The barriers & solutions to providing good quality palliative care in dementia in the GP practice

BACKGROUND: Dementia is a significant worldwide health issue, however, it is often insidious in onset and difficult to diagnose, therefore GPs have expressed a limited confidence in their diagnostic skills, extending into their prognostication of the disease. As a result diagnosing the terminal phase of dementia has been identified as a significant challenge to delivering effective palliative care. Therefore, identifying the challenges faced by the GPs in this field will help to guide their training and support, and as a result could assist in the provision of sustained and effective palliative care for their dementia patients.

Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based MSK and SEM Clinic for Managing Musculoskeletal symptoms in a GP

Musculoskeletal (MSK) complaints are common within primary care (1) (2) (3) but some General Practitioners (GPs)/family physicians do not feel comfortable managing these symptoms (3), preferring to refer onto hospital specialists or Integrated Clinical Assessment and Treatment Services (ICATs). Long waiting times for hospital outpatient reviews are a major cause of patient inconvenience and complaints (4). We therefore aimed to establish a GP-ran MSK and sport and exercise medicine (SEM) clinic based within a Belfast GP surgery that would contribute to a sustainable improvement in managing these common conditions within primary care as well as reducing waiting times for patients with these conditions to see a specialist. This shift from hospital-based to community-based management is in-keeping with recent policy changes within the UK health-system, including Transforming Your Care within Northern Ireland (NI) (5). The GP-ran MSK and SEM clinic was held monthly within a Belfast GP practice, staffed by one GP with a specialist interest in MSK and SEM conditions and its performance was reviewed over a three month period. Parameters audited included cases seen, orthopaedic and x-ray referral rates and secondary care referrals comparing the GP practice’s performance to the same time period in the previous year as well as patient satisfaction questionnaires.

Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based clinic

The problem-Musculoskeletal (MSK) symptoms are common within primary care but some GPs are not comfortable managing these; waiting times for hospital appointments are a major cause of patients’ complaints. Current UK healthcare policies emphasise a need for more community-based management. We aimed to pilot an innovative general practice-based clinic to improve the management of MSK and Sport and Exercise Medicine (SEM) symptoms within general practice.

The approach-This project was conducted in an inner-city practice of approximately 9,000 patients and 5 GP partners. The practice commissioned a novel monthly 4-hour clinic staffed by one GP with a specialist interest in MSK and SEM conditions. Each patient was allocated a 20-minute appointment. All primary care staff within the practice could refer any patient for whom they considered hospital referral appropriate, with no specific exclusion criteria. Management plans included injection therapy, exercise prescription and onward referral. After three months (August-October 2014) numbers of consultations, sources of referral, reasons for referral and management outcomes were described; patient satisfaction was assessed by questionnaire, offered to 10 randomly selected patients by reception staff and self-completed by patients. Costs of the clinic were compared to current options.

Findings- All patients (14 males; 21 females; aged 35-77 years), were seen within four weeks of referral (one third of orthopaedic referrals in 2013 waited over 9 weeks for appointment). Most were referred from other GPs; some came from physiotherapy and podiatry. Shoulder problems were the most frequent reason for referral. The commonest management option was steroid injection, with most patients being given advice regarding exercise and analgesia; there were 3 onward referrals (2 physiotherapy; 1 rheumatology).

Comparing August-October data in 2014 and 2013, total, orthopaedic and rheumatology referrals were reduced by 147, 2 and 3, respectively; within the practice MSK presentations and physiotherapy and x-ray referrals were 60, 47 and 90 fewer, respectively.

The cost per attendance at the clinic was £61; initial orthopaedic-ICAT assessments cost £82 and a consultant appointment £213.

Satisfaction questionnaires were returned by all 10 selected participants and provided positive feedback, expressing preference for community-based, rather than hospital, management.

Consequence- Our pilot study indicates that this novel service model has potential for efficient and effective management of MSK and SEM complaints in primary care, reducing the need for hospital referral and the clinical burden on general practices. The innovation deserves further evaluation in a full-scale trial to determine its generalisability to other practice settings and populations.

Establishing the validity of English GP Patient Survey items evaluating out-of-hours care

Background A 2014 national audit used the English General Practice Patient Survey (GPPS) to compare service users’ experience of out-of-hours general practitioner (GP) services, yet there is no published evidence on the validity of these GPPS items. Objectives Establish the construct and concurrent validity of GPPS items evaluating service users’ experience of GP out-of-hours care. Methods Cross-sectional postal survey of service users (n=1396) of six English out-of-hours providers. Participants reported on four GPPS items evaluating out-of-hours care (three items modified following cognitive interviews with service users), and 14 evaluative items from the Out-of-hours Patient Questionnaire (OPQ). Construct validity was assessed through correlations between any reliable (Cochran's α>0.7) scales, as suggested by a principal component analysis of the modified GPPS items, with the ‘entry access’ (four items) and ‘consultation satisfaction’ (10 items) OPQ subscales. Concurrent validity was determined by investigating whether each modified GPPS item was associated with thematically related items from the OPQ using linear regressions. Results The modified GPPS item-set formed a single scale (α=0.77), which summarised the two-component structure of the OPQ moderately well; explaining 39.7% of variation in the ‘entry access’ scores (r=0.63) and 44.0% of variation in the ‘consultation satisfaction’ scores (r=0.66), demonstrating acceptable construct validity. Concurrent validity was verified as each modified GPPS item was highly associated with a distinct set of related items from the OPQ. Conclusions Minor modifications are required for the English GPPS items evaluating out-of-hours care to improve comprehension by service users. A modified question set was demonstrated to comprise a valid measure of service users’ overall satisfaction with out-of-hours care received. This demonstrates the potential for the use of as few as four items in benchmarking providers and assisting services in identifying, implementing and assessing quality improvement initiatives.

Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

Objectives: To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs).

Methods: Four GPs and two RNs were trained in the assessment of early in?ammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical ?ndings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA.

Results: Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was
0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Signi?cant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions.

Conclusion: Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.

Optical spectroscopy of the M 15 intermediate velocity cloud

We present echelle spectrograph observations in the Na D lines, at resolutions of 6.2-8.5 km s(-1), for 11 stars located in the line-of-sight to the M15 intermediate velocity cloud (IVC), which has a radial velocity of similar to +70 km s(-1) in the Local Standard of Rest. This cloud is a part of IVC Complex gp. The targets range in magnitude from m(V) = 13.3-14.8. Seven of the observed stars are in the M15 globular cluster, the remaining four being field stars. Three of the observed cluster stars are located near a peak in intensity of the IVC Hi column density as observed at a resolution of similar to 1 arcmin. Intermediate velocity gas is detected in absorption towards 7 stars, with equivalent widths in NaD2 ranging from similar to0.09-0.20 Angstrom, corresponding to log(10)(N-Na cm(-2)) similar to 11.8-12.5, and Na I/H I column density ratios (neglecting the HII component) ranging from similar to(1-3) x 10(-8). Over scales ranging from 30 arcsec to 1 arcmin, the Na i column density and the Na i/H i ratio varies by upto 70 per cent and a factor of similar to 2, respectively. Combining the current sightlines with previously obtained Nai data from Kennedy et al. (1998b), the Na i/H i column density ratio over cluster sightlines varies by upto a factor of similar to 25, when using Hi data of resolution similar to 2 x 1 arcmin. One cluster star, M15 ZNG-1, was also observed in the Ca i (lambda(air) = 4226.728 Angstrom) and Ca ii (lambda(air) = 3933.663 Angstrom) lines. A column density ratio N(Ca i)/N(Ca ii) <0.03 was found, typical of values seen in the warm ionised interstellar medium. Towards this sightline, the IVC has a Nai/Ca ii column density ratio of &SIM; 0.25, similar to that observed in the local interstellar medium. Finally, we detect tentative evidence for IV absorption in Ki (?(air) = 7698:974 &ANGS) towards 3 cluster stars, which have N(K i)/N(H i) ratios of &SIM;0.5-3 x 10(-9).

CaIIKinterstellar observations towards early-type disc and halo stars, abundances and distances of intermediate- and high-velocity clouds

We present Ca II K (lambda(air) = 3933.661 angstrom) interstellar observations towards 20 early-type stars, to place lower distance limits to intermediate- and high-velocity clouds (IHVCs) in their lines of sight. The spectra are also employed to estimate the Ca abundance in the low-velocity gas towards these objects, when combined with Leiden-Dwingeloo 21-cm HI survey data of spatial resolution 0 degrees.5. Nine of the stars, which lie towards IHVC complexes H, K and gp, were observed with the intermediate dispersion spectrograph on the Isaac Newton Telescope at a resolution R = lambda/Delta lambda of 9000 (similar to 33 km s(-1)) and signal-to-noise ratio (S/N) per pixel of 75-140. A further nine objects were observed with the Utrecht Echelle Spectrograph on the William Herschel Telescope at R = 40 000 (similar to 7.5 km s(-1)) and S/N per pixel of 10-25. Finally, two objects were observed in both Ca II K and Na I D lines using the 2D COUDE on the McDonald 2.7-m telescope at R = 35 000 (similar to 8.5 km s(-1)). The abundance of Ca II K {log(10)(A) = log(10)[N(Ca II K)]-log(10)[N(HI)]} plotted against HI column density for the objects in the current sample with heights above the Galactic plane (z) exceeding 1000 pc is found to obey the Wakker & Mathis (2000) relation. Also, the reduced column density of Ca II K as function of z is consistent with the larger sample taken from Smoker et al. (2003). Higher S/N observations than those previously taken towards HVC complex H stars HD 13256 and HILT 190 reinforce the assertion that this lies at a distance exceeding 4000 pc. No obvious absorption is detected in observations of ALS 10407 and HD 357657 towards IVC complex gp. The latter star has a spectroscopically estimated distance of similar to 2040 pc, although this was derived assuming the star lies on the main sequence and without any reddening correction being applied. Finally, no Ca II K absorption is detected towards two stars along the line of sight to complex K, namely PG 1610+529 and PG 1710+490. The latter is at a distance of similar to 700 pc, hence placing a lower distance limit to this complex, where previously only an upper distance limit of 6800 pc was available.