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Exeter, United Kingdom

Asprey A.,University of Exeter | Asprey A.,Primary Care Research Group | Paterson C.,University of Bristol | White A.,University of Plymouth
Acupuncture in Medicine

Background Group acupuncture clinics have been introduced in a London hospital and in two general practices in Hertfordshire for the treatment of knee osteoarthritis (OA). Encouraging preliminary reports have been published of the effi cacy of the treatment delivered in this setting but its acceptability to patients has not yet been established. The aim was to investigate the acceptability and perceived advantages and disadvantages of acupuncture delivered in the group setting for the treatment of knee OA. Methods Semistructured interviews were conducted with 16 patients in their own homes and with four nurses over the telephone. Interviews were recorded, transcribed, fully anonymised and analysed thematically. Results Group acupuncture was delivered with enthusiasm by nurses, was acceptable and popular with patients and recognised to be cost-effi cient. Factors affecting acceptability were situational, interpersonal and intrapersonal. Situational factors included adequacy of the physical space used, fl exibility of the appointment system and the changing and adaptable nature of the group. Interpersonal factors were mutual support, the exchange of information, the provision of mixed or single-sex sessions and the role of the acupuncture nurse. Intrapersonal factors that increased acceptability were less clear, but nurses expressed the view that the group setting was less suitable for patients with complex conditions or severe pain. Conclusions Acceptability is very high and may be maximised by taking a number of factors into account: full information should be provided before treatment begins; fl exibility should be maintained in the appointment system and different levels of contact between fellow patients should be fostered; suffi cient space and staffi ng should be provided and single-sex groups used wherever possible. Source

Nagraj S.,University of Cambridge | Abel G.,University of Cambridge | Paddison C.,University of Cambridge | Payne R.,University of Cambridge | And 3 more authors.
BMC Family Practice

Background: Changing family practice (voluntary disenrollment) without changing address may indicate dissatisfaction with care. We investigate the potential to use voluntary disenrollment as a quality indicator for primary care. Methods. Data from the English national GP Patient Survey (2,169,718 respondents), the number of voluntary disenrollments without change of address, data relating to practice characteristics (ethnicity, deprivation, gender of patients, practice size and practice density) and doctor characteristics were obtained for all family practices in England (n = 8450). Poisson regression analyses examined associations between rates of voluntary disenrollment, patient experience, and practice and doctor characteristics. Results: Mean and median rates of annual voluntary disenrollment were 11.2 and 7.3 per 1000 patients respectively. Strongest associations with high rates of disenrollment were low practice scores for doctor-patient communication and confidence and trust in the doctor (rate ratios 4.63 and 4.85). In a fully adjusted model, overall satisfaction encompassed other measures of patient experience (rate ratio 3.46). Patients were more likely to move from small practices (single-handed doctors had 2.75 times the disenrollment rate of practices with 6-9 doctors) and where there were other local practices. After allowing for these, substantial unexplained variation remained in practice rates of voluntary disenrollment. Conclusion: Family practices with low levels of patient satisfaction, especially for doctor patient communication, are more likely to experience high rates of disenrollment. However substantial variation in disenrollment rates remains among practices with similar levels of patient satisfaction, limiting the utility of voluntary disenrollment as a performance indicator for primary care in England. © 2013 Nagraj et al.; licensee BioMed Central Ltd. Source

Blakeman T.,NIHR | Blakeman T.,University of Manchester | Rogers A.,Primary Care Research Group | Bower P.,University of Manchester
British Journal of General Practice

Background: Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood. Aim: To explore the use of computer-based 'disease management' templates and their relevance to self-management dialogue within clinical encounters. Design and setting: Qualitative study of general practices located in three primary care trusts in the north of England. Method: A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17). Results: The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas. Conclusion: In order to enhance the management of longterm conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management. ©British Journal of General Practice. Source

Ramos-Casals M.,Sjogren Syndrome Research Group AGAUR | Tzioufas A.G.,National and Kapodistrian University of Athens | Stone J.H.,Massachusetts General Hospital | Siso A.,Primary Care Research Group | Bosch X.,Instituto Clinico Of Medicina Y Dermatologia
JAMA - Journal of the American Medical Association

Context: A variety of topical and systemic drugs are available to treat primary Sjögren syndrome, although no evidence-based therapeutic guidelines are currently available. Objective: To summarize evidence on primary Sjögren syndrome drug therapy from randomized controlled trials. Data Sources: We searched MEDLINE and EMBASE for articles on drug therapy for primary Sjögren syndrome published between January 1, 1986, and April 30, 2010. Study Selection: Controlled trials of topical and systemic drugs including adult patients with primary Sjögren syndrome were selected as the primary information source. Results: The search strategy yielded 37 trials. A placebo-controlled trial found significant improvement in the Schirmer and corneal staining scores, blurred vision, and artificial tear use in patients treated with topical ocular 0.05% cyclosporine. Three placebo-controlled trials found that pilocarpine was associated with improvements in dry mouth (61%-70% vs 24%-31% in the placebo group) and dry eye (42%-53% vs 26%). Two placebo-controlled trials found that cevimeline was associated with improvement in dry mouth (66%-76% vs 35%-37% in the placebo group) and dry eye (39%-72% vs 24%-30%). Small trials (<20 patients) found no significant improvement in sicca outcomes for oral prednisone or hydroxychloroquine and limited benefits for immunosuppressive agents (azathioprine and cyclosporine). A large trial found limited benefits for oral interferon alfa-2a. Two placebo-controlled trials of infliximab and etanercept did not achieve the primary outcome (a composite visual analog scale measuring joint pain, fatigue, and dryness); neither did 2 small trials (<30 patients) testing rituximab, although significant results were observed in some secondary outcomes and improvement compared with baseline. Conclusions: In primary Sjögren syndrome, evidence from controlled trials suggests benefits for pilocarpine and cevimeline for sicca features and topical cyclosporine for moderate or severe dry eye. Anti-tumor necrosis factor agents have not shown clinical efficacy, and larger controlled trials are needed to establish the efficacy of rituximab. ©2010 American Medical Association. All rights reserved. Source

Brito-Zeron P.,Institute dinvestigacions Biomediques August Pi i Sunyer IDIBAPS | Akasbi M.,Institute dinvestigacions Biomediques August Pi i Sunyer IDIBAPS | Bosch X.,ICMiD | Bove A.,Institute dinvestigacions Biomediques August Pi i Sunyer IDIBAPS | And 10 more authors.
Clinical and Experimental Rheumatology

Objective This paper aims to analyse the etiology, characterisation and outcomes of the different types of peripheral neuropathy in patients with primary Sjögren's syndrome (SS) and their association with clinical and immunological disease expression. Methods A total of 563 consecutive patients diagnosed with primary SS were evaluated. We retrospectively assessed the results of nerve conduction studies carried out in patients with suspected peripheral nervous system involvement. Peripheral neuropathies were classified into mononeuropathy, mononeuropathy multiplex, polyneuropathy and neuronopathy according to the patterns evidenced by electrodiagnostic studies. Results Nerve conduction studies were carried out in 158/563 (28%) SS patients. The results were normal in 49 and abnormal in 109 patients, in whom peripheral neuropathy was diagnosed in 102. After excluding patients with neuropathy associated with other diseases and patients with entrapment mononeuropathies, 55/563 (10%) patients were classified as having SS-related peripheral neuropathy, including axonal sensorimotor polyneuropathy (n=24), pure sensory neuronopathy (n=15), mononeuropathy multiplex (n=15) and demyelinating polyradiculoneuropathy (n=1). In spite of therapy, clinical progression measured by the MOHS scale was observed in 12% of patients with axonal polyneuropathy, 13% of those with mononeuropathy multiplex and 47% of those with neuronopathy. Survival was significantly reduced in patients with peripheral neuropathy (especially in those with mononeuropathy multiplex and axonal polyneuropathy) in comparison with the control group (log rank = 0.001). Conclusion We found a prevalence of SS-related peripheral neuropathy of 10%. Classification of neuropathy according to the clinical presentation and electrodiagnostic tests may be useful in determining the functional outcome, therapeutic response and survival. © Clinical and Experimental Rheumatology 2013. Source

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