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Evidence-based problem solving: What is the efficacy of pneumococcal vaccination in people with asthma?
Aims: To determine the efficacy of pneumococcal vaccination in asthmatic patients using a pragmatic evidence-based approach to solve therapeutic problems. Methods: Use of local information, expert-opinion guidelines, evidence-based guidelines and a systematic literature search of the Medline database to identify clinical trials designed to assess vaccine efficacy among asthmatics. Results: Expert-opinion guidelines advocating the use of pneumococcal vaccine among asthmatics were found, but there was no evidence-based assessment of vaccine efficacy among asthmatics. The Medline database described no clinical trials that specifically addressed our question, although a number of studies assessing broader question of overall vaccine efficacy were identified, with conflicting results. Conclusions: Current UK expert opinion recommends that people with asthma receive pneumococcal vaccination, but there is little high-quality evidence to support this. The search strategy used may be adapted to address other therapeutic questions that may arise in primary care consultations.
Writing research protocols: An innovative approach
Aims: To develop a mechanism to write three research protocols within 10 hours while simultaneously enhancing the research protocol writing skills of participants. Method: Members of the General Practitioners In Asthma Group (GPIAG) were invited to attend a research protocol workshop with pre- and post-workshop questionnaires. The main outcome measures were the development of three detailed research protocols and improvement in participants' perceived research protocol writing skills. Results: Three detailed research protocols were completed within the time allocated. Thirty (88%) participants completed pre- and post-workshop questionnaires. Participants believed there were improvements in their ability to formulate an answerable research question (p < 0.01), choose an appropriate methodology to answer the question (p < 0.01), choose appropriate outcome measures (p = 0.03), choose appropriate statistical methods (p = 0.01), devise a research timetable (p < 0.01), and improve their overall ability to write a research protocol (p < 0.01). Conclusion: It is possible to identify a mechanism, based on a weekend workshop, to write accelerated research protocols whilst simultaneously significantly increasing the research protocol writing skills of participants. This approach has potential to promote the development of research skills within primary care.
Pneumococcal vaccination: A practice based audit
Objective: To audit the use of pneumococccal vaccine in patients at increased risk of pneumococcal infection, in a general practice setting. Design: Computer and manual search of patient records - before and one year after intervention. Setting and subjects: All patients registered at a four partner, inner-city, training practice in Wembley. Intervention: Practice based pneumococcal vaccination campaign, with implementation of practice protocol, and clinical guidelines issued to all members of the primary health care team. Outcome Measures: Proportion of patients at risk of pneumococcal infection that had been vaccinated on 16th May 1998, compared with proportion vaccinated on 1st April 1997. Results: Significant increase in the proportion of patients that had been vaccinated from 2 (0%) before the intervention to 60 (7.6%) one year later (p < 0.001, 95% CI 5.4 - 9.2%). Conclusions: A practice based campaign can deliver significant improvements in pneumococcal vaccination uptake in patients considered to be at risk of pneumococcal disease.
Undergraduate allergy teaching in a UK medical school: mapping and assessment of an undergraduate curriculum.
BackgroundConcerns have been expressed by patient and professional bodies, and the UK Parliamentary Health Select Committee, about the poor standard of allergy teaching in UK medical schools. It is argued that this deficiency is an important contributing factor to the generally poor quality of care experienced by patients with allergic disorders. Allergy services are currently being reviewed by the Scottish Executive and Department of Health for England.ObjectiveTo describe and map the teaching of allergy-related topics in the formal undergraduate curriculum of a UK medical school.MethodsWe undertook a systematic analysis of learning objectives and other electronic documentation of modules taught during the five years of undergraduate medical training at the University of Edinburgh.ResultsAllergy and allergy-related topics are mentioned within the learning objectives of 11 (26%) of the 43 modules in the five-year MBChB curriculum. Our overall assessment reveals significant gaps in the described curriculum regarding allergy-related topics.ConclusionAlthough formal teaching on allergic disorders has been identified in a number of modules throughout the five years, it is not comprehensively described in the course documentation and significant gaps exist. We accept that the delivered curriculum may not be captured by the level of detail present in the learning objectives and recommend that further mapping and triangulation is undertaken through student focus groups and information gathering from teaching staff. We also recommend that in the absence of informal and clinical attachment opportunities in allergic disorders, the stated learning objectives be developed into a coherent vertical element throughout the medical curriculum. This, together with an advocate and suitable assessment, would increase the impact of allergy training on students and emphasise the knowledge and skills required to deliver high quality allergy care.
Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study.
ObjectiveTo understand factors influencing patients' decisions to attend for outpatient follow up consultations for asthma and to explore patients' attitudes to telephone and email consultations in facilitating access to asthma care.DesignExploratory qualitative study using in depth interviews.SettingHospital outpatient clinic in West London.ParticipantsNineteen patients with moderate to severe asthma (12 "attenders" and 7 "non-attenders").ResultsPatients' main reasons for attending were the wish to improve control over asthma symptoms and a concern not to jeopardise the valued relationship with their doctor. Memory lapses, poor health, and disillusionment with the structure of outpatient care were important factors implicated in non-attendance. The patients were generally sceptical about the suggestion that greater opportunity for telephone consulting might improve access to care. They expressed concerns about the difficulties in effectively communicating through non-face to face media and were worried that clinicians would not be in a position to perform an adequate physical examination over the telephone. Email and text messaging were viewed as potentially useful for sending appointment reminders and sharing clinical information but were not considered to be acceptable alternatives to the face to face clinic encounter.ConclusionsMemory lapses, impaired mobility due to poor health, and frustration with outpatient clinic organisation resulting in long waiting times and discontinuity of care are factors that deter patients from attending for hospital asthma assessments. The idea of telephone review assessments was viewed with scepticism by most study subjects. Particular attention should be given to explaining to patients the benefits of telephone consultations, and to seeking their views as to whether they would like to try them out before replacing face to face consultations with them. Email and text messaging may have a role in issuing reminders about imminent appointments.
Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK.
BackgroundPrimary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK.MethodsUsing a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews.ResultsThe 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependent on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service.ConclusionThe introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.
Antibiotics versus placebo for acute bacterial conjunctivitis.
BackgroundThere are concerns about whether antibiotic therapy confers significant clinical benefit in the treatment of acute bacterial conjunctivitis.ObjectivesThe aim of this review was to assess the benefit and harm of antibiotic therapy in the management of acute bacterial conjunctivitis.Search strategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register), MEDLINE, EMBASE, SIGLE, NRR, PubMed and the reference lists of identified trial reports. We used the Science Citation Index to look for articles that cited the relevant studies, and we contacted investigators and pharmaceutical companies for information about additional trials.Selection criteriaWe included double masked randomised controlled trials in which any form of antibiotic treatment had been compared with placebo in the management of acute bacterial conjunctivitis. This included topical, systemic and combination (for example, antibiotics and steroids) antibiotic treatments.Data collection and analysisOne author extracted data and the accuracy was checked by a second author.Main resultsThis review includes five trials which randomised a total of 1034 participants. One further trial is currently 'awaiting assessment'. This has been published in abstract form and has yet to be fully reported. Three of the trials have been conducted on a selected specialist care patient population and the two more recent trials have been conducted in a community care setting. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. Meta-analyses of data on clinical and microbiological remission rates reveal that topical antibiotics are of benefit in improving early (days 2 to 5) clinical (RR 1.24, 95% CI 1.05 to 1.45) and microbiological (RR 1.77, 95% CI 1.23 to 2.54) remission rates; later (days 6 to 10) data reveal that these early advantages in clinical (RR 1.11, 95% CI 1.02 to 1.21) and microbiological cure rates are reduced (RR 1.56, 95% CI 1.17 to 2.09), but persist. Most cases however resolve spontaneously with clinical remission being achieved in 65% (95% CI 59 to 70) by days 2 to 5 in those receiving placebo. No serious outcomes were reported in either the active or placebo arms of these trials, indicating that important sight-threatening complications are an infrequent occurrence.Authors' conclusionsAcute bacterial conjunctivitis is frequently a self-limiting condition, but the use of antibiotics is associated with significantly improved rates of clinical and microbiological remission.