Introduction

Top Abstract Introduction Participants and methods Interventions Results Discussion References

Increasing attendance in primary care is an important problem for the health service.¹ It increases stress on health professionals and has contributed to changing arrangements for out of hours care.² It is also a potential threat to consultation time and the quality of care provided for patients.³ If changing patient expectations and a demand for advice have contributed to the rising rates of consultation, then providing written information could reduce consultation rates for minor or self limiting illness.

Although information leaflets about specific acute illness may enhance patients' ability to manage their own illness and can modify reattendance,^4-6 these data cannot necessarily be extrapolated to the provision of general information leaflets.

We hypothesised that providing information by post about the self management of minor illness and when to contact the doctor could help patients' confidence in managing minor illness, help in their decision to consult the doctor, and hence reduce rates of consultation for minor illness. We report the main results of a randomised controlled trial of two kinds of general patient information about minor illness: an extensive booklet detailing the management of 42 conditions and a two page summary card dealing predominantly with the self management of respiratory illness.

	Participants and methods

Top Abstract Introduction Participants and methods Interventions Results Discussion References

This study was approved by the Southampton and South West Hants, and Salisbury local research ethics committees. We chose six general practices and randomly selected 4002 households, sampling equal numbers from the age-sex register of each practice. We selected one adult per household to avoid contamination of groups and randomised at patient level. Patients from nursing homes and those older than 80 were excluded as many of this group would have difficulty completing questionnaires. When the random choice of participant was a child (aged under 16), an adult was asked to complete the questionnaire.

Patients were sent a letter from their doctors explaining that the project was investigating the value of patient information leaflets or booklets and would also involve examining their notes for attendance. The doctors endorsed the leaflet or booklet enclosed with the letter and encouraged patients to use them before consulting.

	Interventions

Top Abstract Introduction Participants and methods Interventions Results Discussion References

Patients were randomised to receive one of three types of information.

Booklet groupPatients were sent What Should I Do?, a booklet summarising self management for 42 conditions and when to contact the doctor.⁷

Summary card groupPatients were sent a two sided summary of self management. One page dealt with respiratory illnesses and the second page with other common illness. The content of this leaflet was based, when possible, on evidence from trials or systematic reviews (for more detail see the BMJ's website).

Control groupPatients received a one page leaflet giving the surgery times and how to contact the doctor in an emergency.

Baseline questionnaire
We enclosed a baseline questionnaire with the letter and the leaflet or booklet. This contained questions on demographic details, attitudes to doctors, the use of the pharmacy and surgery, lifestyle, medical problems, perception of somatic symptoms, health anxiety, and perceived health. Patients who had not returned a completed questionnaire were sent second and third mailings.

Review of notes
We reviewed patients' notes at one year to assess attendances for the minor illnesses listed in the booklet. Notes were assessed by one of two assessors, who were blind to randomisation group.

Follow up questionnaire
A follow up questionnaire was sent at one year. All the practices requested that to avoid undue pressure on patients this questionnaire be sent only to those who had returned the original questionnaire. The follow up questionnaire asked whether the patient could remember receiving the booklet, if they had used it, whether they found the information useful, and whether they felt more confident in managing minor illness. The questionnaire also contained questions about willingness to wait before seeing the doctor (see BMJ 's website for more details).

Sample size
To have 80% power and 95% confidence in detecting an average 5% reduction in attendance with the leaflets among those attending commonly for minor illness (twice or more), and assuming a larger effect size with the booklet (30% control, 26.5% summary card, 23.5% booklet), we needed 2673 patients, or a minimum of 3341 in total allowing for 20% loss to follow up.

Analysis
We assessed more frequent attendance with minor illness (2 consultations a year, representing 30% of the population) in the year after providing the leaflets or booklets using logistic regression and controlling for attendance in the previous year. We also controlled for cluster effects at a practice level. Because the summary card particularly dealt with respiratory illness, we also assessed whether attendance with minor illness was reduced among patients who had attended with respiratory illness in the past year as a secondary outcome. We also fitted a longitudinal Poisson regression model to estimate the effect of intervention on the change in incidence of consultations with minor illness over time.

	Results

Top Abstract Introduction Participants and methods Interventions Results Discussion References

Of the 4002 randomised patients, only 238 (6%) were reported not living at that address and thus did not receive the intervention as allocated (figure). Table 1 gives the baseline and demographic data for the three intervention groups.

View larger version (25K): [in this window] [in a new window]   Study design and trial flow

Compared with the control group, fewer patients in the booklet and summary card groups attended frequently with minor illnesses (table 2). Among patients who had attended with respiratory tract infections in the previous year, there was also a reduction in attendance in the booklet group (0.81; 95% confidence interval 0.62 to 1.07; z=1.5, P=0.14) and summary card group (0.67; 0.51 to 0.89; z=2.8, P=0.005) compared with the control group. Compared with the previous year there were small non-significant reductions in the incidence of contacts with minor illness for the booklet group (incidence ratio 0.97; 0.84 to 1.13) and summary card group (0.93; 0.80 to 1.07).

Most respondents could remember receiving a leaflet or booklet (booklet 85% (572/671), card 70% (467/665), control 52% (335/639), P<0.001) and found them useful (booklet 81% (452/557), card 78% (577/984), control 62% (245/397), P<0.001). More patients in the intervention groups felt greater confidence in managing common illness than in the control group (booklet 32% (178/551), card 34% (156/466), control 12% (42/338), P<0.001), but there was no difference in willingness to wait score (booklet 31.9, card 32.2, control 32.0, P=0.67).

	Discussion

Top Abstract Introduction Participants and methods Interventions Results Discussion References

This study shows that information provided by post helped patients feel more confident in managing minor illness and can reduce subsequent attendance with minor illness. However, the impact of a detailed information booklet on overall consultations is likely to be modest for most patients. Before the results are discussed in detail the limitations of the study must be identified.

Sources of bias
There are no absolutely reliable measures of attendance; documented attendance may be preferable but is open to bias from omission, and reported attendance has inherent recall bias. However, we found good agreement between documented and reported attendance in the baseline sample, which supports the internal reliability of the data. Furthermore, any biases in measurement of attendance within each practice would be expected to be similar in all groups and would reduce the chance of finding differences between groups. We have shown that the documentation of minor illness by the two people who reviewed the notes was very reliable.

Interpretation of results
Fewer patients attended frequently with minor illness in the booklet group and in the summary card group, although the effect was modest. An odds ratio of 0.82 corresponds to about a 4% reduction in those attending frequentlythat is, from 29% to 25%. Our data support previous evidence that both general information and specific information can modify patients' use of services. ^{4-6 10-12} However, the absolute change in terms of consultations for minor illness was not significant for either the booklet or summary card. The estimate of the reduction in contacts with the summary card was 7%, but the confidence intervals greatly overlapped unity.