Attitudes of women with menstrual disorders to the use of clinical guidelines in their care.

BACKGROUND: Despite their growing influence on patient management and outcomes, very little is known about patients' perceptions of clinical guidelines. This is a significant omission, particularly for services advocating patient-centred care and informed decision making. OBJECTIVES: To explore the knowledge and attitudes of women with menstrual disorders towards the use of evidence-based clinical guidelines for their condition. METHODS: Semi-structured interviews were conducted with women with menstrual disorders. RESULTS: Some women were not aware of the existence of clinical guidelines for their condition. Many were unsure as to their exact nature. The most consistent interpretation of guidelines was as a 'set of rules'. Numerous positive aspects of the use of guidelines were identified, for example, ensuring quality and safety for patients, earlier diagnosis, reducing waiting times and improving continuity of care. Negative views involved seeing guidelines as a tool for rationing and concerns over inflexibility. Patients recognized that implementation of guidelines in general practice can be problematic, especially if resources are not made available. An unmet need for information became apparent in this group of patients. Many women felt that they should have access to guidelines that are being used in their medical care and that guidelines had the potential to act as an information resource for patients. CONCLUSIONS: A patient-centred service should endeavour to increase patient awareness of the existence and use of clinical guidelines. A patient version of clinical guidelines may be useful in promoting patients involvement in decision making and may improve outcomes.

The efficacy and safety of PDE5 inhibitors.

Inhibition of phosphodiesterase-5 (PDE5) reduces the degradation of cyclic guanosine monophosphate, which allows erectile function to occur by relaxation of penile smooth muscle. Three PDE5 inhibitors (sildenafil, tadalafil, and vardenafil) in a range of doses are available. PDE5 therapy, compared with placebo, significantly improves scores on the International Index of Erectile Function and has been found to be effective in special clinical populations, such as those with prostate cancer, diabetes, and cardiovascular disease. Sildenafil and vardenafil show some interaction with food intake. Time to onset of action is usually 30-120 minutes, but there are reports of shorter times to onset of action. The duration of action of sildenafil and vardenafil is about 4 hours, whereas that of tadalafil is about 36 hours. The overall safety of the treatments is good, even in patients with a history of cardiovascular disease. However, there is a risk of hypotension if nitrates are given concurrently. Increased QTc intervals have been reported, the longest with vardenafil, shortest with tadalafil, and intermediate with sildenafil. Priapism and prolonged erection are rare adverse events. Common side-effects include headache, facial flushing, nasal congestion, and dyspepsia. There may be interactions with other medications metabolized in a similar way, such as erythromycin and HIV protease inhibitors.

Cluster randomised controlled trial of an educational outreach visit to improve influenza and pneumococcal immunisation rates in primary care.

BACKGROUND: Improvement in the delivery of influenza and pneumococcal vaccinations to high-risk groups is an important aspect of preventive care for primary healthcare teams. AIM: To investigate the effect of an educational outreach visit to primary healthcare teams on influenza and pneumococcal vaccination uptake in high-risk patients. DESIGN: Cluster randomised controlled trial. SETTING: Thirty general practices in the Trent region, UK. METHODS: Fifteen practices were randomised to intervention and 15 to the control group after stratifying for baseline vaccination rate. All intervention practices were offered and received an educational outreach visit to primary healthcare teams, in addition to audit and feedback directed at improving influenza and pneumococcal vaccination rates in high-risk groups. Control practices received audit and feedback alone. All practices measured influenza and pneumococcal vaccination rates in high-risk groups. Primary outcomes were improvements in vaccination rates in patients aged 65 years and over, and patients with coronary heart disease (CHD), diabetes and a history of splenectomy. RESULTS: Improvements in pneumococcal vaccination rates in the intervention practices were significantly greater compared with controls in patients with CHD, 14.8% versus 6.5% (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.13 to 1.34) and diabetes, 15.5% versus 6.8% (OR = 1.18, 95% CI = 1.08 to 1.29) but not splenectomy, 6.5% versus 4.7% (OR = 0.96, 95% CI = 0.65 to 1.42). Improvements for influenza vaccination were also usually greater in intervention practices but did not reach statistical significance. The increases for influenza vaccination in intervention versus control practices were for CHD, 18.1% versus 13.1% (OR = 1.06, 95% CI = 0.99 to 1.12); diabetes, 15.5% versus 12.0% (OR = 1.07, 95% CI = 0.99 to 1.16), splenectomy 16.1% versus 2.9% (OR = 1.22, 95% CI = 0.78 to 1.93); and those over 65 years 20.7% versus 25.4% (OR = 0.99, 95% CI = 0.96 to 1.02). CONCLUSION: Practices where primary care teams received an educational outreach visit demonstrated a significantly greater improvement in uptake in high-risk groups for pneumococcal but not influenza vaccine.

Limited role of multi-attribute utility scale and SF-36 in predicting management outcome of heavy menstrual bleeding.

OBJECTIVE: To compare the value of SF36v2 versus multi-attribute utility score (MAS) for predicting treatment outcome in heavy menstrual bleeding (HMB). STUDY DESIGN: Longitudinal observational study, in an outpatient service of a large UK teaching hospital. 193 women took part. Women were asked to complete SF36v2 and a multi-attribute utility score (MAS) for menorrhagia before the first consultation. Patient management was determined through an evidence based guideline and blind to their response to the questionnaire. Treatment outcome at 8 months was examined in relation to the physical (PCS) and mental (MCS) health summary scales of SF36v2 and to MAS. RESULTS: At study entry equal numbers of patients, 179 (93%), returned usable responses for SF36v2 and the multi-attribute scale; 178 (92%) returned both. Baseline SF36v2 scores for role physical, bodily pain, social functioning and mental health were significantly lower (p<0.05) for the group of women who finally required surgery, but the difference in PCS or MCS was not statistically significant. The mean MAS score for those who did not need surgery was 50.7, and for those who needed surgery following failed medical treatment was 35.06. The difference was statistically significant (p<0.001, 95% CI 7.47-23.82). Using logistic regression analysis there was a statistically significant association between baseline MAS but not MCS or PCS and the need for surgery. However, there was considerable overlap between treatment groups. CONCLUSIONS: MAS may be a better predictor of management outcome compared to SF36v2 for HMB; but its utility for the individual patient is limited.

Primary healthcare teams' views on using mortality data to review clinical policies.

BACKGROUND AND OBJECTIVE: A UK-wide scheme to monitor mortality in general practices has been recommended to improve safety. A monitoring scheme might also have a role in improving quality by informing clinical policies. This study investigated the views of primary care teams on the desirable characteristics of mortality data to help them review and plan their clinical policies. SETTING: 10 general practices in Leicestershire, UK. METHODS: Development of a format for presentation of mortality data for primary care teams, presentations of the data to team meetings, and subsequent interviews of 16 general practitioners and nurses to identify issues about the improvement and use of the data for informing clinical policies. RESULTS: The presentation was important in helping teams to understand the data. Comparisons should be between practices with similar patient populations, and information provided on deaths from diseases potentially amenable to prevention through clinical intervention. Practice teams used the data in reflecting on their own clinical care. CONCLUSIONS: Presentation of data about mortality in practice populations can enable practices to reflect on their clinical policies. The proposed national scheme for monitoring mortality should provide data in a format that helps teams to improve the quality of care as well as improve patient safety.

Making use of mortality data to improve quality and safety in general practice: a review of current approaches.

OBJECTIVE: To review studies of the use of mortality data in quality and safety improvement in general practice. DESIGN: Narrative review. METHODS: Search of Medline, Embase and CINAHL for articles reporting mortality monitoring or mortality reviews in general practice. The included articles were reported in English and of any study design, excluding case reports and comment pieces. Studies of palliative care and bereavement, and of primary care programmes in developing countries, were excluded. RESULTS: 229 articles were identified in the searches, 65 were identified as potentially relevant and 53 were included in the review. The studies addressed the impact of primary care provision on mortality rates, methods of monitoring mortality, and the role of audit and death registers in quality and safety improvement. General practitioners were interested in using mortality data but reported difficulties in obtaining complete information. There were no experimental studies of the impact of the use of mortality data, and little evidence of long-term systematic initiatives to use mortality data in quality and safety improvement in general practice. CONCLUSIONS: Mortality data are not used systematically in general practice although general practitioners appear interested in the potential of this information in improving quality and safety. Improved systems to provide complete data are needed and experimental studies required to determine the effectiveness of use of the data to improve general practice care.

An integrated care pathway for menorrhagia across the primary-secondary interface: patients' experience, clinical outcomes, and service utilisation.

BACKGROUND: "Referral" characterises a significant area of interaction between primary and secondary care. Despite advantages, it can be inflexible, and may lead to duplication. OBJECTIVE: To examine the outcomes of an integrated model that lends weight to general practitioner (GP)-led evidence based care. DESIGN: A prospective, non-random comparison of two services: women attending the new (Bridges) pathway compared with those attending a consultant-led one-stop menstrual clinic (OSMC). Patients' views were examined using patient career diaries, health and clinical outcomes, and resource utilisation. Follow-up was for 8 months. SETTING: A large teaching hospital and general practices within one primary care trust (PCT). RESULTS: Between March 2002 and June 2004, 99 women in the Bridges pathway were compared with 94 women referred to the OSMC by GPs from non-participating PCTs. The patient career diary demonstrated a significant improvement in the Bridges group for patient information, fitting in at the point of arrangements made for the patient to attend hospital (ease of access) (p<0.001), choice of doctor (p = 0.020), waiting time for an appointment (p<0.001), and less "limbo" (patient experience of non-coordination between primary and secondary care) (p<0.001). At 8 months there were no significant differences between the two groups in surgical and medical treatment rates or in the use of GP clinic appointments. Significantly fewer (traditional) hospital outpatient appointments were made in the Bridges group than in the OSMC group (p<0.001). CONCLUSION: A general practice-led model of integrated care can significantly reduce outpatient attendance while improving patient experience, and maintaining the quality of care.