framework responses for the four providers contained between 24 and 32 distinct behaviour change techniques, and programme manuals contained between 23 and 45 distinct behaviour change techniques, indicating variation in behaviour change content between providers' intervention documents. Thus, each provider planned to deliver 74% of the unique behaviour change techniques specified, and a large amount of behaviour change content not mandated. CONCLUSIONS: There is good fidelity to the specified service parameters of the NHS-DPP; however, the four providers planned to deliver approximately three-quarters of behaviour change techniques specified by the NHS-DPP. Given that behaviour change techniques are the 'active ingredients' of interventions, and some of these techniques in the programme manuals may be missed in practice, this highlights possible limitations with fidelity to the NHS-DPP programme specification at the intervention design stage.

Sociodemographic disparities in non-diabetic hyperglycaemia and the transition to type 2 diabetes: evidence from the English Longitudinal Study of Ageing.

AIM: To explore whether there are social inequalities in non-diabetic hyperglycaemia (NDH) and in transitions to type 2 diabetes mellitus and NDH low-risk status in England. METHODS: Some 9143 men and women aged over 50 years were analysed from waves 2, 4, 6 and 8 (2004-2016) of the English Longitudinal Study of Ageing (ELSA). Participants were categorized as: NDH 'low-risk' [HbA1c < 42 mmol/mol (< 6.0%)], NDH [HbA1c 42-47 mmol/mol (6.0-6.4%)] and type 2 diabetes [HbA1c > 47 mmol/mol (> 6.4%)]. Logistic regression models estimated the association between sociodemographic characteristics and NDH, and the transitions from NDH to diagnosed or undiagnosed type 2 diabetes and low-risk status in future waves. RESULTS: NDH was more prevalent in older participants, those reporting a disability, those living in deprived areas and in more disadvantaged social classes. Older participants with NDH were less likely to progress to undiagnosed type 2 diabetes [odds ratio (OR) 0.27, 95% confidence interval (CI) 0.08, 0.96]. NDH individuals with limiting long-standing illness (OR 1.72, 95% CI 1.16, 2.53), who were economically inactive (OR 1.60, 95% CI 1.02, 2.51) or from disadvantaged social classes (OR 1.63, 95% CI 1.02, 2.61) were more likely to progress to type 2 diabetes. Socially disadvantaged individuals were less likely (OR 0.64, 95% CI 0.41, 0.98) to progress to NDH low-risk status. CONCLUSIONS: There were socio-economic differences in NDH prevalence, transition to type 2 diabetes and transition to NDH low-risk status. Disparities in transitions included the greater likelihood of disadvantaged social groups with NDH developing type 2 diabetes and greater likelihood of advantaged social groups with NDH becoming low-risk. These socio-economic differences should be taken into account when targeting prevention initiatives.

The Patient Assessment of Chronic Illness Care produces measurements along a single dimension: results from a Mokken analysis.

BACKGROUND: As the worldwide prevalence of chronic illness increases so too does the demand for novel treatments to improve chronic illness care. Quantifying improvement in chronic illness care from the patient perspective relies on the use of validated patient-reported outcome measures. In this analysis we examine the psychometric and scaling properties of the Patient Assessment of Chronic Illness Care (PACIC) questionnaire for use in the United Kingdom by applying scale data to the non-parametric Mokken double monotonicity model. METHODS: Data from 1849 patients with long-term conditions in the UK who completed the 20-item PACIC were analysed using Mokken analysis. A three-stage analysis examined the questionnaire's scalability, monotonicity and item ordering. An automated item selection procedure was used to assess the factor structure of the scale. Analysis was conducted in an 'evaluation' dataset (n = 956) and results were confirmed using an independent 'validation' (n = 890) dataset. RESULTS: Automated item selection procedures suggested that the 20 items represented a single underlying trait representing "patient assessment of chronic illness care": this contrasts with the multiple domains originally proposed. Six items violated invariant item ordering and were removed. The final 13-item scale had no further issues in either the evaluation or validation samples, including excellent scalability (Ho = .50) and reliability (Rho = .88). CONCLUSIONS: Following some modification, the 13-items of the PACIC were successfully fitted to the non-parametric Mokken model. These items have psychometrically robust and produce a single ordinal summary score. This score will be useful for clinicians or researchers to assess the quality of chronic illness care from the patient's perspective.

Comparison of non-directive counselling and cognitive behaviour therapy for patients presenting in general practice with an ICD-10 depressive episode: a randomized control trial.

BACKGROUND: Most evidence in the UK on the effectiveness of brief therapy for depression concerns cognitive behaviour therapy (CBT). In a trial published in 2000, we showed that non-directive counselling and CBT were equally effective in general practice for patients with depression and mixed anxiety and depression. Our results were criticized for including patients not meeting diagnostic criteria for a depressive disorder. In this reanalysis we aimed to compare the effectiveness of the two therapies for patients with an ICD-10 depressive episode. METHOD: Patients with an ICD-10 depressive episode or mixed anxiety and depression were randomized to counselling, CBT or usual general practitioner (GP) care. Counsellors provided nondirective, interpersonal counselling following a manual that we developed based on the work of Carl Rogers. Cognitive behaviour therapists provided CBT also guided by a manual. Modelling was carried out using generalized estimating equations with the multiply imputed datasets. Outcomes were mean scores on the Beck Depression Inventory, Brief Symptom Inventory, and Social Adjustment Scale at 4 and 12 months. RESULTS: A total of 134 participants were randomized to CBT, 126 to counselling and 67 to usual GP care. We undertook (1) an interaction analysis using all 316 patients who were assigned a diagnosis and (2) a head-to-head comparison using only those 130 (41%) participants who had an ICD-10 depressive episode at baseline. CBT and counselling were both superior to GP care at 4 months but not at 12 months. There was no difference in the effectiveness of the two psychological therapies. CONCLUSIONS: We recommend that national clinical guidelines take our findings into consideration in recommending effective alternatives to CBT.

Food for thought: pilot randomized controlled trial of lay health trainers supporting dietary change to reduce cardiovascular disease in deprived communities.

BACKGROUND: Cardiovascular disease (CVD) accounts for 30% of UK deaths. It is associated with modifiable lifestyle factors, including insufficient consumption of fruit and vegetables (F&V). Lay health trainers (LHTs) offer practical support to help people develop healthier behaviour and lifestyles. Our two-group pilot randomized controlled trial (RCT) investigated the effectiveness of LHTs at promoting a heart-healthy lifestyle among adults with at least one risk factor for CVD to inform a full-scale RCT. METHODS: Eligible adults (aged 21-78 years), recruited from five practices serving deprived populations, were randomized to health information leaflets plus LHTs' support for 3 months (n = 76) versus health information leaflets alone (n = 38). RESULTS: We recruited 114 participants, with 60% completing 6 month follow-up. Both groups increased their self-reported F&V consumption and we found no evidence for LHTs' support having significant added impact. Most participants were relatively less deprived, as were the LHTs we were able to recruit and train. CONCLUSIONS: Our pilot demonstrated that an LHT's RCT whilst feasible faces considerable challenges. However, to justify growing investment in LHTs, any behaviour changes and sustained impact on those at greatest need should be demonstrated in an independently evaluated, robust, fully powered RCT.

Gonosomal mosaicism for an NF1 deletion in a sperm donor: evidence of the need for coordinated, long-term communication of health information among relevant parties.

BACKGROUND: Screening of gamete donors can reduce but cannot eliminate the risks for medical problems in donor-conceived offspring. We present a case of gonosomal mosaicism discovered in an anonymous sperm donor after receiving two reports of neurofibromatosis type 1 (NF1) in donor-conceived offspring, to illustrate that long-term, systematic investigation of health issues in donors and offspring can be invaluable to the welfare of these individuals. METHODS: A repeat physical evaluation and ophthalmology examination were performed on the donor. DNA samples were examined by RTPCR fragment analysis, multiplex ligation-dependent probe amplification (MLPA) and targeted array-comparative genomic hybridization (aCGH). RESULTS: Gonosomal mosaicism for a deletion mutation in the NF1 gene was identified in 20% of sperm and a smaller percentage of lymphocytes. CONCLUSIONS: Long-term communication of medical information among donors, recipients and donor-conceived offspring is beneficial for the health management of all parties. Development of a secure, coordinated data system is critical to achieving this goal. Recommendations are provided for management and communication of critical information based on this experience.

Frailty among Older Adults and Its Distribution in England.

BACKGROUND: Information on the spatial distribution of the frail population is crucial to inform service planning in health and social care. OBJECTIVES: To estimate small-area frailty prevalence among older adults using survey data. To assess whether prevalence differs between urban, rural, coastal and inland areas of England. DESIGN: Using data from the English Longitudinal Study of Ageing (ELSA), ordinal logistic regression was used to predict the probability of frailty, according to age, sex and area deprivation. Probabilities were applied to demographic and economic information in 2020 population projections to estimate the district-level prevalence of frailty. RESULTS: The prevalence of frailty in adults aged 50+ (2020) in England was estimated to be 8.1 [95% CI 7.3-8.8]%. We found substantial geographic variation, with the prevalence of frailty varying by a factor of 4.0 [3.5-4.4] between the most and least frail areas. A higher prevalence of frailty was found for urban than rural areas, and coastal than inland areas. There are widespread geographic inequalities in healthy ageing in England, with older people in urban and coastal areas disproportionately frail relative to those in rural and inland areas. CONCLUSIONS: Interventions aimed at reducing inequalities in healthy ageing should be targeted at urban and coastal areas, where the greatest benefit may be achieved.

Telephone delivery of psychological interventions: Balancing protocol with patient-centred care.

Common mental health problems of anxiety and depression affect significant proportions of the global population. Within the UK, and increasingly across western countries, a key policy response has been the introduction of high volume, low intensity psychological assessment and treatment services, such as the NHS's Improving Access to Psychological Therapies (IAPT) service, the largest service delivery model yet to be implemented at a national level (England). IAPT may be delivered in face-to-face meetings or over the telephone, as well as through other media. In order to increase access and achieve wide reach with efficient use of resources, IAPT's service models utilise relatively structured and standardised protocols, whilst aiming simultaneously to deliver a tailored and personalised experience for patients. Previous research has revealed that this can be a challenging balance for front-line practitioners to strike. Here we report research into the telephone delivery of guided self-help, low intensity interventions within IAPT, examining the challenges faced in remote delivery when combining structure with personalisation during assessment and treatment sessions. We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient's story, thereby compromising the personalisation and responsiveness of the service. Our study contributes new insights to our understanding of the association between personalisation, engagement and patient experience within high volume, low-intensity psychological treatment services. Our research on the telephone delivery of IAPT is particularly timely in view of the current global Covid-19 health crisis, as a result of which face-to-face delivery of IAPT has had to be (temporarily) suspended.

Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged).

OBJECTIVE: To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations. METHODS: Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate. RESULTS: 8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured. CONCLUSION: The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare. PRACTICE IMPLICATIONS: There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings.

OBJECTIVES: To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures. DATA SOURCES: Major electronic databases (including PsycINFO) were searched from inception to 2002. REVIEW METHODS: A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated. RESULTS: The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard. CONCLUSIONS: The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Effectiveness and cost effectiveness of counselling in primary care.

BACKGROUND: The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors. OBJECTIVES: To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling. SEARCH STRATEGY: To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers. SELECTION CRITERIA: All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review. DATA COLLECTION AND ANALYSIS: Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. MAIN RESULTS: Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. AUTHORS' CONCLUSIONS: Counselling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.

A novel suppressor tRNA from the dimorphic fungus Candida albicans.

Unfractionated tRNAs from a number of prokaryotes and eukaryotes were examined for their ability to promote termination codon readthrough in a cell-free system isolated from Saccharomyces cerevisiae. tRNA from the dimorphic fungus Candida albicans was found to have significant UGA and UAG readthrough activity and this activity was present in tRNA extracted from both the yeast and the hyphal phase of the fungus. Unusually the efficiency of readthrough activity in vitro was not affected by the [psi] determinant. C. albicans tRNA was fractionated by one-dimensional and two-dimensional gel electrophoresis and both readthrough activities appeared to be associated with a single species of tRNA.

Conceptual framework and systematic review of the effects of participants' and professionals' preferences in randomised controlled trials.

OBJECTIVES: To develop a conceptual framework of preferences for interventions in the context of randomised controlled trials (RCTs), as well as to examine the extent to which preferences affect recruitment to RCTs and modify the measured outcome in RCTs through a systematic review of RCTs that incorporated participants' and professionals' preferences. Also to make recommendations on the role of participants' and professionals' preferences in the evaluation of health technologies. DATA SOURCES: Electronic databases. REVIEW METHODS: The conceptual review was carried out on published papers in the psychology and economics literature concerning concepts of relevance to patient decision-making and preferences, and their measurement. For the systematic review, studies across all medical specialities meeting strict criteria were selected. Data were then extracted, synthesised and analysed. RESULTS: Key elements for a conceptual framework were found to be that preferences are evaluations of an intervention in terms of its desirability and these preferences relate to expectancies and perceived value of the process and outcome of interventions. RCTs differed in the information provided to patients, the complexity of techniques used to provide that information and the degree to which preference elicitation may simply produce pre-existing preferences or actively construct them. Most current RCTs used written information alone. Preference can be measured in many different ways and most RCTs did not provide quantitative measures of preferences, and those that did tended to use very simple measures. The second part of the study, the systematic review included 34 RCTs. The findings gave support to the hypothesis that preferences affect trial recruitment. However, there was less evidence that external validity was seriously compromised. There was some evidence that preferences influenced outcome in a proportion of trials. However, evidence for preference effects was weaker in large trials and after accounting for baseline differences. Preference effects were also inconsistent in direction. There was no evidence that preferences influenced attrition. Therefore, the available evidence does not support the operation of a consistent and important 'preference effect'. Interventions cannot be categorised consistently on degree of participation. Examining differential preference effects based on unreliable categories ran the risk of drawing incorrect conclusions, so this was not carried out. CONCLUSIONS: Although patients and physicians often have intervention preferences, our review gives less support to the hypothesis that preferences significantly compromise the internal and external validity of trials. This review adds to the growing evidence that when preferences based on informed expectations or strong ethical objections to an RCT exist, observational methods are a valuable alternative. All RCTs in which participants and/or professionals cannot be masked to treatment arms should attempt to estimate participants' preferences. In this way, the amount of evidence available to answer questions about the effect of treatment preferences within and outwith RCTs could be increased. Furthermore, RCTs should routinely attempt to report the proportion of eligible patients who refused to take part because of their preferences for treatment. The findings also indicate a number of approaches to the design, conduct and analysis of RCTs that take account of participants' and/or professionals' preferences. This is referred to as a methodological tool kit for undertaking RCTs that incorporate some consideration of patients' or professionals' preferences. Future research into the amount and source of information available to patients about interventions in RCTs could be considered, with special emphasis on the relationship between sources inside and outside the RCT context. Qualitative research undertaken as part of ongoing RCTs might be especially useful. The processes by which this information leads to preferences in order to develop or extend the proposed expectancy--value framework could also be examined. Other areas for consideration include: how information about interventions changes participants' preferences; a comparison of the feasibility and effectiveness of different informed consent procedures; how strength of preference varies for different interventions within the same RCT and how these differences can be taken account of in the analysis; the differential effects of patients' and professionals' preferences on evidence arising from RCTs; and whether the standardised measurement of preferences within all RCTs (and analysis of the effect on outcome) would allow the rapid development of a significant evidence base concerning patient preferences, albeit in relation to a single preference design.

Long-term follow-up of internal mammary artery myocardial implantation.

A study was made of 100 patients who had undergone internal mammary artery myocardial implantation 7 to 10 years previously. Forty-two patients had single implantation with or without a free omental graft, and 54 received double implantations. Four patients had a single internal mammary artery implant plus a single aortocoronary bypass graft. Eleven patients died at operation or within the first month, and 17 died from 1 to 7 years following operation. Two were lost to follow-up, and 15 refused follow-up angiograms. From 7 to 10 years postoperatively, angiographic studies were performed on 55 patients with 73 internal mammary artery implants. Of these 73 implants, 17 (23%) were occluded; 10 (14%) were patent but did not show myocardial filling; 15 (21%) showed myocardial blush or filling of small vessels; and 31 (42%) showed filling of a major coronary artery. The patency rate correlated well with the amount of coronary disease and slightly with the amount of symptomatic improvement. This study shows that the Vineberg operation is physiologically sound; however, the ideal candidates are those patients with coronary arteries of adequate size who could benefit more by direct perfusion.

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care.

OBJECTIVES: The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner (GP) care compared with two types of brief psychological therapy (non-directive counselling and cognitive-behaviour therapy) in the management of depression as well as mixed anxiety and depression in the primary care setting. DESIGN: The design was principally a pragmatic randomised controlled trial, but was accompanied by two additional allocation methods allowing patient preference: the option of a specific choice of treatment (preference allocation) and the option to be randomised between the psychological therapies only. Of the 464 patients allocated to the three treatments, 197 were randomised between the three treatments, 137 chose a specific treatment, and 130 were randomised between the psychological therapies only. The patients underwent follow-up assessments at 4 and 12 months. SETTING: The study was conducted in 24 general practices in Greater Manchester and London. SUBJECTS: A total of 464 eligible patients, aged 18 years and over, were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms. INTERVENTIONS: The interventions consisted of brief psychological therapy (12 sessions maximum) or usual GP care. Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling. Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies. Usual GP care included discussions with patients and the prescription of medication, but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months. Most therapy sessions took place on a weekly basis in the general practices. By the 12-month follow-up, GP care in some cases did include referral to mental healthcare specialists. MAIN OUTCOME MEASURES: The clinical outcomes included depressive symptoms, general psychiatric symptoms, social function and patient satisfaction. The economic outcomes included direct and indirect costs and quality of life. Assessments were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post. RESULTS: At 4 months, both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care. Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4-5 points lower than the mean score of patients in the usual GP care group, a difference that was also clinically significant. These differences did not generalize to other measures of outcome. There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients randomised to a psychological therapy by either randomised allocation method. At 12 months, the patients in all three groups had improved to the same extent. The lack of a significant difference between the treatment groups at this point resulted from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups. At 4 months, patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group. However, by 12 months, patients who had received non-directive counselling were more satisfied than those in either of the other two groups. There were few differences in the baseline characteristics of patients who were randomised or expressed a treatment preference, and no differences in outcome between these patients. Similar outcomes were found for patients who chose either psychological therapy. Again, there were no significant differences between the two groups at 4 or 12 months. Patients who chose counselling were more satisfied with treatment than those who chose c

Team structure, team climate and the quality of care in primary care: an observational study.

OBJECTIVES: To determine whether practice structure (for example, list size, number of staff) predicts team processes and whether practice structure and team process in turn predict team outcomes DESIGN: Observational study using postal questionnaires and medical note audit. Team process was assessed through a measure of "climate" which examines shared perceptions of organisational policies, practices, and procedures. SETTING: Primary care. SUBJECTS: Members of the primary health care team from 42 practices. MAIN OUTCOME MEASURES: Objective measures of quality of chronic disease management, patients' evaluations of practices, teams' self-reported ratings of effectiveness, and innovation. RESULTS: Team climate was better in singlehanded practices than in partnerships. Practices with longer booking intervals provided superior chronic disease management. Higher team climate scores were associated with superior clinical care in diabetes, more positive patient evaluations of practice and self-reported innovation and effectiveness. CONCLUSIONS: Although the conclusions are preliminary because of the limited sample size, the study suggests that there are important relationships between team structure, process, and outcome that may be of relevance to quality improvement initiatives in primary care. Possible causal mechanisms that might underlie these associations remain to be determined.

Patient-centredness: a conceptual framework and review of the empirical literature.

A 'patient-centred' approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor-patient relationship encompassed by the concept of 'patient-centredness' and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; 'patient-as-person'; sharing power and responsibility; therapeutic alliance; and 'doctor-as-person'. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.

Symptom attribution and the recognition of psychiatric morbidity.

OBJECTIVE: Patients' interpretation of ambiguous physical symptoms may influence illness presentation in primary care. The present study sought to investigate the influence of symptom attribution style on the recognition of psychiatric morbidity by general practitioners (GPs). METHODS: Patients consulting GPs completed assessments of attribution style and General Health Questionnaires (GHQs), while GPs provided independent ratings of psychiatric distress. Analysis examined the relationship between patient demographic variables, attribution style (using the Symptom Interpretation Questionnaire [SIQ]), and GP and GHQ assessments of patients' mental health. RESULTS: The results indicate that severity of disorder and patient age were reliable predictors of recognition: normalizing and psychological attributions were additional predictors in some analyses, but their effects were inconsistent. CONCLUSIONS: The results provide some support for the role of symptom attribution in the recognition of psychiatric morbidity, but suggest that the predictive value of such attributions may be relatively modest. The SIQ may not be the optimum instrument for the measurement of attributions.

The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review.

Anxiety and depression are prevalent in primary care; however, current treatments differ in their availability, cost-effectiveness, and acceptability to patients. Self-help treatments (such as manual-based bibliotherapy) may be an appropriate intervention for some patients. The aim of this research was to determine the clinical and cost-effectiveness of self-help treatments for anxiety and depression in primary care by conducting a systematic review of randomised and non-randomised trials of self-help interventions for patients with anxiety and depression in primary care, from electronic database searches, correspondence with authors, and limited handsearching. Eight studies were identified, examining written interventions based mostly on behavioural principles. Although the majority of trials reported some significant advantages in outcome associated with self-help treatments, the number of included studies was limited and a number of methodological limitations were identified. There were no data concerning long-term clinical benefits or cost-effectiveness. In conclusion, self-help treatments may have the potential to improve the overall cost-effectiveness of mental health service provision. However, the available evidence is limited in quantity and quality and more rigorous trials are required to provide more reliable estimates of the clinical and cost-effectiveness of these treatments.

Conducting randomized trials in general practice: methodological and practical issues.

The evaluation of the outcome of health services technologies is a requirement for their efficient provision in clinical practice. The most reliable evidence for treatment efficacy comes from randomized trials. Randomized trials in general practice pose particular methodological and practical difficulties. In this paper, we discuss how best to plan and manage a clinical trial in this setting. We base our discussion on our experience of conducting randomized trials to evaluate the effectiveness of brief psychotherapy in general practice.