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Purpose: To assess the effect of a primary care-based community-links practitioner (CLP) intervention on patients' quality of life and well-being.Methods: Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months.Primary Outcome: health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity).Secondary Outcomes: well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked.Results: Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources.Conclusions: We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach. [ABSTRACT FROM AUTHOR]

Purpose: The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation.Methods: We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups.Results: In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727).Conclusions: In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation.Methods: We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat.Results: Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue.Conclusions: It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas.Trial Registration: Trial Registration: ISRCTN 34092919 , assigned 14/1/2013. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity prevalence rates vary considerably depending on the conditions considered in the morbidity count, but there is no standardised approach to the number or selection of conditions to include. Methods and findings: We conducted a cross-sectional study using English primary care data for 1,168,260 participants who were all people alive and permanently registered with 149 included general practices. Outcome measures of the study were prevalence estimates of multimorbidity (defined as ≥2 conditions) when varying the number and selection of conditions considered for 80 conditions. Included conditions featured in ≥1 of the 9 published lists of conditions examined in the study and/or phenotyping algorithms in the Health Data Research UK (HDR-UK) Phenotype Library. First, multimorbidity prevalence was calculated when considering the individually most common 2 conditions, 3 conditions, etc., up to 80 conditions. Second, prevalence was calculated using 9 condition-lists from published studies. Analyses were stratified by dependent variables age, socioeconomic position, and sex. Prevalence when only the 2 commonest conditions were considered was 4.6% (95% CI [4.6, 4.6] p < 0.001), rising to 29.5% (95% CI [29.5, 29.6] p < 0.001) considering the 10 commonest, 35.2% (95% CI [35.1, 35.3] p < 0.001) considering the 20 commonest, and 40.5% (95% CI [40.4, 40.6] p < 0.001) when considering all 80 conditions. The threshold number of conditions at which multimorbidity prevalence was >99% of that measured when considering all 80 conditions was 52 for the whole population but was lower in older people (29 in >80 years) and higher in younger people (71 in 0- to 9-year-olds). Nine published condition-lists were examined; these were either recommended for measuring multimorbidity, used in previous highly cited studies of multimorbidity prevalence, or widely applied measures of "comorbidity." Multimorbidity prevalence using these lists varied from 11.1% to 36.4%. A limitation of the study is that conditions were not always replicated using the same ascertainment rules as previous studies to improve comparability across condition-lists, but this highlights further variability in prevalence estimates across studies. Conclusions: In this study, we observed that varying the number and selection of conditions results in very large differences in multimorbidity prevalence, and different numbers of conditions are needed to reach ceiling rates of multimorbidity prevalence in certain groups of people. These findings imply that there is a need for a standardised approach to defining multimorbidity, and to facilitate this, researchers can use existing condition-lists associated with highest multimorbidity prevalence. Using a UK wide primary-care dataset and including more than 80 index conditions, Clare MacRae and colleagues report multimorbidity prevalence and how prevalence estimates change when varying the number and type of index conditions. Author summary: Why was this study done?: There is wide variety in the conditions considered by researchers when measuring multimorbidity prevalence. A systematic review of 566 studies, published in 2021, found lack of consensus in the selection of conditions considered. In half of studies only 8 conditions (diabetes, stroke, cancer, chronic obstructive pulmonary disease, hypertension, coronary heart disease, chronic kidney disease, and heart failure) were consistently considered, and the number of conditions considered varied from 2 to 285 (median 17). A more consistent approach to measuring multimorbidity is needed to facilitate comparability and generalisability across studies. What did the researchers do and find?: We examined the impact of varying the conditions considered when measuring multimorbidity prevalence. We combined different numbers of conditions (from a list of 80) and selections of conditions (using 9 published condition-lists used to define and measure comorbidity, multimorbidity, and its prevalence) to determine how multimorbidity prevalence changed. All conditions were counted in the same way using publicly available code lists. There are large differences in prevalence, a range of 4.6% to 40.5%, when different numbers and selections of conditions are considered. People who are the oldest, living in the most deprived areas, and men require fewer conditions to be considered to reach close to multimorbidity prevalence when considering all 80 conditions (the ceiling effect, where the prevalence approaches the upper limit of prevalence possible in the study). Highest multimorbidity prevalence was found when using the Ho always + usually (derived from a recent Delphi consensus study), Barnett (widely used to measure multimorbidity prevalence), and Fortin (recommended for use in measuring multimorbidity) condition-lists. What do these findings mean?: There is a need for standardisation when measuring multimorbidity prevalence so that results across studies are comparable and population subgroups are accurately represented. To address this, researchers can consider using the Ho always + usually, Barnett, or Fortin condition-lists that report the highest and most stable estimates of multimorbidity prevalence (where adding further conditions to the count had very little impact). [ABSTRACT FROM AUTHOR]

Background: The Consultation and Relational Empathy (CARE) Measure is a widely used patient-rated experience measure which has recently been translated into Chinese and has undergone preliminary qualitative and quantitative validation. The objective of this study was to determine the reliability of the Chinese-version of the CARE Measure in reliably differentiating between doctors in a primary care setting in Hong Kong Methods: Data were collected from 984 primary care patients attending 20 doctors with differing levels of training in family medicine in 5 public clinics in Hong Kong. The acceptability of the Chinese-CARE measure to patients was assessed. The reliability of the measure in discriminating effectively between doctors was analysed by Generalisability-theory (G-Theory) Results: The items in the Chinese-CARE measure were regarded as important by patients and there were few 'not applicable' responses. The measure showed high internal reliability (coefficient 0.95) and effectively differentiated between doctors with only 15-20 patient ratings per doctor (inter-rater reliability > 0.8). Doctors' mean CARE measure scores varied widely, ranging from 24.1 to 45.9 (maximum possible score 50) with a mean of 34.6. CARE Measure scores were positively correlated with level of training in family medicine (Spearman's rho 0.493, p < 0.05). Conclusion: These data demonstrate the acceptability, feasibility and reliability of using the Chinese-CARE Measure in primary care in Hong Kong to differentiate between doctors interpersonal competencies. Training in family medicine appears to enhance these key interpersonal skills. [ABSTRACT FROM AUTHOR]

Background: Primary care based management of long-term conditions (LTCs) is high on the international healthcare agenda, including the Asia-Pacific region. Hong Kong has a 'mixed economy' healthcare system with both public and private sectors with a range of types of primary care doctors. Recent Hong Kong Government policy aims to enhance the management of LTCs in primary care possibly based on a 'family doctor' model. Patients' views on this are not well documented and the aim of the present study was to explore the views of patients with LTCs on family doctors in Hong Kong. Methods: The views of patients (with a variety of LTCs) on family doctors in Hong Kong were explored. Two groups of participants were interviewed; a) those who considered themselves as having a family doctor, b) those who considered themselves as not having a family doctor (either with a regular primary care doctor but not a family doctor or with no regular primary care doctor). In-depth individual semi-structured interviews were carried out with 28 participants (10 with a family doctor, 10 with a regular doctor, and 8 with no regular doctor) and analysed using the constant comparative method. Results: Participants who did not have a family doctor were familiar with the concept but regarded it as a 'luxury item' for the rich within the private healthcare system. Those with a regular family doctor (all private) regarded having one as important to their and their family's health. Participants in both groups felt that as well as the more usual family medicine specialist or general practitioner, traditional Chinese medicine practitioners also had the potential to be family doctors. However most participants attended the public healthcare system for management of their LTCs whether they had a family doctor or not. Cost, perceived need, quality, trust, and choice were all barriers to the use of family doctors for the management of their LTCs. Conclusions: Important barriers to the adoption of a 'family doctor' model of management of LTCs exist in Hong Kong. Effective policy implementation seems unlikely unless these complex barriers are addressed. [ABSTRACT FROM AUTHOR]

Objective: The aim of this pilot prospective study was to investigate the relationships between general practitioners (GPs) empathy, patient enablement, and patient-assessed outcomes in primary care consultations in an area of high socio-economic deprivation in Scotland. Methods: This prospective study was carried out in a five-doctor practice in an area of high socio-economic deprivation in Scotland. Patients’ views on the consultation were gathered using the Consultation and Relational Empathy (CARE) Measure and the Patient Enablement Instrument (PEI). Changes in main complaint and well-being 1 month after the contact consultation were gathered from patients by postal questionnaire. The effect of GP empathy on patient enablement and prospective change in outcome was investigated using structural equation modelling. Results: 323 patients completed the initial questionnaire at the contact consultation and of these 136 (42%) completed and returned the follow-up questionnaire at 1 month. Confirmatory factor analysis confirmed the construct validity of the CARE Measure, though omission of two of the six PEI items was required in order to reach an acceptable global data fit. The structural equation model revealed a direct positive relationship between GP empathy and patient enablement at contact consultation and a prospective relationship between patient enablement and changes in main complaint and well-being at 1 month. Conclusion: In a high deprivation setting, GP empathy is associated with patient enablement at consultation, and enablement predicts patient-rated changes 1 month later. Further larger studies are desirable to confirm or refute these findings. Practice implications: Ways of increasing GP empathy and patient enablement need to be established in order to maximise patient outcomes. Consultation length and relational continuity of care are known factors; the benefit of training and support for GPs needs to be further investigated. [Copyright &y& Elsevier]

The article focuses on the inverse care law on clinical primary care in deprived and affluent areas of Scotland. Under the inverse care law, the availability of good medical care vary inversely with the need for it in the population served. Study show that patients in deprived areas had greater number of psychological problems, more long-term illness, more multimorbidity and more chronic health problems. This lead to high demands on clinical encounters in primary care.

Background: The challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patient's views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care. Methods: In the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure. Results: Study 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores. Conclusion: There is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life. [ABSTRACT FROM AUTHOR]

Background: Participation by communities in improving the quality of health services has become a feature of government policy in the United Kingdom. The aim of the study was to involve a deprived community in the UK in shaping quality improvements of local primary care services. The specific objectives were firstly to create participation by local people in evaluating the primary care services available in the area and secondly to bring about change as a result of this process. Methods: The methods of participatory action research was used. The study was set in an area of high socio-economic deprivation served by a 'Local Health Care Co-operative' in a peripheral housing estate in Glasgow, Scotland. 72 local residents took part in 11 focus groups: eight of these were with community groups and three with other residents. 372 local residents completed questionnaires either by brief face-to-face interviews (114) or by self or carer completion (258). Results: The study group produced recommendations on physical access to the health centre, time constraints in accessing services and problems encountered in individual relationships with health staff. They also highlighted the social gap between health service providers and the daily life of community residents. Action was taken to bring these recommendations to the attention of the Primary Care Organisation. Conclusion: Participatory action research was used to involve a deprived community in the UK in a 'bottom-up' approach aimed at improving quality of local primary care services. Although successful in creating a partnership between academic researchers and lay researchers and participation by local people in evaluating the primary care services available in the area, the impact of the study in terms of immediate action taken over specific issues has been modest. The possible reasons for this are discussed. [ABSTRACT FROM AUTHOR]

Focuses on the organization of community mental health care. Improvement of medical education in psychiatry; Encouragement of team work with general practitioners; Discussion on the treatment of doctors with the patients.

Background: Multimorbidity (the co‐existence of two or more long‐term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions. Objective: This article proposes self‐determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity. Methods: We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework. Results: SDT‐based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care‐based complex intervention for patients with multimorbidity in deprived areas of Scotland). Conclusions: SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories. Patient or Public Contribution: Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long‐term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The future of primary care nurses and health visitors," by C. Derrett and L. Burke in the December 9, 2006 issue.

Background. The Patient Enablement Instrument (PEI) was developed to measure patients’ enablement, which is an indicator of the effectiveness of a primary care consultation; however, to date, the PEI has not been tested in Asian populations. [ABSTRACT FROM PUBLISHER]

Background: Research comparing sex differences in the effects of antipsychotic medications on acute ischemic heart disease (IHD) is limited and the findings ambiguous. This study aimed to investigate these associations within a primary care setting.Methods: Hong Kong public general outpatient electronic records of patients aged 45+ during 2007-2010 were extracted, with the last consultation date as the baseline for a 4-year follow-up period to observe acute IHD hospitalizations (2011-2014). Antipsychotic use was defined as any prescription over the previous 12 months from a list of 16 antipsychotics, while acute IHD was defined by ICD-9: 410.00-411.89. Both sex-specific and sex-combined (both sexes) mixed-effects Cox models (random intercept across 74 clinics) were implemented to examine the association and test the interaction between antipsychotics and sex.Results: Among 1,043,236 included patients, 17,780 (1.7%) were prescribed antipsychotics, and 8342 (0.8%) developed IHD. In sex-specific analyses, antipsychotic prescription was associated with a 32% increased hazard rate of acute IHD among women (95% CI 1.05-1.67) but not among men. A likelihood ratio test comparing sex-combined models with and without the interaction between antipsychotic use and sex suggested significant interaction (χ2 = 4.72, P = 0.030). The association between antipsychotic use and IHD among women attenuated and became non-significant when haloperidol was omitted from the operationalization of antipsychotic use (HR = 1.23, 95% CI 0.95-1.60).Conclusion: Our results suggest that antipsychotic prescription is moderately associated with an increased risk of acute IHD among women in primary care and this relationship may be explained by specific antipsychotics. Further research should observe and capture the potential intermediary mechanisms and the dose-response relationship of this association to provide more rigorous evidence to establish causality and inform clinical practices. [ABSTRACT FROM AUTHOR]

Purpose: Multimorbidity challenges health systems globally. New models of care are urgently needed to better manage patients with multimorbidity; however, there is no agreed framework for designing and reporting models of care for multimorbidity and their evaluation.Methods: Based on findings from a literature search to identify models of care for multimorbidity, we developed a framework to describe these models. We illustrate the application of the framework by identifying the focus and gaps in current models of care, and by describing the evolution of models over time.Results: Our framework describes each model in terms of its theoretical basis and target population (the foundations of the model) and of the elements of care implemented to deliver the model. We categorized elements of care into 3 types: (1) clinical focus, (2) organization of care, (3) support for model delivery. Application of the framework identified a limited use of theory in model design and a strong focus on some patient groups (elderly, high users) more than others (younger patients, deprived populations). We found changes in elements with time, with a decrease in models implementing home care and an increase in models offering extended appointments.Conclusions: By encouragin greater clarity about the underpinning theory and target population, and by categorizing the wide range of potentially important elements of an intervention to improve care for patients with multimorbidity, the framework may be useful in designing and reporting models of care and help advance the currently limited evidence base. [ABSTRACT FROM AUTHOR]

Background: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true.Methods: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting.Results: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices.Conclusions: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled. [ABSTRACT FROM AUTHOR]

Background: Empathy is an essential skill in doctor-patient communication with positive effects on compliance, patient satisfaction and symptom duration. There are no validated patient-rated empathy measures available in Dutch.Objective: To investigate the validity and reliability of a Dutch version of the Consultation and Relational Empathy (CARE) Measure, a widely used 10-item patient-rated questionnaire of physician empathy.Methods: After translation and back translation, the Dutch CARE Measure was distributed among patients from 19 general practitioners in 5 primary care centers. Tests of internal reliability and validity included Cronbach's alpha, item total correlations and factor analysis. Seven items of the QUality Of care Through the patient's Eyes (QUOTE) questionnaire assessing 'affective performance' of the physician were included in factor analysis and used to investigate convergent validity.Results: Of the 800 distributed questionnaires, 655 (82%) were returned. Acceptability and face validity were supported by a low number of 'does not apply' responses (range 0.2%-11.9%). Internal reliability was high (Cronbach's alpha 0.974). Corrected item total correlations were at a minimum of 0.837. Factor analysis on the 10 items of the CARE Measure and 7 QUOTE items resulted in two factors (Eigenvalue > 1), the first containing the CARE Measure items and the second containing the QUOTE items. Convergent construct validity between the CARE Measure and QUOTE was confirmed with a modest positive correlation (r = 0.34, n = 654, P < 0.001).Conclusion: The findings support the preliminary validity and reliability of the Dutch CARE Measure. Future research is required to investigate divergent validity and discriminant ability between doctors. [ABSTRACT FROM AUTHOR]

Background: The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown. Objective: This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings. Methods: This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors. Results: Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting. Conclusion: Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors’ training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors’ empathy and enablement for chronic illness patients. [ABSTRACT FROM AUTHOR]

Background: Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care. Methods: Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman's correlation and principal component analysis (construct validity), Cronbach's alpha (internal consistency), and Generalisability theory (inter-rater reliability). Results: A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73%) felt that the CARE Measure items were very important to their current consultation. The number of 'not applicable' responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach's alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients' age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home. Conclusions: The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes. [ABSTRACT FROM AUTHOR]

Background Schizophrenia is associated with increased cardiovascular mortality. Although cardiovascular disease (CVD) risk prediction algorithms are widely in the general population, their utility for patients with schizophrenia is unknown. Methods A primary care dataset was used to compare CVD risk scores (Joint British Societies (JBS) score), cardiovascular risk factors, rates of pre-existing CVD and age of first diagnosis of CVD for schizophrenia (n = 1997) relative to population controls (n = 215,165). Results Pre-existing rates of CVD and the recording of risk factors for those without CVD were higher in the schizophrenia cohort in the younger age groups, for both genders. Those with schizophrenia were more likely to have a first diagnosis of CVD at a younger age, with nearly half of men with schizophrenia plus CVD diagnosed under the age of 55 (schizophrenia men 46.1% vs. control men 34.8%, p < 0.001; schizophrenia women 28.9% vs. control women 23.8%, p < 0.001). However, despite high rates of CVD risk factors within the schizophrenia group, only a very small percentage (3.2% of men and 7.5% of women) of those with schizophrenia under age 55 were correctly identified as high risk for CVD according to the JBS risk algorithm. Conclusion The JBS2 risk score identified only a small proportion of individuals with schizophrenia under the age of 55 as being at high risk of CVD, despite high rates of risk factors and high rates of first diagnosis of CVD within this age group. The validity of CVD risk prediction algorithms for schizophrenia needs further research. [ABSTRACT FROM AUTHOR]

Aims Prescribing multiple medications is associated with various adverse outcomes, and polypharmacy is commonly considered suggestive of poor prescribing. Polypharmacy might thus be associated with unplanned hospitalization. We sought to test this assumption. Methods Scottish primary care data for 180 815 adults with long-term clinical conditions and numbers of regular medications were linked to national hospital admissions data for the following year. Using logistic regression (age, gender and deprivation adjusted), we modelled the association of prescribing with unplanned admission for patients with different numbers of long-term conditions. Results Admissions were more common in patients on multiple medications, but admission risk varied with the number of conditions. For patients with one condition, the odds ratio for unplanned admission for four to six medications was 1.25 (95% confidence interval 1.11-1.42) vs. one to three medications, and 3.42 (95% confidence interval 2.72-4.28) for ≥10 medications vs. one to three medications. However, this effect was greatly reduced for patients with multiple conditions; amongst patients with six or more conditions, those on four to six medications were no more likely to have unplanned admissions than those taking one to three medications (odds ratio 1.00; 95% confidence interval 0.88-1.14), and those taking ≥10 medications had a modestly increased risk of admission (odds ratio 1.50; 95% confidence interval 1.31-1.71). Conclusions Unplanned hospitalization is strongly associated with the number of regular medications. However, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed. [ABSTRACT FROM AUTHOR]

Background: Visual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions. Methods: We conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without. Results: Twenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)). Conclusions: Patients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services. [ABSTRACT FROM AUTHOR]

Background. The Consultation and Relational Empathy (CARE) Measure is a validated patient-rated measure of consultation quality in the UK. [ABSTRACT FROM PUBLISHER]

Blood pressure (BP) is known to vary by time of day and day of year. Studies differ substantially on the magnitude of the effect and there is doubt whether variation is clinically meaningful. We used more than 2 million BP measurements obtained between 1996 and 2004 from Geisinger Clinic primary care patients. General estimating equations were used to determine the effect of time of day and month of year on the probability of identifying BP values above four diagnostic cutoff points (SBP120 mm Hg, SBP140 mm Hg, DBP80 mm Hg, DBP90 mm Hg). Time of day and month of year were significantly associated with the odds of measuring elevated BP, regardless of definition. The odds ratio (OR) for SBP120 mm Hg in the evening (1900 hours) versus midday (1200 hours) was 1.32 (P<0.001). The OR for SBP120 mm Hg in winter to summer months was 1.24 (P<0.001). Similar results were found for each age/gender group. These data indicate that in clinical practice, measurement of an elevated BP may vary by 40% depending on the time of day and month of year. The magnitude of the variability in BP measurement attributable to the combined effect of these temporal factors is clinically significant. Anticipation of changes in BP attributable to temporal factors may improve accuracy of diagnosis and precision of therapy.Journal of Human Hypertension (2008) 22, 755–760; doi:10.1038/jhh.2008.44; published online 5 June 2008 [ABSTRACT FROM AUTHOR]

Background: Increasing use is being made of routinely collected electronic patient data in health services research. The aim of the present study was to evaluate the potential usefulness of a comprehensive database used routinely in the public healthcare system in Hong Kong, using antihypertensive drug prescriptions in primary care as an example. Methods: Data on antihypertensive drug prescriptions were retrieved from the electronic Clinical Management System (e-CMS) of all primary care clinics run by the Health Authority (HA) in the New Territory East (NTE) cluster of Hong Kong between January 2004 and June 2007. Information was also retrieved on patients' demographic and socioeconomic characteristics, visit type (new or follow-up), and relevant diseases (International Classification of Primary Care, ICPC codes). Results: 1,096,282 visit episodes were accessed, representing 93,450 patients. Patients' demographic and socio-economic details were recorded in all cases. Prescription details for anti-hypertensive drugs were missing in only 18 patients (0.02%). However, ICPC-code was missing for 36,409 patients (39%). Significant independent predictors of whether disease codes were applied included patient age ≥ 70 years (OR 2.18), female gender (OR 1.20), district of residence (range of ORs in more rural districts; 0.32-0.41), type of clinic (OR in Family Medicine Specialist Clinics; 1.45) and type of visit (OR follow-up visit; 2.39). In the 57,041 patients with an ICPC-code, uncomplicated hypertension (ICPC K86) was recorded in 45,859 patients (82.1%). The characteristics of these patients were very similar to those of the non-coded group, suggesting that most non-coded patients on antihypertensive drugs are likely to have uncomplicated hypertension. Conclusion: The e-CMS database of the HA in Hong Kong varies in quality in terms of recorded information. Potential future health services research using demographic and prescription information is highly feasible but for disease-specific research dependant on ICPC codes some caution is warranted. In the case of uncomplicated hypertension, future research on pharmaco-epidemiology (such as prescription patterns) and clinical issues (such as side-effects of medications on metabolic parameters) seems feasible given the large size of the data set and the comparability of coded and non-coded patients. [ABSTRACT FROM AUTHOR]

Background: Empathy is widely regarded as being key to effective consultation in general practice. The Consultation and Relational Empathy (CARE) Measure is a widely used and well-validated patient-rated measure in English. A Japanese version of the CARE Measure has undergone preliminary validation, but its ability to differentiate between individual doctors has not been established. The current study sought to investigate the reliability of the Japanese version of the CARE Measure in terms of discrimination between doctors. Methods: We conducted secondary analysis of a dataset involving 252 patients assessed by nine attending General Practitioners. The intra-cluster correlation coefficient was evaluated as an index of the reliability of the Japanese version of the CARE Measure for discriminating between doctors. With a criterion of intra-cluster correlation coefficient = 0.8, we conducted a decision (D) study using generalizability theory to determine the required number of patients for reliable CARE Measure estimates. Results: The ability of the CARE Measure to discriminate between doctors increased with the number of patients assessed per doctor. A sample size of 38 or more patients provided an average intra-cluster correlation coefficient of 0.8. Conclusions: The Japanese CARE Measure appears to reliably discriminate between doctors with a feasible number of patient-ratings per doctor. Further studies involving larger numbers of doctors with a multicenter analysis are required to confirm the results of the current study, which was conducted at a single institution. [ABSTRACT FROM AUTHOR]