Context as a drug: some consequences of placebo research for primary care.

OBJECTIVE: On the basis of emerging research evidence, this review aims to discuss the importance of the context surrounding the doctor-patient encounter for the success of treatment. DESIGN AND SETTING: Discussion paper based on placebo-nocebo and pain studies conducted in the western world. MAIN OUTCOME MEASURES: Literature-based theory about impact of communication elements on seriousness of symptoms in clinical practice. RESULTS: The therapeutic outcome seems to be impacted by rituals around a clinical encounter and by the doctor patient communication and relation. A warm, friendly and empathic attitude is crucial in the first contact with the practice and during the consultation as it influences the patient's perceived outcome. It is important to raise positive expectations when discussing the prognosis, conducting treatment and prescribing medications as the effect may be reduced if the physician expresses doubt about the effectiveness of the medication. Additionally, overly focus on side effects in the doctor-patient conversation about proposed treatments seems to influence the magnitude of perceived side effects in the patient. Thus, shared decision-making might be a desirable tool for ensuring better expectations in the patient and successful symptom relief. CONCLUSIONS: The context of the doctor-patient interplay matters. Placebo-nocebo research provides strong evidence for this link. The therapeutic context induces biomedical processes in the patient's brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects. KEY POINTS Increased awareness of the context drug may help GPs alleviate symptoms and better motivate patients for treatment. Treatment is affected by multiple types of context, as also confirmed by placebo-nocebo research. The therapeutic context influences the biomedical processes, which may enhance or reduce intervention effects on symptoms. The impact of context should be considered in daily general practice as it may serve as a drug, with real effects and side effects.

A differentiated approach to referrals from general practice to support early cancer diagnosis - the Danish three-legged strategy.

When aiming to provide more expedited cancer diagnosis and treatment of cancer at an earlier stage, it is important to take into account the symptom epidemiology throughout the pathway, from first bodily sensation until the start of cancer treatment. This has implications for how primary-care providers interpret the presentation and decisions around patient management and investigation. Symptom epidemiology has consequences for how the health-care system might best be organised. This paper argues for and describes the organisation of the Danish three-legged strategy in diagnosing cancer, which includes urgent referral pathways for symptoms suspicious of a specific cancer, urgent referral to diagnostic centres when we need quick and profound evaluation of patients with nonspecific, serious symptoms and finally easy and fast access to 'No-Yes-Clinics' for cancer investigations for those patients with common symptoms in whom the diagnosis of cancer should not be missed. The organisation of the health-care system must reflect the reality of symptoms presented in primary care. The organisational change is evaluated and monitored with a comprehensive research agenda, data infrastructure and education.

Childhood cancer and factors related to prolonged diagnostic intervals: a Danish population-based study.

BACKGROUND: Early diagnosis of childhood cancer provides hope for better prognoses. Shorter diagnostic intervals (DI) in primary care require better knowledge of the association between presenting symptoms, interpretation of symptoms and the wording of the referral letter. METHODS: A Danish nationwide population-based study. Data on 550 children aged <15 years with an incident cancer diagnosis (January 2007-December 2010) were collected through questionnaires to parents (response rate=69%) and general practitioners (GPs) (response rate=87%). The DI from the first presentation in general practice until diagnosis was categorised as short or long based on quartiles. Associations between variables and long DIs were assessed using logistic regression. RESULTS: The GPs interpreted symptoms as 'vague' in 25.4%, 'serious' in 50.0% and 'alarm' in 19.0% of cases. Symptom interpretation varied by cancer type (P<0.001) and was associated with the DI (P<0.001). Vomiting was associated with a shorter DI for central nervous system (CNS) tumours, and pain with a longer DI for leukaemia. Referral letter wording was associated with DI (P<0.001); the shortest DIs were observed when cancer suspicion was raised in the letter. CONCLUSION: The GPs play an important role in recognising early signs of childhood cancer as their symptom interpretation and referral wording have a profound impact on the diagnostic process.

Patient involvement and expectations during CT scans. Tinkering to involve patients and offer care in radiographic practice.

INTRODUCTION: This study investigated how patients expected and experienced to be put first and cared for in diagnostic imaging settings and how putting the patient first was operationalized in practice. METHODS: A qualitative field study was conducted in two Danish hospitals to investigate patients' expectations and experiences of care and involvement during CT examinations. Data collection methods included semi-structured interviews and participant observations of five examination cases. Three Computed Tomography (CT) guided lung biopsy intervention studies and two conventional CT studies of the chest of patients being investigated for lung cancer in Fast Track Cancer Referral Programs (FTCRP) were included. RESULTS: Patients reported low expectations of receiving care and being involved during examinations. Perceptions of receiving care predominantly consisted of being received in a kind, personalized manner. Expectations of involvement in the procedure were reported in terms of readiness to do as they were told, complying with requests put to each patient. Concepts of care and involvement were challenged in their formal meanings and found to be entangled in complex interactions within sociotechnical boundaries. CONCLUSION: Patient's expectations of receiving care and being involved in the diagnostic imaging procedures, were expressed in noncommittal terms, and were overshadowed by patients' focus on getting through the examination, in order to get an answer to their tentative diagnose. The concepts of care and patient involvement were negotiated and reconceptualized within the sociotechnical framework of the diagnostic imaging situation of the individual patient. The concept of "tinkering" is suggested as a means of understanding how patientcare is performed during diagnostic imaging procedures. IMPLICATIONS FOR PRACTICE: Issues were identified that may help professionals to put "the patient first", thus, improving patient centered care.

The Aarhus statement: improving design and reporting of studies on early cancer diagnosis.

Early diagnosis is a key factor in improving the outcomes of cancer patients. A greater understanding of the pre-diagnostic patient pathways is vital yet, at present, research in this field lacks consistent definitions and methods. As a consequence much early diagnosis research is difficult to interpret. A consensus group was formed with the aim of producing guidance and a checklist for early cancer-diagnosis researchers. A consensus conference approach combined with nominal group techniques was used. The work was supported by a systematic review of early diagnosis literature, focussing on existing instruments used to measure time points and intervals in early cancer-diagnosis research. A series of recommendations for definitions and methodological approaches is presented. This is complemented by a checklist that early diagnosis researchers can use when designing and conducting studies in this field. The Aarhus checklist is a resource for early cancer-diagnosis research that should promote greater precision and transparency in both definitions and methods. Further work will examine whether the checklist can be readily adopted by researchers, and feedback on the guidance will be used in future updates.

Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care.

BACKGROUND: The relationship between the diagnostic interval and mortality from colorectal cancer (CRC) is unclear. This association was examined by taking account of important confounding factors at the time of first presentation of symptoms in primary care. METHODS: A total of 268 patients with CRC were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from first presentation of symptoms until diagnosis. We analysed patients separately according to the general practitioner's interpretation of symptoms. Logistic regression was used to estimate 3-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for tumour site, comorbidity, age, and sex. RESULTS: In patients presenting with symptoms suggestive of cancer or any other serious illness, the risk of dying within 3 years decreased with diagnostic intervals up to 5 weeks and then increased (P=0.002). In patients presenting with vague symptoms, the association was reverse, although not statistically significant. CONCLUSION: Detecting cancer in primary care is two sided: aimed at expediting ill patients while preventing healthy people from going to hospital. This likely explains the counterintuitive findings; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, this study provides evidence for the hypothesis that the length of the diagnostic interval affects mortality in CRC patients.

Social support, gender and patient delay.

BACKGROUND: The purpose of this study was to examine the relationship between perceived social support and patient delay (PD) among female and male cancer patients. METHODS: A population-based study with register-sampled cancer patients was designed. Patient delay was defined as the time interval between the patient's experience of the first symptom and the first contact with a health-care professional. Both dates were provided by the patients (n=910). The patients completed a purpose-designed questionnaire, which assessed the patient's perceptions of how the partner reacted ('Partner Avoidance' and 'Partner Support') and how others in the social network responded ('Other Avoidance' and 'Other Support') to the patient's worries about the symptoms. The associations between the social support subscales and PD were analysed separately for men and women. RESULTS: In female patients, Partner Support and Other Support were associated with shorter PD, whereas Other Avoidance was associated with longer PD. In the multivariate analysis, Other Avoidance remained associated with longer PD. Moreover, disclosure of symptoms to someone reduced the likelihood of a long PD in female patients. In male patients, none of the social support scales significantly increased or decreased the risk of a long PD in the univariate analysis, but Partner Support significantly decreased risk of a long PD in the multivariate analysis. CONCLUSIONS: The results of this study suggest that social support and avoidance from network members influence length of PD differently in male and female cancer patients. This gender difference may explain previous mixed findings obtained in this field.

First-trimester Down syndrome screening: pregnant women's knowledge.

OBJECTIVES: The primary aim of this study was to assess pregnant women's knowledge of first-trimester combined Down syndrome screening in a setting of required informed consent. As the secondary aim, we wanted to identify relevant differences in knowledge level among subgroups of pregnant women, including those informed in different ways about prenatal examinations. METHODS: Data stem from a population-based cross-sectional questionnaire study including 15 multiple-choice questions assessing knowledge of different aspects of screening. Included were 6427 first-trimester pregnant women from three Danish obstetric departments offering prenatal screening free of charge. Both participants and non-participants in the screening program were included. The results are based on 4095 responders (64%). Differences between subgroups were examined using chi-squared tests and logistic regression analysis. Estimates are stated with 95% CI. RESULTS: The majority of the participants (87.6 (86.6-88.6)% to 92.6 (91.7-93.3)%) correctly identified the test concept and the main condition being screened for. Fewer participants (16.4 (15.3-17.6)% to 43.3 (41.8-44.8)%) correctly recognized test accuracy and the potential risk of adverse findings other than Down syndrome. Knowledge level was positively associated with length of education (adjusted ORs 1.0 (0.8-1.4) to 3.9 (2.4-6.4)) and participation in the screening program (adjusted OR 0.9 (0.6-1.3) to 5.9 (3.9-8.8)). Participation in an individual information session was weakly associated with more knowledge. CONCLUSION: The majority of the pregnant women correctly identified the test concept and the main condition being screened for. The pregnant women were found less knowledgeable on test accuracy and drawbacks.

Delay in diagnosis: the experience in Denmark.

BACKGROUND: Denmark has poorer 5-year survival rates than many other Western European countries, and cancer patients tend to have more advanced stages at diagnosis than those in other Scandinavian countries. Part of this may be due to delay in diagnosis. The aim of this paper is to give an overview of the initiatives currently underway to reduce delays. METHODS: Description of Danish actions to reduce delay. RESULTS: Results of surveys of patient-, doctor- and system-related delays are presented and so are the political initiatives to ensure that cancer is seen as an acute disease. CONCLUSION: In future, fast-track diagnosis and treatment will be provided for suspected cancers and access to general diagnostic investigations will be improved. A large national experiment with cancer seen as an acute disease is currently being implemented, and as yet the results are unknown.

Are Cancer Patients' Socioeconomic and Cultural Factors Associated with Contact to General Practitioners in the Last Phase of Life?

Introduction. General practitioners (GPs) play an important role in end of life care, which should be offered regardless of socioeconomic position and cultural factors. The aim was to analyse associations between GP contacts at the end of life and socioeconomic and cultural characteristics of Danish cancer patients. Method. Population-based study identifying 599 adults who died of cancer from March to November 2006, in Aarhus County, Denmark. Associations between health register-based data on "total GP face-to-face contacts" and "GP home visits" during the last 90 days of life and patients' socioeconomic and cultural characteristics were calculated. Results. Having low income (RR: 1.18 (95% CI: 1.03; 1.35)) and being immigrants or descendants of immigrants (RR: 1.17 (95% CI: 1.02; 1.35)) were associated with GP face-to-face contacts. However, patients living in large municipalities had lower likelihood of having both GP face-to-face contacts in general (RR: 0.85 (95% CI: 0.77;0.95)) and GP home visits (RR: 0.89 (95% CI: 0.80; 0.99)). Conclusion. This study indicates higher proportion of GP contacts to economically deprived patients and immigrants/descendants of immigrants. These subgroups were, however, small and results should be looked upon with caution. Furthermore, palliative needs were not included and together with urban/rural the underlying causes need further investigation.

A case-control study of cervical cytology before diagnosis of cervical cancer in Denmark.

The number of previous vaginal smear examinations in 428 patients who developed invasive cancer of the cervix was compared with previous screening in age- and area-matched controls. The average age was 53 years. There was a highly significant difference in the numbers who had never undergone screening, ie 55% of the cancer patients and 33% of the controls. Equally there was a highly significant difference between cases and controls in the number examined according to recommended guidelines for prophylactic examination. It was shown that about 40% of the cytological tests were done for gynaecological reasons, and it is probable that the number of false negatives among the cases was not negligible. Despite this, however, regular screening reduced the relative risk of cancer to about 0.25, compared with those never examined. When only symptomless patients were considered in the assessment of regular screening, the relative risk was reduced to 0.15 in patients screened every three years. Even the group which was screened more than five years previously had a relative reduction in risk to 0.67, compared with those never screened. It is concluded that PAP-smears are important in the prevention of cancer of the cervix. The greatest need is to eliminate the group which is never examined. An increase in the number of screenings has only a marginal benefit.

Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy.

OBJECTIVE: To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity. DESIGN: Independent double-blind study. SETTING: University medical hospital. PATIENT(S): One hundred six consecutive premenopausal women who underwent hysterectomy for benign diseases. INTERVENTION(S): Results of MRI, TVS, HSE, and hysteroscopy were compared with the results of histopathologic examination at hysterectomy (the gold standard). RESULT(S): The overall sensitivity was MRI 0.76, TVS 0.69, HSE 0.83, and hysteroscopy 0.84. The specificity was MRI 0.92, TVS 0.83, HSE 0.90, and hysteroscopy 0.88 (MRI, HSE, hysteroscopy vs. TVS <0.05). Polyps were missed in 9 of 12 cases at MRI, 7 at TVS, 4 at HSE, and 2 at hysteroscopy (MRI vs. hysteroscopy, and TVS vs. hysteroscopy <0.05). The sensitivity for identification of submucous myomas was MRI 1.0, TVS 0.83, HSE 0.90, and hysteroscopy 0.82; the specificity was MRI 0.91, TVS 0.90, HSE 0.89, and hysteroscopy 0.87 (MRI vs. TVS, and MRI vs. hysteroscopy). Magnetic resonance imaging was significantly more precise than TVS, HSE, and hysteroscopy in determining submucous myoma in-growth (2-way ANOVA <0.05). CONCLUSION(S): For exclusion of abnormalities in the uterine cavity, MRI, HSE, and hysteroscopy were equally effective and slightly superior to TVS. Magnetic resonance imaging and TVS missed endometrial abnormalities such as polyps, but MRI and HSE were most accurate for the evaluation of submucous myomas, and MRI was superior in evaluation of exact submucous myoma in-growth.

Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis.

OBJECTIVE: To compare the diagnostic potential of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVS) in the diagnosis of adenomyosis. DESIGN: Double blind set-up. SETTING: University medical school. PATIENT(S): We studied 106 consecutive premenopausal women who underwent hysterectomy for benign reasons. INTERVENTION(S): Transvaginal ultrasonography and MRI were compared with histopathologic examination as the golden standard. MAIN OUTCOME MEASURE(S): Adenomyosis. RESULT(S): Twenty-two (21%) patients had adenomyosis. The sensitivity and specificity were as follows: sensitivity: MRI 0.70 (0.46-0.87) and TVS 0.68 (0.44-0.86) (P=.66); specificity: MRI 0.86 (0.76-0.93) and TVS 0.65 (0.50-0.77) (P=.03). The combination of MRI and TVS was most sensitive (0.89 [0.64-0.98]), but produced the lowest specificity (0.60 [0.44-0.73]). Adenomyosis was not detected by either MRI or TVS at uterine volumes >400 mL. Exclusion of uteri >400 mL from the analysis improved the diagnostic precision of MRI, but not that of TVS. The diagnostic accuracy at MRI was improved by calculating the maximum difference between the thinnest and thickest junctional zone (JZdif) (i.e., > or =5-7 mm). CONCLUSION(S): Magnetic resonance imaging was superior to TVS for the diagnosis of adenomyosis. Magnetic resonance imaging had a higher specificity than TVS, but their sensitivities were in line. The diagnostic accuracy of MRI, as that of TVS, was at an intermediate level, but the diagnostic accuracy of the former improved by exclusion of uteri >400 mL. The combination of MRI and TVS produced the highest level of accuracy for exclusion of adenomyosis, but the low specificity may necessitate further investigation of positive findings. Measurement of the difference in junctional zone thickness may optimize the diagnosis of adenomyosis at MRI.

Comparison of patients' and general practitioners' evaluations of general practice care.

OBJECTIVES: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care. DESIGN: Written surveys among patients and GPs. SETTING: General practice in the Netherlands. SUBJECTS: 1772 patients (from 45 GPs) and a random sample of 315 GPs. MAIN OUTCOME MEASURES: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale. RESULTS: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone"). CONCLUSIONS: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

Randomised controlled trial of a shared care programme for newly referred cancer patients: bridging the gap between general practice and hospital.

OBJECTIVE: To determine the effect of a shared care programme on the attitudes of newly referred cancer patients towards the healthcare system and their health related quality of life and performance status, and to assess patients' reports on contacts with their general practitioner (GP). SETTING: Department of Oncology at Aarhus University Hospital and general practices. DESIGN: Randomised controlled trial in which patients completed questionnaires at three time points. The shared care programme included transfer of knowledge from the oncologist to the GP, improved communication between the parties, and active patient involvement. PARTICIPANTS: 248 consecutive cancer patients recently referred to the department. MAIN OUTCOME MEASURES: Patients' attitudes towards the healthcare services, their health related quality of life, performance status, and reports on contacts with their GPs. RESULTS: The shared care programme had a positive effect on patient evaluation of cooperation between the primary and secondary healthcare sectors. The effect was particularly significant in men and in younger patients (18-49 years) who felt they received more care from the GP and were left less in limbo. Young patients in the intervention group rated the GP's knowledge of disease and treatment significantly higher than young patients in the control group. The number of contacts with the GP was significantly higher in the intervention group. The EORTC quality of life questionnaire and performance status showed no significant differences between the two groups. CONCLUSIONS: An intersectoral shared care programme in which GPs and patients are actively involved has a positive influence on patients' attitudes towards the healthcare system. Young patients and men particularly benefit from the programme.

A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain.

To make health care more responsive to patient needs, insight into patient priorities is needed. A systematic literature review, using electronic and manual searches, was made of studies on patient priorities with regard to primary health care. Data-extraction was performed by two researchers, followed by systematic analyses of study features. 57 studies were included. The aspects of care and methods used showed a wide variation. Aspects most often included were "informativeness", "humaneness" and "competence/accuracy". Based on an analysis of 19 studies, the following aspects were seen by patients as most important in more than 50% of the studies that included them: "humaneness", "competence/accuracy", "patients' involvement in decisions", "time for care", "other aspects of availability/accessibility", "informativeness", "exploring patients' needs", "other aspects of relation and communication" and "availability of special services".

Characteristics of subgroups of attenders and non-attenders in an organised screening programme for cervical cancer.

OBJECTIVE: Several studies have compared attenders and non-attenders in organised cervical screening programmes but few have analysed subgroups of attenders and non-attenders. This study presents social and other characteristics of such subgroups. SETTING: Aarhus County, Denmark. METHODS: A case-control study in a cohort of 133,500 women, aged 23-60, included in the programme from 1 October 1990 to 1 April 1994. The participation rate was 75%, and those taking part comprised women with opportunistic screening or who had had a smear owing to symptoms in the previous three years ("active" attenders), and women who were invited for screening because they had not been otherwise tested ("passive" attenders). "Passive" (n = 708) and "active" attenders (n = 692) were compared. Women who had never had a smear test ("never" attenders, n = 287) were then compared with "ever" attenders (n = 1215)-that is, women who had not had a smear test during the previous 42 months, but had had at least one previous test. Data were collected by mailed questionnaires. RESULTS: The response rate was 81% and 53% for attenders and non-attenders, respectively. After correction for age, there was no difference between the "active" and "passive" attenders for cancer risk factors (smoking, age of first intercourse, number of sexual partners, and social group), or in the degree of responsibility for close relatives, but "active" attenders seemed to have more frequent contact with their general practitioner. "Never" attenders had less frequent contact with their general practitioner than "ever" attenders. They were more often living alone and nullipara, but had no overrepresentation of cancer risk factors. CONCLUSIONS: Increased effect cannot be obtained by focusing on the described groups, but by increasing the participation rate. "Never" attenders do not belong to a special risk group.

A comparative study of prescribing of hormone replacement therapy in USA and Europe.

OBJECTIVES: The use of hormone replacement therapy (HRT) has been shown to vary from one country to another through international studies of sample populations and by comparison of data obtained from comparable national studies. Drawing international prescribing comparisons is very difficult as data sources are few, incomplete and of uncertain accuracy and comparability. As an alternative to direct prescribing information, pharmaceutical sales information indicates medication used. This paper sought to demonstrate international differences in the use of HRT using an economic analysis methodology based on national pharmaceutical sales statistics. METHODS: A recognised economic analysis methodology was used to translate 1991/1992 pharmaceutical sales data into women treatment years of HRT used in each country. From this was calculated the percentage of the female population in each country, eligible for HRT, who would have been taking HRT. RESULTS: The results show a wide variance in the percentage of the eligible female population in each country calculated to have been taking HRT, from <1%-20%. The results indicated that HRT usage fell into three groupings: USA being the greatest user with UK and Scandinavian countries in the middle group and continental Europe having the lowest usage. CONCLUSIONS: National patterns of HRT usage, as calculated by this study, correlate well with those of other studies. Since similar morbidity could be expected as menopause is a naturally occurring event, not a disease, possible reasons for the variance in national prescribing patterns are discussed. The study indicates the need for further research on health beliefs and physicians' and women's attitudes to HRT in different countries to explain the variance in HRT usage, also considering access to healthcare, in particular women's health services. It confirms the validity of using economic analysis of pharmaceutical sales data as a proxy for prescribing data in the arena of prescribing research.

Patients with urinary tract infection: proposed management strategies of general practitioners, microbiologists and urologists.

BACKGROUND: It is difficult to implement change in general practice. It is not known how best to conduct effective continuing medical education in general practice. General practitioners' criteria for good clinical practice vary and it is unknown whether systematic education by hospital specialists could be expected to reduce variation between general practitioners. AIM: A study was undertaken to describe general practitioners', microbiologists' and urologists' strategies for diagnosis, treatment, and follow up of female patients with symptoms of urinary tract infection, a common reason for consultation in general practice. The findings of the study were to be used as a base upon which to discuss the advantages and disadvantages of using hospital specialists as a resource in general practitioners' peer group based continuing medical education. METHOD: Three vignettes together with several proposals for diagnosis, treatment and follow up were presented in a questionnaire to general practitioners, microbiologists and urologists in Denmark. The case histories concerned three female patients (aged 10, 30 and 60 years) who consulted their general practitioner for advice. The female patients were otherwise healthy and well known to the practice. General practitioners', microbiologists' and urologists' recommendations for good clinical practice were compared. RESULTS: A total of 154 general practitioners (77%), 45 microbiologists (51%) and 54 urologists (61%) who were eligible for the study responded to the questionnaire. There was considerable variation in the management strategies proposed by doctors within each specialty and between the specialties. Microbiologists and urologists were more likely to suggest treating the 30-year-old woman by giving advice and a prescription by telephone compared with their general practitioner colleagues. Conversely, the microbiologists and urologists were more likely to suggest asking the 10- and 60-year-old patients to attend the clinic for examination compared with the general practitioners. The general practitioners reported asking the patients to return for follow up more commonly than the hospital specialists. CONCLUSION: Large variation in suggested strategies for diagnosis, treatment and follow up was shown both within and between specialties. Continuing medical education of general practitioners based on small peer group discussions using hospital specialists as a group resource would not necessarily reduce variation in clinical practice between general practitioners. A need for evidence-based rather than consensus-directed guidelines would be needed in order to reduce variation in clinical practice between doctors.

Psychological distress and somatisation as prognostic factors in patients with musculoskeletal illness in general practice.

BACKGROUND: Musculoskeletal illness is a common cause of absenteeism from work, workers' compensation, and disability retirement, and accounts for 9.3% to 17% of patient contacts in general practice. To understand the increase in self-reported musculoskeletal illness and to improve treatment and prevention, it is important to know which factors to target when dealing with these patients. AIM: To investigate whether the prognosis for patients with musculoskeletal illness referred to physiotherapy from general practice can be predicted by the presence of psychological distress and somatisation identified by a general practitioner (GP) and standard questionnaires. METHOD: A multi-practice survey based on questionnaires (index and three-month follow-up). Nine hundred and five consecutive patients referred to physiotherapy from 124 different general practices in Denmark were included. Outcome measures were physical health change, sick leave, patient self-rated improvement, and change in use of medication. RESULTS: Psychological distress and somatisation rated by both GPs and standard questionnaires acted with almost no exception as significant predictors of all four outcome measures. CONCLUSION: Psychological distress and somatisation are important factors when considering preventive initiatives and treatment of patients with musculoskeletal illness in general practice.