Economic evaluation of nurse practitioners versus GPs in treating common conditions. A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study C-reactive protein point of care testing and physician communication skills training for lower respiratory tract infections in general practice: economic evaluation of a cluster randomized trial. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Effects on Knowledge and Attitudes of Using Stages of Change to Train General Practitioners on Management of Depression: A Randomized Controlled Study Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme. Keele Aches and Pains Study protocol: validity, acceptability, and feasibility of the Keele STarT MSK tool for subgrouping musculoskeletal patients in primary care Effects of a co-financed interdisciplinary collaboration model in primary health care on service utilisation among patients with musculoskeletal disorders. General practitioner assessment of structured oncological information accompanying newly referred cancer patients A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial The effect of an active implementation of a disease management programme for chronic obstructive pulmonary disease on healthcare utilization - a cluster-randomised controlled trial Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378] General practitioner consultations at residential aged-care facilities. Feasibility study of a communication and education asthma intervention for general practitioners in Australia. Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial Development of an intervention to improve appropriate polypharmacy in older people in primary care using a theory-based method Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Improving management of patients with acute cough by C-reactive protein point of care testing and communication training (IMPAC3T): study protocol of a cluster randomised controlled trial
BACKGROUND As studies evaluating substitution of care have revealed only limited evidence on cost-effectiveness , a trial was conducted to evaluate  nurse practitioners as a first point of contact in Dutch general practice s. AIM To estimate costs of GP versus nurse practitioner consultations from practice and societal perspectives . DESIGN OF STUDY An economic evaluation was conducted alongside a r and omised controlled trial between May and October 2006 , wherein 12 nurse practitioners and 50 GPs working in 15 general practice s ( study practice s ) participated .  Consultations by study practice s were also compared with an external reference group , with 17 GPs working in five general practice s without the involvement of nurse practitioners .  METHOD Direct costs within the healthcare sector included re source use , follow-up consultations , length of consultations , and salary costs . Costs outside the healthcare sector were productivity losses . Sensitivity analyses were performed . RESULTS Direct costs were lower for nurse practitioner consultations than for GP consultations at study practice s. This was also the case for direct costs plus costs from a societal perspective for patients aged < 65 years .  Direct costs of consultations at study practice s were lower than those of reference practice s , while practice s did not differ for direct costs plus costs from a societal perspective for patients aged < 65 years . Cost differences are mainly caused by the differences in salary . CONCLUSION By involving nurse practitioners , substantial economic ' savings ' could be used for re design ing primary care , to optimise the best skill mix , and to cover the full range of primary care activities BACKGROUND General practitioners ( GPs ) can be provided with effective training in the skills to manage depression . However , it remains uncertain whether such training achieves health gain for their patients . METHOD The study aim ed to measure the health gain from training GPs in skills for the assessment and management of depression . The study design was a cluster r and omized controlled trial . GP participants were assessed for recognition of psychological disorders , attitudes to depression , prescribing patterns and experience of psychiatry and communication skills training . They were then r and omized to receive training at baseline or the end of the study . Patients selected by GPs were assessed at baseline , 3 and 12 months . The primary outcome was depression status , measured by HAM-D. Secondary outcomes were psychiatric symptoms ( GHQ-12 ) quality of life ( SF-36 ) , satisfaction with consultations , and health service use and costs . RESULTS Thirty-eight GPs were recruited and 36 ( 95 % ) completed the study . They selected 318 patients , of whom 189 ( 59 % ) were successfully recruited . At 3 months there were no significant differences between intervention and control patients on HAM-D , GHQ-12 or SF-36 . At 12 months there was a positive training effect in two domains of the SF-36 , but no differences in HAM-D , GHQ-12 or health care costs . Patients reported trained GPs as somewhat better at listening and underst and ing but not in the other aspects of satisfaction . CONCLUSIONS Although training programmes may improve GPs ' skills in managing depression , this does not appear to translate into health gain for depressed patients or the health service BACKGROUND Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts .  Educational outreach into practice s , alongside other measures , such as audit and feedback , have the potential to enable GP prescribing to become more evidence based . High GP prescribing costs are associated with GPs who see drug company representatives ; tend to end consultations with prescriptions ; and ' try out ' new drugs on an ' ad hoc basis ' and use this as evidence of the drug 's effect . An educational intervention called ' reflective practice ' was developed to meet these and other educational needs . The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice . OBJECTIVES The study investigated the following : ( i ) Is it feasible for GPs to attend the sessions included in the educational intervention ? ( ii ) Is the intervention acceptable to the participants and the session facilitators ? ( iii ) What are the barriers to the group educational processes , and how can these be overcome ? METHODS Four practice s were recruited in South West Engl and , all of them experiencing problems with prescribing appropriateness and cost .  Reflective practice sessions ( including a video-taped scenario ) were run in each of these practice s and qualitative methods were used to explore the complex attitudes and behaviour of the participants . A research er observed and audio-taped sessions in each practice . At the end of the programme , a sample of doctors and all the facilitators were interviewed about their experiences . The recorded data were transcribed and analysed using st and ard qualitative methods . RESULTS The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions . Elsewhere , doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality . Facilitators came from a broad range of professional background s. While knowledge of prescribed drug management issues was important , the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory . The video-taped scenario was found to be useful to set the scene for the discussion . Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion . Reaching a consensus on management of common conditions was sometimes difficult , partly because the use of the term ' best buy ' implies economic pressures , rather than benefits to patients , and partly because of the value with which GPs regard the concept of clinical autonomy . ' Reflective Practice ' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence . CONCLUSION The study indicates the importance of preparing the practice adequately , including providing protected time for all GPs to attend the educational intervention . Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness . Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized . We have also identified the skill profile of the facilitator role . Our study indicates a need for a clearer underst and ing of GPs ' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment . The intervention is now ripe for further development , perhaps by integrating it with other interventions to change professional behaviour . The improved intervention should then be evaluated in a r and omized controlled trial OBJECTIVES To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care , and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner ( GP ) . DESIGN An observational , retrospective cohort study review ing medical records , and a separate consecutive non-r and omised study of patient satisfaction . SETTING Primary healthcare centre . PARTICIPANTS Four hundred and thirty-two patients with musculoskeletal disorders , primarily assessed by a physiotherapist . Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction question naire . INTERVENTIONS Primary assessment and management of patients with musculoskeletal disorders . MAIN OUTCOME MEASURES Data from medical records within 3-month after the visit , and patient satisfaction question naire . RESULTS Eighty-five percent ( 367/432 ) of patients did not need to see a GP . Serious pathologies were found among the 6 % ( 26/432 ) of patients who were referred to a GP by a physiotherapist , but no serious pathologies were found among the 9 % ( 39/432 ) of patients who subsequently returned for a GP appointment for the same disorder . Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP . Patients also had higher confidence in the ability of physiotherapists to assess their disorder ( P<0.002 ) . CONCLUSION Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP , patients with confirmed serious pathologies were identified by the physiotherapists , and patients were satisfied with assessment by a physiotherapist Background In the UK , 8–15 % of women suffer from postnatal depression with long term consequences for maternal mood and child development . Current guidelines state that health visitors and GPs should continue to have a major role in the detection and management of postnatal depression . Previous literature suggests that women are reluctant to disclose symptoms of postnatal depression . This study aim ed to explore general practitioners ' ( GPs ) , health visitors ' and women 's views on the disclosure of symptoms which may indicate postnatal depression in primary care . Methods In-depth interviews with GPs , health visitors and women who were participating in a r and omised controlled trial of anti-depressants versus health visitor delivered non-directive counselling for the treatment of postnatal depression . Interviews were audio-taped and fully transcribed . Thematic analysis with an iterative approach was used , allowing the views of practitioners and patients to be explored and then compared . Results Nineteen GPs , 14 health visitors and 28 women were interviewed . A number of common themes were identified across all three data sets : underst and ing and negotiating the diagnosis of postnatal depression , hindering and facilitating disclosure , and the system of care . Both women and health professionals described postnatal depression in psychosocial terms : an adjustment reaction to change in life circumstances and the reality of motherhood not meeting personal expectations . Women described making a conscious decision about whether or not to disclose their feelings to their GP or health visitor . Health professionals described strategies used to hinder disclosure and described a reluctance to make a diagnosis of postnatal depression , as they had few personal re sources to manage women with postnatal depression themselves , and no services to which to refer women for further treatment . Conclusion To improve disclosure of symptoms in primary care , there should be a move away from question ing why health professionals do not make the diagnosis of depression and in response suggesting that education and training will improve skills and thus improve detection of depression . Improving the detection and management of postnatal depression in primary care requires recognition of the context in which women consult , and system changes that ensure health professionals work in an environment that can facilitate disclosure and that the necessary re sources for management are available . Trail Registration IS RCT N RATIONALE , AIMS AND OBJECTIVES An economic evaluation of general practitioner ( GP ) use of C-reactive protein ( CRP ) point of care test , GP communication skills training , and both GP use of CRP and communication skills training on antibiotic use for lower respiratory tract infections ( LRTIs ) in general practice . METHODS Cost-effectiveness analysis with a time horizon of 28 days alongside a factorial , cluster r and omized trial in 431 patients with LRTIs recruited by 40 GPs . INTERVENTIONS usual care ( control group ) , GP use of CRP point of care test , GP communication skills training , and both CRP use and communication skills training . MAIN OUTCOME MEASURE health care costs . Cost-effectiveness , using the primary outcome measure antibiotic prescribing at index consultation , was assessed by incremental cost-effectiveness ratios ( ICER ) . To adjust for skewed data and clustering , we used non-parametric bootstrapping re-sampling to derive percentile intervals for the mean difference in total costs and the mean difference in effectiveness between the groups . Various implementation scenarios according to GP preference were modelled with corresponding net monetary benefit ( NMB ) curves based on a given willingness-to-pay ( λ ) for a 1 % lower antibiotic prescribing rate . RESULTS The total mean cost per patient in the usual care group was € 35.96 with antibiotic prescribing of 68 % , € 37.58 per patient managed by GPs using CRP tests ( antibiotic prescribing 39 % , ICER € 5.79 ) , € 25.61 per patient managed by GPs trained in enhanced communication skills ( antibiotic prescribing 33 % , dominant ) and € 37.78 per patient managed by GPs using both interventions ( antibiotic prescribing 23 % , ICER € 4.15 ) . The interventions are cost-effective in any combination ( yielding NMB at no willingness-to-pay ) , taking into account GPs ' preferences where at least 15 % of GPs chose to implement the communication skills training . CONCLUSIONS The two strategies , both singly and combined , are cost-effective interventions to reduce antibiotic prescribing for LRTI , at no , or low willingness-to-pay . Taking GP preferences into account will optimize investment in strategies to reduce antibiotic prescribing for LRTI Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Objective : To assess the impact on knowledge and attitudes of a tailored educational intervention on depression using a modified version of the Prochaska stages of change model , compared with st and ard continuing medical education , for general practitioners ( GPs ) in primary care in Iran . Method : Using a r and omized controlled trial , a total of 192 GPs were evenly r and omized to intervention or control arm . The topic for the educational intervention was depressive disorders . The participants were divided in to small and large groups , depending on their initial stage of change . The GPs ' knowledge and skills regarding management of depressive disorders were assessed through a question naire with 7 multiple choice questions , 11 Likert statements , 3 case vignettes , and 1 essay question .  Attitudes toward management of depressive disorders were also assessed . Both question naires were vali date d. Results : There was a significant improvement in knowledge mean scores regarding multiple choice and Likert questions ( intervention effect 6 % ; P = 0.002 ) , as well as for the case vignettes and essay question ( intervention effect 12 % ; P = 0.011 ) in the intervention arm , in comparison with the control arm . There were significant changes in mean attitude scores in both study arms , but no difference between them . Conclusions : A theoretical model of medical learning and behavioural change can be used to devise educational formats that suit different stages of learning . Such tailored educational formats can improve GPs ' knowledge and skills regarding management of depressive disorders OBJECTIVES The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner ( GP ) care compared with two types of brief psychological therapy ( non-directive counselling and cognitive-behaviour therapy ) in the management of depression as well as mixed anxiety and depression in the primary care setting . DESIGN The design was principally a pragmatic r and omised controlled trial , but was accompanied by two additional allocation methods allowing patient preference : the option of a specific choice of treatment ( preference allocation ) and the option to be r and omised between the psychological therapies only . Of the 464 patients allocated to the three treatments , 197 were r and omised between the three treatments , 137 chose a specific treatment , and 130 were r and omised between the psychological therapies only . The patients underwent follow-up assessment s at 4 and 12 months . SETTING The study was conducted in 24 general practice s in Greater Manchester and London . SUBJECTS A total of 464 eligible patients , aged 18 years and over , were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms . INTERVENTIONS The interventions consisted of brief psychological therapy ( 12 sessions maximum ) or usual GP care . Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling . Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies . Usual GP care included discussion s with patients and the prescription of medication , but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months . Most therapy sessions took place on a weekly basis in the general practice s. By the 12-month follow-up , GP care in some cases did include referral to mental healthcare specialists . MAIN OUTCOME MEASURES The clinical outcomes included depressive symptoms , general psychiatric symptoms , social function and patient satisfaction . The economic outcomes included direct and indirect costs and quality of life . Assessment s were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post . RESULTS At 4 months , both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care . Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4 - 5 points lower than the mean score of patients in the usual GP care group , a difference that was also clinical ly significant . These differences did not generalize to other measures of outcome . There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients r and omised to a psychological therapy by either r and omised allocation method . At 12 months , the patients in all three groups had improved to the same extent . The lack of a significant difference between the treatment groups at this point result ed from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups . At 4 months , patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group . However , by 12 months , patients who had received non-directive counselling were more satisfied than those in either of the other two groups . There were few differences in the baseline characteristics of patients who were r and omised or expressed a treatment preference , and no differences in outcome between these patients . Similar outcomes were found for patients who chose either psychological therapy . Again , there were no significant differences between the two groups at 4 or 12 months . Patients who chose counselling were more satisfied with treatment than those who chose AIMS To assess the impact of a French adaptation of the Staged Diabetes Management ( SDM ) programme on glycaemic control of people with Type 2 diabetes in primary care . Secondary endpoints were blood pressure , blood lipids , healthcare costs and quality of life . METHODS Prospect i ve , r and omized controlled study , of 1 years ' duration . General practitioners ( GPs ) were recruited in four separate districts of a French region . They enrolled consecutive patients with Type 2 diabetes . GPs in the intervention group were educated in the SDM programme . GPs in the control group were asked to provide usual care .  Healthcare costs were collected by medical departments of the Health Insurance systems . Quality of life was assessed with the Duke Health Profile . RESULTS Three hundred and forty patients enrolled by 57 GPs completed the study , 192 in the intervention group and 148 in the control group . Patients in the intervention group were managed more adequately in accordance with the guidelines ( P < 0.05 for nine out of 10 items ) . HbA(1c ) decreased by 0.31 % in the intervention group and increased by 0.56 % in the control group , result ing in a difference of 0.87 % by the end of the study ( P = 0.001 ) . Blood pressure and blood lipids did not differ between groups . Occurrence of major complications was low and identical in both groups . Incremental costs during the study in the intervention group were 35 euros per patient per month , and this was not significantly different in comparison with the control group . Quality of life was not affected by the intervention . CONCLUSIONS Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting , without significantly increasing healthcare costs Musculoskeletal conditions represent a considerable burden worldwide , and are predominantly managed in primary care . Evidence suggests that many musculoskeletal conditions share similar prognostic factors . Systematic ally assessing patient ’s prognosis and matching treatments based on prognostic subgroups ( stratified care ) has been shown to be both clinical ly effective and cost-effective . This study ( Keele Aches and Pains Study ) aims to refine and examine the validity of a brief question naire ( Keele STarT MSK tool ) design ed to enable risk stratification of primary care patients with the five most common musculoskeletal pain presentations . We also describe the subgroups of patients , and explore the acceptability and feasibility of using the tool and how the tool is best implemented in clinical practice . The study design is mixed methods : a prospect i ve , quantitative observational cohort study with a linked qualitative focus group and interview study . Patients who have consulted their GP or health care practitioner about a relevant musculoskeletal condition will be recruited from general practice . Participating patients will complete a baseline question naire ( shortly after consultation ) , plus question naires 2 and 6 months later . A sub sample of patients , along with participating GPs and health care practitioners , will be invited to take part in qualitative focus groups and interviews . The Keele STarT MSK tool will be refined based on face , discriminant , construct , and predictive validity at baseline and 2 months , and vali date d using data from 6-month follow-up . Patient and clinician perspectives about using the tool will be explored . This study will provide a vali date d prognostic tool ( Keele STarT MSK ) with established cutoff points to stratify patients with the five most common musculoskeletal presentations into low- , medium- , and high-risk subgroups . The qualitative analysis of patient and health care perspectives will inform practitioners on how to embed the tool into clinical practice using established general practice IT systems and clinician-support packages BACKGROUND In 1994 Sweden introduced a trial legislation allowing co-financing between authorities . The legislation aim ed to stimulate new ways of collaboration between health and social care providers . One of the specific objectives was to make management of patients with conditions requiring multidisciplinary care more efficient and reduce costs . This study aims to assess if there were any differences in management of patients with musculoskeletal disorders at health centres applying the trial legislation compared to health centre with conventional care with regards to health services utilisation , health care interventions received , and costs . METHOD A comparative prospect i ve study was conducted . Consecutive patients aged 16 - 64 with musculoskeletal disorders attending the health care centres with ( n=107 ) and without ( n=31 ) co-financing model were interviewed at inclusion and after 6 and 12 months . Number of contacts with professionals and interventions received were registered . RESULTS Patients at the intervention centres had significantly more contact with physiotherapists and physicians than the controls . Contacts with other services such as social insurance office , social services office or hospitals did not differ significantly between the groups . Costs were higher for the interventions centres . CONCLUSION The findings do not suggest that the trial legislation reduced health care utilisation or costs for patients with musculoskeletal disorders Sc and J Prim Health Care 2003;21:00 - 00 . ISSN 0281 - 3432 Objective r - r To investigate general practitioner ( GP ) assessment of a structured oncology information pack sent to GPs when newly referred patients had visited a department of oncology for the first time , and to compare their assessment of this material with their assessment of traditional information provided by the department . Design r - r R and omised , unblinded clinical trial . Setting r - r Patients and GPs in the catchment area of a regional oncology department . Subjects / patients r - r 248 cancer patients and their 199 GPs . Main outcome measures r - r GP assessment of the quality of the information material received for each patient . Results r - r 88.3 % of the 248 question naires were returned . The structured information pack improved GP knowledge of oncology ; GPs found themselves better equipped to support and counsel patients during the course of their illness , and practitioner satisfaction with the department rose . Conclusion r - r Intervention , though reasonably simple , inexpensive and not particularly time-consuming , improved cooperation between the specialist department and the GP . While this is a small step in the right direction , the need remains for new initiatives and further studies into how to improve cooperation and communication between the primary and secondary healthcare sectors Abstract Background World-wide healthcare systems are faced with an epidemic of type 2 diabetes . In the United Kingdom , clinical care is primarily provided by general practitioners ( GPs ) rather than hospital specialists . Intermediate care clinics for diabetes ( ICCD ) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors . This study aims to ( 1 ) compare patients with type 2 diabetes registered with practice s that have access to an ICCD service with those that have access only to usual hospital care ; ( 2 ) assess the cost-effectiveness of the intervention ; and ( 3 ) explore the views and experiences of patients , health professionals and other stakeholders . Methods / Design This two-arm cluster r and omized controlled trial ( with integral economic evaluation and qualitative study ) is set in general practice s in three UK Primary Care Trusts . Practice s are r and omized to one of two groups with patients referred to either an  ICCD ( intervention ) or to hospital care ( control ) . Intervention group : GP practice s in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist . Patients are review ed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice .or Control group : St and ard GP care , with referral to secondary care as required , but no access to ICCD .  Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control . The primary outcome is the proportion of participants reaching three risk factor targets : HbA1c ( ≤7.0 % ) ; blood pressure ( < 140/80 ) ; and cholesterol ( < 4 mmol/l ) , at the end of the 18-month intervention period . The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD ) and stroke assessed by the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) risk engine . Other secondary outcomes include body mass index and waist circumference , use of medication , reported smoking , emotional adjustment , patient satisfaction and views on continuity , costs and health related quality of life . We aim ed to r and omize 50 practice s and recruit 2,555 patients . Discussion Forty-nine practice s have been r and omized , 1,997 patients have been recruited to the trial , and 20 patients  have been recruited to the qualitative study . Results will be available late 2012.Trial registration [ Clinical Trials.gov : Identifier NCT00945204 Background The growing population living with chronic conditions calls for efficient healthcare-planning and effective care . Implementing disease-management-programmes is one option for responding to this dem and . Knowledge is scarce about the effect of implementation processes and their effect on patients ; only few studies have reported the effectiveness of disease-management-programmes targeting patients with chronic obstructive pulmonary disease ( COPD ) . The objective of this paper was to determine the effect on healthcare-utilization of an active implementation model for a disease-management-programme for patients with one of the major multimorbidity diseases , COPD . Methods The st and ard implementation of a new disease-management-programme for COPD was ongoing during the study -period from November 2008 to November 2010 in the Central Denmark Region . We wanted to test a strategy using Breakthrough Series , academic detailing and lists of patients with COPD . It targeted GPs and three hospitals serving approx . 60,000 inhabitants aged 35 or older and included interventions directed at professionals , organisations and patients . The study was a non-blinded block- and cluster-r and omised controlled trial with GP- practice s as the unit of r and omisation . In Ringkoebing-Skjern Municipality , Denmark , 16 GP- practice s involving 38 GPs were r and omised to either the  intervention-group  or the  control-group . A comparable neighbouring municipality acted as an external-control-group which included nine GP- practice s with 25 GPs . An algorithm based on health-registry- data on lung-related contacts to the healthcare-system identified 2,736 patients who were alive at the end of the study -period . The population included in this study counted 1,372 ( 69.2 % ) patients who responded to the baseline question naire and confirmed their COPD diagnosis ; 458 ( 33.4 % ) patients were from the intervention-group , 376 ( 27.4 % ) from the control-group and 538(39.2 % ) from the external-control-group . The primary outcome was adherence to the disease-management-programme measured at patient-level by use of specific services from general practice . Secondary outcomes were use of out-of-hours-services , outpatient-clinic , and emergency-department and hospital-admissions . Results The intervention practice s provided more planned preventive consultations , additional preventive consultations and spirometries than non-intervention practice s. A comparison of the development in the intervention practice s with the development in the control- practice s showed that the intervention result ed in more planned preventive-consultations , fewer conventional consultations and fewer patients admitted without a lung-related-diagnosis . Conclusions Use of the active implementation model for the disease-management-programme for COPD changed the healthcare utilization in accordance with the programme . Trial registration Clinical trials.gov identifier : NCT01228708 Introduction Critical appraisal skills are believed to play a central role in an evidence -based approach to health practice . The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aim ed at health care professionals . Methods This prospect i ve controlled trial r and omized 145 self-selected general practitioners , hospital physicians , professions allied to medicine , and healthcare managers/administrators from the South West of Engl and to a half-day critical appraisal skills training workshop  ( based on the model of problem-based small group learning ) or waiting list control . The following outcomes were assessed at 6-months follow up : knowledge of the principles necessary for appraising evidence ; attitudes towards the use of evidence about healthcare ; evidence seeking behaviour ; perceived confidence in appraising evidence ; and ability to critically appraise a systematic review article . Results At follow up overall knowledge score [ mean difference : 2.6 ( 95 % CI : 0.6 to 4.6 ) ] and ability to appraise the results of a systematic review [ mean difference : 1.2 ( 95 % CI : 0.01 to 2.4 ) ] were higher in the critical skills training group compared to control . No statistical significant differences in overall attitude towards evidence , evidence seeking behaviour , perceived confidence , and other areas of critical appraisal skills ability ( methodology or generalizability ) were observed between groups . Taking into account the workshop provision costs and costs of participants time and expenses of participants , the average cost of providing the critical appraisal workshops was approximately £ 250 per person . Conclusions The findings of this study challenge the policy of funding ' one-off ' educational interventions aim ed at enhancing the evidence -based practice of health care professionals . Future evaluations of evidence -based practice interventions need to take in account this trial 's negative findings and method ological difficulties OBJECTIVES To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities ( RACFs ) , and to ascertain how these differ from all GP encounters in Australia as a whole . DESIGN AND PARTICIPANTS A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health ( BEACH ) study , April 2004 to March 2006 , comparing RACF consultations ( identified by Medicare item numbers ) with  all BEACH study encounters in Australia . Participants were a r and om sample of GPs who had cl aim ed at least 375 general practice Medicare items in the 3 months prior to the study . MAIN OUTCOME MEASURES Differences in the characteristics of GPs and patients at RACF consultations , morbidities managed , and treatments provided to patients . RESULTS Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters ; 360/1970 GPs ( 18.4 % ) recorded at least one RACF consultation . GPs aged > or = 45 years were more likely to record at least one RACF consultation than those aged < 45 years . Patients were predominantly women ( 70.7 % ) , and 83.4 % were aged > or = 75 years . At RACF consultations , problems managed significantly more often included chronic problems , as well as psychological , neurological , urological , circulatory , eye and musculoskeletal problems . Dementia was the most common problem managed , at 33 times the usual management rate in everyday practice . Significantly fewer medications , non-pharmacological treatments , referrals , pathology and imaging tests were recorded at RACF consultations . CONCLUSION GP encounters at RACFs involve the management of chronic and complex conditions , including some not frequently seen in everyday general practice . The provision of additional education and re sources where required may assist with workforce shortages in this setting The Physician Asthma Care Education ( PACE ) program significantly improved asthma prescribing and communication behaviours of primary care paediatricians in the USA . We tested the feasibility and acceptability of a modified PACE program with Australian general practitioners ( GP ) and measured its impact on self-reported consulting behaviours in a pilot study . Recruitment took place through a local GP division . Twenty-five GP completed two PACE Australia workshops , which incorporated paediatric asthma management consistent with Australian asthma guidelines and focussed on effective communication strategies .  Program feasibility , usefulness and perceived benefit were measured by question naires before the workshop and 1 month later , and an evaluation question naire after each workshop . GP were universally enthusiastic and supportive of the workshops . The most useful elements they reported were communication skills , case studies , device demonstrations and the toolkit provided . GP self reports of the perceived helpfulness of the key communication strategies and their confidence in their application and reported frequency of use increased significantly after the workshops . The PACE program shows promise in improving the way in which Australian GP manage asthma consultations , particularly with regard to doctor-patient communication . The impact ofthe modified PACE Australia program on the processes and outcomes ofGP care ofchildren with asthma is now being measured in a r and omised controlled trial AIMS To assess the effect of a tailored multi-faceted improvement programme on  general practitioners ' ( GPs ' ) behaviour towards prevention of hazardous and harmful alcohol consumption . The improvement programme consisted of activities aim ed at the GP , organization and patient . Educational training sessions and visits by a facilitator were tailored to the GPs ' needs and attitudes . DESIGN Cluster r and omized controlled trial . SETTING General practice s in the Netherl and s. PARTICIPANTS Seventy-seven general practice s ; 119 GPs participated . Data from 6318 patients were available , of whom 765 ( 12.1 % ) were at risk . A total of 1502 patients ' electronic medical records were review ed . MEASUREMENTS The primary outcome was the number of eligible patients who received screening and advice .  FINDINGS Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme . Although GPs in both groups became more involved after enrolment , this improvement waned during the trial . The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning ( intervention group ) , compared to our control condition , result ing in average improvement rates of 5 % ( screening ) and 2 % ( advice-giving ) at 12-month follow-up ( not significant ) . CONCLUSIONS A tailored , multi-faceted programme aim ed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement . There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care Background Smoking , excessive alcohol consumption , lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world . Brief interventions in health care consultations can be effective in changing single health behaviours . General Practice holds considerable potential for primary prevention through modifying patients ' multiple risk behaviours , but feasible , acceptable and effective interventions are poorly developed , and uptake by practitioners is low . Through a process of theoretical development , modeling and exploratory trials , we have developed an intervention called Behaviour Change Counselling ( BCC ) derived from Motivational Interviewing ( MI ) . This paper describes the protocol for an evaluation of a training intervention ( the Talking Lifestyles Programme ) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours . Methods / Design This cluster r and omised controlled efficacy trial ( RCT ) will evaluate the outcomes and costs of this training intervention for General Practitioners ( GPs ) and nurses . Training methods will include : a practice -based seminar , online self-directed learning , and reflecting on video recorded and simulated consultations . The intervention will be evaluated in 29 practice s in Wales , UK ; two clinicians will take part ( one GP and one nurse ) from each practice . In intervention practice s both clinicians will receive training . The aim is to recruit 2000 patients into the study with an expected 30 % drop out . The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months . Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians .  Economic and process evaluations will also be conducted . Discussion Opportunistic engagement by health professionals potentially represents a cost effective medical intervention . This study integrates an existing , innovative intervention method with an innovative training model to enable clinicians to routinely use BCC , providing them with new tools to encourage and support people to make healthier choices . This trial will evaluate effectiveness in primary care and determine costs of the intervention . Trial Registration IS RCT Background It is advocated that interventions to improve clinical practice should be developed using a systematic approach and intervention development methods should be reported . However , previous interventions aim ed at ensuring that older people receive appropriate polypharmacy have lacked details on their development . This study formed part of a multiphase research project which aim ed to develop an intervention to improve appropriate polypharmacy  in older people in primary care . Methods The target behaviours for the intervention were prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners ( GPs ) and community pharmacists . Intervention development followed a systematic approach , including previous mapping of behaviour change techniques ( BCTs ) to key domains from the Theoretical Domains Framework that were perceived by GPs and pharmacists to influence the target behaviours . Draft interventions were developed to operationalise selected BCTs through team discussion . Selection of an intervention for feasibility testing was guided by a subset of the APEASE ( Affordability , Practicability , Effectiveness/cost-effectiveness , Acceptability , Side-effects/safety , Equity ) criteria . Results Three draft interventions comprising selected BCTs were developed , targeting patients , pharmacists and GPs , respectively . Following assessment of each intervention using a subset of the APEASE criteria ( affordability , practicability , acceptability ) , the GP-targeted intervention was selected for feasibility testing . This intervention will involve a demonstration of the behaviour and will be delivered as an online video . The video demonstrating how GPs can prescribe appropriate polypharmacy during a typical consultation with an older patient will also demonstrate salience of consequences ( feedback emphasising the positive outcomes of performing the behaviour ) . Action plans and prompts/cues will be used as complementary intervention components . The intervention is design ed to facilitate the prescribing of appropriate polypharmacy in routine practice . Conclusion A GP-targeted intervention to improve appropriate polypharmacy  in older people has been developed using a systematic approach . Intervention content has been specified using an established taxonomy of BCTs and selected to maximise feasibility . The results of a future feasibility study will help to determine if the theory-based intervention requires further refinement before progressing to a larger scale r and omised evaluation Background . The IMPaCT Back study ( IMplementation to improve Patient Care through Targeted treatment for Back pain ) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain ( LBP ) in primary care . This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aim ed at equipping clinicians to deliver it . The subgrouping and targeted treatment system . This system differs from ‘ one-size fits all ’ usual practice as it suggests that first contact health care practitioners should systematic ally allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity . Patients in each subgroup ( those at low , medium or high risk of chronicity ) are then managed according to a targeted treatment system of increasing complexity . The subgrouping tools . Subgrouping tools help guide clinical decision-making about treatment and onward referral . Two subgrouping tools have been used in the IMPaCT Back study , a 9-item version used by participating physiotherapists and a 6-item version used by GPs . The targeted treatments . The targeted treatments include a minimal intervention delivered by GPs ( for those patients at low risk of poor outcome ) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability  ( for those at medium risk ) and additional cognitive-behavioural approaches to help address  psychological and social obstacles to recovery  ( for those at high risk ) . The training packages . Building on previous interventions for other pilot studies and r and omized trials , we have developed and delivered clinical training and support programmes for GPs and physiotherapists . Discussion . This paper describes in detail the IMPaCT Back study ’s subgrouping for targeted treatment system and the training and mentoring packages aim ed at equipping clinicians to deliver it , within the IMPaCT Back study . Study registration . IS RCT N55174281 Background Most antibiotic prescriptions for acute cough due to lower respiratory tract infections ( LRTI ) in primary care are not warranted . Diagnostic uncertainty and patient expectations and worries are major drivers of unnecessary antibiotic prescribing . A C-reactive protein ( CRP ) point of care test may help GPs to better guide antibiotic treatment by ruling out pneumonia in cases of low test results . Alternatively , enhanced communication skills training to help clinicians address patients ' expectations and worries could lead to a decrease in antibiotic prescribing , without compromising clinical recovery , while enhancing patient enablement . The aim of this paper is to describe the design and methods of a study to assess two interventions for improving LRTI management in general practice . Methods / Design This cluster r and omised controlled , factorial trial will introduce two interventions in general practice ; point of care CRP testing and enhanced communication skills training for LRTI .  Twenty general practice s with two participating GPs per practice will recruit 400 patients with LRTI during two winter periods . Patients will be followed up for at least 28 days . The primary outcome measure is the antibiotic prescribing rate . Secondary outcomes are clinical recovery , cost-effectiveness , use of other diagnostic tests and medical services ( including reconsultation ) , and patient enablement . Discussion This trial is the first cluster r and omised trial to evaluate the influence of point of care CRP testing in the h and s of the general practitioner and enhanced communication skills , on the management of LRTI in primary care . The pragmatic nature of the study , which leaves treatment decisions up to the responsible clinicians , will enhance the applicability and generalisability of findings . The factorial design will allow conclusion to be made about the value of CRP testing on its own , communication skills training on its own , and the two combined . Evaluating a biomedical and communication based intervention ( ' hard ' and ' soft ' technologies ) together in this way makes this trial unique in its field
The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes .The direction of the targeted behaviour ( i.e. increasing or decreasing a behaviour ) does not seem to affect the effectiveness of an intervention .
There is good- quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline -consistent GP behaviour , result ing in better diagnosis and treatment rates .
Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline -consistent GP behaviour with regard to low back pain , while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline -consistent behaviour respectively .
BACKGROUND Musculoskeletal conditions require particular management skills .
Identification of interventions which are effective in equipping general practitioners ( GPs ) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs .
OBJECTIVES To determine the effectiveness of professional interventions for GPs  that aim to improve the management of musculoskeletal conditions in primary care .
We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions .