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ABSTRACT: Pain Management Programmes (PMPs) are a multi-disciplinary approach to the management of chronic low back pain (CLBP). Notwithstanding evidence of effectiveness, successful take-up of programmes requires acceptability to patients. We used a discrete choice experiment to investigate patient preferences for alternative PMPs for managing CLBP in primary care. Specifically, we estimated the probability of uptake of alternative configurations of PMPs. Potential attributes and associated levels influencing take-up were identified through a systematic literature review, survey of current PMPs, expert consultation, and focus groups. Five attributes were included: content; provider; schedule; group size; and travel time to clinic. Four hundred and fourteen questionnaires were mailed to patients attending clinics and 124 questionnaires were returned suitable for analysis. Method of delivery influenced probability of take-up, with small group sizes and low intensity programmes over a prolonged period increasing the probabilities. Travel time was also important. However, providers and contents of PMPs were not main drivers of preferences, though those with more severe pain did prefer PMPs provided by more specialists. Probability of take-up increases when PMPs better reflect patient preferences. Given preferences, resource constraints, and evidence on clinical outcomes of alternative configurations it is suggested more resource-intensive PMPs be reserved for those with the most severe and disabling pain and less intensive programmes delivered over a longer time period in smaller groups for those with less severe pain. These findings can inform future randomised trials to evaluate acceptable PMPs in primary care.
European journal of pain (London, England) 11/2010; 15(5):531.e1-10. · 3.37 Impact Factor
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ABSTRACT: Previous maternal use of the oral contraceptive pill (OCP) has been linked with asthma in subsequent offspring and has been implicated in the increased prevalence of childhood asthma in recent decades. We conducted a matched case-control study to test the hypothesis that maternal OCP used close to conception is associated with asthma in the offspring, particularly in children with coexistent eczema. We examined maternal OCP exposure in relation to asthma in the offspring (n = 6730) compared with offspring with no asthma (n = 6730) further stratifying by eczema, age group, treatment category and gender of the offspring. Maternal use of OCP was classified as: no OCP use in the 2 years prior to conception; past OCP use within 2 years but >6 months before conception; and recent OCP use within 6 months of conception. The adjusted odds ratio (OR) for asthma in the offspring was 1.16 [95% confidence interval 1.06, 1.27] among mothers who were recent users of the OCP when compared with mothers who had not used the OCP. Past OCP use was not associated with asthma in the offspring. In the stratified analyses, we observed weak but statistically significant associations between recent maternal OCP use and asthma in the offspring among children: without a history of eczema (adjusted OR 1.22 [1.09, 1.36]), those aged < or = 3 years (adjusted OR 1.24 [1.12, 1.37]), those not on treatment for their asthma (adjusted OR 1.33 [1.12, 1.58]) and among females (adjusted OR 1.34 [1.13, 1.51]). We did not find convincing evidence for a causal relationship between maternal OCP used close to conception and asthma in the offspring. The small statistically significant associations were not among children with characteristic features of asthma such as those with eczema and may be due to bias, uncontrolled confounding or chance.
Paediatric and Perinatal Epidemiology 11/2009; 23(6):567-73. · 2.31 Impact Factor
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ABSTRACT: The aim of this study was to explore the practical experiences and feelings of people with cutaneous malignant melanoma about receiving structured melanoma follow-up from their general practitioner (GP) as an alternative to traditional hospital-based follow-up.
Semi-structured audio-taped telephone interviews were conducted with patient recipients of a GP-led follow-up programme for people with cutaneous malignant melanoma.
Eighteen people with cutaneous malignant melanoma that had received structured GP-led routine follow-up for cutaneous malignant melanoma took part in this study.
GP-led melanoma follow-up worked well from the perspectives patients. Patients appreciated convenience of the system, less rushed appointments with more thorough examinations, a more pleasant atmosphere and greater continuity of care. They regarded the GP-led follow-up positively, irrespective of distance from the major cancer centre. Concerns expressed included awareness that most GPs had less experience of melanoma than hospital specialists.
GP-led melanoma follow-up is feasible and is generally viewed positively by those patients that have experienced it.
Supportive Care in Cancer 06/2009; 18(2):225-33. · 2.09 Impact Factor
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ABSTRACT: Patient-reported outcomes such as Quality of Life often play an important part in the efficacy assessment of drug treatment. Although instruments that measure quality of life can detect the positive effects of treatments on health status, they may not measure the effect of negative treatment-related symptoms. Patients often fail to spontaneously report common or clinically mild drug-related symptoms, even though the same symptoms can result in the stopping or skipping of prescribed doses. Therefore, as with quality of life assessments, the perception of patients on possible side effects of treatments is best captured by the use of self-report questionnaires. There are substantial challenges with creating well-validated, relevant questionnaires that capture the full range of patient-reported symptoms and signs. A review of 13 existing instruments showed that many patient-rated side effect questionnaires had been developed, often to a high standard, using well-established psychometric methods. However, there were some inconsistencies in the methods used by the questionnaire developers, indicating the need for standardisation when creating new, or adapting previous, instruments. Even with their current deficits, it is important that patient-reported side effect questionnaires be used more in drug development, health outcomes research and resource allocation; all with the ultimate aim of improving quality of patient care.
Pharmacoepidemiology and Drug Safety 04/2008; 17(3):278-96. · 2.53 Impact Factor
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ABSTRACT: A patient-centered approach is increasingly recognized as an important component in the evaluation of healthcare services.
To assess patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general, and to evaluate the effect of the community pharmacy-led medications management service on these factors.
Postal questionnaire surveys were completed at baseline and after 12 months (follow-up) as part of a randomized controlled trial of the service. The setting was 9 primary care organizations in England. Patients with coronary heart disease were recruited from general practice registers and randomly allocated to the intervention (pharmacy-led medications management service) or control group.
Survey response rates at baseline and follow-up were 88.4% (1232/1394) and 80.1% (1085/1355), respectively. The respondents indicated that they wanted pharmacists to provide dispensing, medications review, advice on medications and health, private consultation areas, and short visit times. At follow-up, intervention patients were more likely than control patients (p < 0.01) to rate the service provided by their pharmacist with a higher level of satisfaction, and most intervention patients stated a preference for seeing their physician to discuss their medications, although this was less marked than in control patients (76% vs 85%; p < 0.01). Intervention patients were also more willing than control patients to ask the pharmacist questions that they would be unable to ask a physician (20% vs 11%, respectively; p < 0.01), to ask the pharmacist questions about their medications (32% vs 18%, respectively; p < 0.01), and to recommend this practice to others (51% vs 40%, respectively; p < 0.01).
Pharmacist intervention was associated with significant and positive changes in patient satisfaction. While patients probably continue to prefer a physician-led service, they value aspects of a pharmacy service. Patients generally preferred discussing medications with the family physician, but experiencing the community pharmacy-led service resulted in an attitudinal shift toward the pharmacist. These findings suggest a benefit in developing the community pharmacist's role as a reviewer of, and adviser on, patients' medications.
Annals of Pharmacotherapy 12/2007; 41(12):1962-70. · 2.13 Impact Factor
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ABSTRACT: Abstract
Background
Associations between symptom experience and mortality have rarely been investigated. One study has suggested that the number of symptoms people experience may be an important predictor of mortality. This novel and potentially important finding may have important implications but needs to be tested in other cohorts.
Methods
858 people aged around 58 years were interviewed by nurses in 1990/1 as part of the West of Scotland Twenty-07 Study. They were asked about the presence of symptoms in the last month from a checklist of 33 symptoms. Measures of morbidity included symptom type (respiratory, musculoskeletal, gastrointestinal, mental health, neurological, systemic) and symptom summary measures looking at the number and impact of symptoms (total number; number participants tended to have; number participants did not tend to have; number which restricted usual activities; number which led to GP consultation). Hazard ratios for thirteen-year all-cause mortality were calculated for symptom types, symptom summary measures, and self-assessed health with and without adjustment.
Results
On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals reporting respiratory, systemic and mental health symptoms. After additional adjustment for chronic conditions and self-assessed health, only the association between mental health symptoms and mortality remained significant. On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals with many (≥ 6) symptoms in four of the symptom summary measures examined. These relationships were no longer significant after additional adjustment for chronic conditions and self-assessed health. A clear trend of increasing mortality as self-assessed health became poorer was observed. This pattern remained statistically significant after adjustment for gender, socio-economic status, smoking, chronic conditions and the total number of symptoms experienced.
Conclusion
Symptoms often thought of as minor may have important consequences later in life especially for those reporting mental health-related symptoms or those experiencing many symptoms. In this study however, self-assessed health appeared to be a better predictor of mortality than the type or number of symptoms experienced, even when the tendency to have and impact of the symptoms were taken into account.
BMC Health Services Research. 01/2006;
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ABSTRACT: Abstract
Background
Few qualitative studies of headache have been conducted and as a result we have little in-depth understanding of the experiences and perceptions of people with headache. The aim of this paper was to explore the perceptions and experiences of individuals with headache and their experiences of associated healthcare and treatment.
Methods
A qualitative study of individuals with headache, sampled from a population-based study of chronic pain was conducted in the North-East of Scotland, UK. Seventeen semi-structured interviews were conducted with adults aged 65 or less. Interviews were analysed using the Framework approach utilising thematic analysis.
Results
Almost every participant reported that they were unable to function fully as a result of the nature and unpredictability of their headaches and this had caused disruption to their work, family life and social activities. Many also reported a negative impact on mood including feeling depressed, aggressive or embarrassed. Most participants had formed their own ideas about different aspects of their headache and several had searched for, or were seeking, increased understanding of their headache from a variety of sources. Many participants reported that their headaches caused them constant worry and anguish, and they were concerned that there was a serious underlying cause. A variety of methods were being used to manage headaches including conventional medication, complementary therapies and self-developed management techniques. Problems associated with all of these management strategies emerged.
Conclusion
Headache has wide-ranging adverse effects on individuals and is often accompanied by considerable worry. The development of new interventions or educational strategies aimed at reducing the burden of the disorder and associated anxiety are needed.
BMC Family Practice. 01/2006;
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ABSTRACT: To assess the risk of colorectal cancer among women who have used oral contraception or hormone replacement therapy (HRT), especially those exposed to both classes of exogenous hormones.
Nested case-control study using prospectively collected data from the Royal College of General Practitioners' Oral Contraception Study (OCS). The 146 cases were women with a diagnosis of colorectal cancer recorded on the OCS database by March 2003. Each case was matched with three controls who were free of the disease at the time of the case's diagnosis, of similar age and with similar length of follow-up in the OCS.
Compared with never use, current use of oral contraception was associated with a reduced risk of colorectal cancer: adjusted odds ratio (OR) 0.38 [95% confidence interval (CI) 0.11-1.32]; former use 0.89 (95% CI 0.59-1.33); ever use 0.84 (95% CI 0.56-1.24). Similar comparisons for HRT were: current use 0.34 (95% CI 0.13-0.91); former use 0.59 (95% CI 0.30-1.14); ever user 0.49 (95% CI 0.27-0.87). The OR among women who had used both classes of hormones was 0.34 (95% CI 0.15-0.79) compared with those who have used neither.
Ever users of oral contraceptives do not benefit from a long-term reduction in colorectal cancer, although current and recent use may confer some protection. Women who have ever used HRT appear to have important reductions in their risk of colorectal cancer, especially while using these hormones. Further study is needed in order to determine how long any benefits last and whether these are stronger in women exposed to both classes of exogenous hormones.
Contraception 03/2005; 71(2):95-8. · 2.72 Impact Factor
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ABSTRACT: UK Government policy increasingly encourages self-care of minor illnesses, including self-medication. Analgesics constitute a quarter of UK over-the-counter medicines sales, but concerns have been expressed about their potential for inappropriate use.
To estimate the prevalence of recent use of non-prescription analgesics in Scotland, to describe by whom they are used, and to estimate inappropriate use.
A cross-sectional postal survey consisting of a self-completed questionnaire that collected data on respondents' use of non-prescription and prescription medicines, as well as demographic and lifestyle data. The sample comprised 2708 subjects of 18 years and over, randomly selected from the Scottish electoral roll.
The response rate was 55% (n=1501). Some 37% (555/1501) of respondents had used a non-prescription analgesic in the previous two weeks. Analgesics accounted for 59% (636/1081) of all non-prescription medicines used in that period. After controlling for all other variables, age, sex, level of education, self-reported health status, prescription exemption status, and use of prescription analgesics, remained significant predictors of non-prescription analgesic use. There was evidence of possible inappropriate use of non-prescription analgesics including use of multiple analgesics (n=67), use by individuals self-reporting conditions associated with cautious use of certain analgesics (n=51), and potential drug-drug interactions (n=15). A few respondents appeared to be using non-prescription analgesics to supplement medical treatment of chronic conditions (n=4).
Our findings have demonstrated a high level of use of non-prescription analgesics amongst the general public, with significant potential for inappropriate use. As we move towards a culture of increased self-management of minor illness, this demonstrated need for improved pharmacovigilance of non-prescribed medicines must be addressed.
Family Practice 03/2005; 22(1):78-85. · 1.50 Impact Factor
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ABSTRACT: Psychological intervention may be effective in chronic pain. A brief, valid and reliable screening tool may assist the targeting of appropriate intervention in primary care. We tested the Psychological Vulnerability Scale (PVS) for use in future community-based studies. A postal questionnaire was sent to 160 adults sampled from a general practice in North East Scotland, and to 40 adults from a hospital-based pain management clinic. The questionnaire included the SF-36, the Chronic Pain Grade (CPG) and chronic pain definition questionnaire. Factor analysis identified one relevant factor with a high eigenvalue of 3.65. All correlations with the SF-36 were significant. The PVS had good internal consistency and moderate test-retest scores, showing the PVS to be a reliable instrument for use in a general population sample. The difference in PVS total score between the pain clinic and general population sample was highly significant (p = 0.006). 32% of community-based individuals with chronic pain and 49% of pain clinic attendees had high psychological vulnerability. Further work is required to assess the usefulness of the PVS in future chronic pain research and clinical practice.
The Pain Clinic 06/2004; 16(2):153-162.
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ABSTRACT: The aim of the study was to determine factors influencing general practitioners' (GPs') decisions to provide pre-hospital thrombolysis for acute myocardial infarction.
Semi-structured, face-to-face interviews were carried out with 21 GPs in Grampian (10 rural; 11 urban).
The GPs believed that thrombolysis has an important role in the management of acute myocardial infarction, but urban practitioners were not convinced that time savings could be made by GP provision. Practical issues such as taking an electrocardiogram, ascertaining contra-indications in patients, maintaining skills, equipment, and workload were barriers preventing the provision of pre-hospital thrombolysis. There was a sense that primary care needed to feel that it is initiating change rather than having change thrust upon it.
Decision-making processes in primary care are complex, even when the evidence supporting change is strong. Health service planners wishing to implement successful change need to consider other issues such as practical matters, support structures, current morale and practitioner perceptions of control.
Journal of Public Health 04/2004; 26(1):38-41. · 2.06 Impact Factor
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ABSTRACT: Women who have had preeclampsia (PE) or gestational hypertension (GH) exhibit relatively high rates of circulatory diseases. PE is a disease associated with inflammation and vascular endothelial dysfunction. We therefore hypothesised that women with a history of PE or GH might have abnormal levels of markers of endothelial activation or inflammation, reflecting either an innate predisposition to preeclampsia or changes induced by the eclamptic process. Levels of von Willebrand factor, fibrinogen and C-reactive protein were compared in 392 women with a history of PE between 1951 and 1970, 297 women with a history of GH and 163 matched controls. Although no significant differences between those with either PE or GH and controls were noted, subjects with a history of PE had significantly higher CRP values than those with GH. No significant differences were found when the three groups were compared for von Willebrand factor or fibrinogen. Overall, the data do not support our hypothesis. In addition, our data document increasing von Willebrand factor levels increase with age, which may help explain the age dependent increase in venous or arterial thrombosis. Moderate alcohol consumption was also associated with lower levels of inflammatory markers.
Thrombosis and Haemostasis 01/2004; 90(6):1192-7. · 5.04 Impact Factor
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ABSTRACT: Many apparently distinctive clinical syndromes of pain and dysfunction show considerable overlap in both population and clinical settings. If the explanation is that they all share a common underlying mechanism, then we hypothesize that any one syndrome will be unlikely to retain its distinctiveness over time. Consultation data from general practice records for 10073 women, collected between 1968 and 1978, was linked with information on pain complaints obtained from a subsequent postal survey carried out in 1994. Illness episodes were identified from the general practice records and grouped into diagnostic subcategories. Associations between these and future pain complaints were explored, adjusting for age, smoking, body mass index and social class in a series of nested case-control analyses. Overall, the strongest independent associations of current pain were with episodes of musculoskeletal illness and mental disorders recorded 15-25 years earlier; these associations were more marked for widespread pain (odds ratios 1.8 and 1.7, respectively) than for non-widespread pain (ORs 1.3 and 1.2, respectively). In analyses of specific illness subcategories, the strongest links for head and neck pain were with earlier migraine. Back pain was most strongly associated with earlier back complaints, and abdominal pain with earlier intestinal-related problems. By contrast, chest pain was most strongly linked with earlier psychological illness. Earlier soft tissue illness episodes showed no distinctive patterns of associations over time with subsequent regional pain complaints. This analysis provides some support for shared mechanisms of chronicity across regional pain complaints, particularly in relation to the earlier occurrence of mental illness and the development of widespread pain. However, there is strong evidence that regional pain complaints also track distinctively over time. This argues against chronic functional and pain syndromes all being the same problem with a common mechanism of persistence, and in favor of unique regional influences on chronicity as well.
Pain 10/2003; 105(1-2):309-17. · 5.78 Impact Factor
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ABSTRACT: To examine the association between hypertensive diseases of pregnancy (gestational hypertension and pre-eclampsia) and the development of circulatory diseases in later life.
Cohort study of women who had pre-eclampsia during their first singleton pregnancy. Two comparison groups were matched for age and year of delivery, one with gestational hypertension and one with no history of raised blood pressure.
Maternity services in the Grampian region of Scotland.
Women selected from the Aberdeen maternity and neonatal databank who were resident in Aberdeen and who delivered a first, live singleton from 1951 to 1970.
Current vital and cardiovascular health status ascertained through postal questionnaire survey, clinical examination, linkage to hospital discharge, and mortality data.
There were significant positive associations between pre-eclampsia/eclampsia or gestational hypertension and later hypertension in all measures. The adjusted relative risks varied from 1.13-3.72 for gestational hypertension and 1.40-3.98 for pre-eclampsia or eclampsia. The adjusted incident rate ratio for death from stroke for the pre-eclampsia/eclampsia group was 3.59 (95% confidence interval 1.04 to 12.4).
Hypertensive diseases of pregnancy seem to be associated in later life with diseases related to hypertension. If greater awareness of this association leads to earlier diagnosis and improved management, there may be scope for reducing a proportion of the morbidity and mortality from such diseases.
BMJ (Clinical research ed.). 05/2003; 326(7394):845.
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ABSTRACT: The National Health Service (NHS) intends to introduce a system of electronic transfer of prescription-related information between general practitioners (GPs) and community pharmacies. The NHS Plan describes how this will be achieved.
To gather opinions of patients, GPs, and community pharmacists on the development of a system of electronic transfer of prescription-related information between GPs and community pharmacies.
Survey combining interviews, focus groups, and postal questionnaires.
General practitioners, opinion leaders, computing experts, pharmacists, and patients. Eight hundred members of the public, 200 GPs, and 200 community pharmacists, all living in Scotland.
Content-setting interviews and focus groups were conducted with purposive samples of relevant groups. Postal questionnaires were developed and sent to random samples of members of the public selected from the electoral roll, GPs, and community pharmacists.
The corrected postal response rates were: 69% (patients); 74% (GPs); and 74% (community pharmacists). All three groups were generally supportive of electronic transfer of prescription-related information. Different aspects appealed to each group: patients anticipated improved convenience; GPs, better repeat prescribing; and pharmacists, an enhanced professional role. Security of patient-identifiable information was the main concern. All groups acknowledged potential benefits of a full primary care information system, but GPs and patients had reservations about allowing community pharmacists to access parts of the medical record that did not concern medication.
Electronic transfer of prescription-related information is likely to be acceptable to all users, but concerns about patient confidentiality and an extended role for pharmacists in prescription management need to be addressed.
British Journal of General Practice 04/2003; 53(488):204-9. · 1.83 Impact Factor
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ABSTRACT: Pharmaceutical advances over the past 50 years have benefited many people in terms of disease prevention and management. However, probably without exception, most pharmaceutical products can cause adverse consequences of varying severity and frequency. In the last 10 years, many medicines that were originally prescription only have now become available over the counter (OTC), either from pharmacies or other general retail outlets. The volume and value of OTC medicine sales have increased accordingly. These switches have been well regulated and based on clear criteria and evidence of safety. Benefits of the changes include increased convenience to patients, greater self-management of minor ailments and a reduction in government drug expenditure.However, there are important differences between medicines supplied OTC and on medical prescription. With OTC medicines there is generally less healthcare professional input into the recommendation or ongoing monitoring of use. There is an absence of records per se, or linkage to other medication records elsewhere, and most countries allow direct-to-consumer advertising of the product. Taken together these differences can result in inappropriate expectations, demand and use of the OTC medicines, with limited opportunity for ongoing patient follow-up and monitoring of safety. Methodologies for pharmacy-based epidemiological studies of OTC medicines need to be developed. Studies should be large enough to detect associations that might exist, and to consider other explanations for associations such as chance, bias or confounding. There have already been some pilot studies with encouraging results with respect to follow-up rates. Outcome data however have usually been self-reported and the studies have lacked a suitable comparison group. Purchasers and suppliers of OTC medicines should also be made aware of, and encouraged to use, existing systems for spontaneous reporting of suspected adverse events, such as the Yellow Card Scheme in the UK. While available OTC medicines are perceived to be generally safe, problems have occasionally arisen with some earlier switched products (e.g. terfenadine). There have also been concerns about some traditional herbal and homeopathic remedies such as St John's wort. While such adverse events are rare, they emphasise the need for healthcare professionals and the public to understand and manage such risks. Many doctors are unaware of the range of OTC preparations available, and therefore do not consider them as a possible cause of presenting symptoms. Neither do they take them into account when making a new prescribing decision. The public need to be aware that OTC medicines should be treated with the same care as prescribed medicines, and that advice on recommended dose, contraindications and interactions should be adhered to.
Drug Safety 02/2003; 26(15):1065-74. · 3.63 Impact Factor
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Philip Hannaford
The Annals of Family Medicine 7(3):277-8. · 5.36 Impact Factor
