Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
GPs to blame again
- Trefor Roscoe (19 September 2008)
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Patients need improved knowledge and access to services rather than general practice
- Amit Patel (21 September 2008)
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Constraints in secondary care not delays in primary care are likely to be a bigger problem
- Daniel P. Edgcumbe (21 September 2008)
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Patients need improved knowledge and access to services rather than general practice - erratum
- Amit Patel (21 September 2008)
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Pseudoscience is Political Propaganda
- Andrew J Ashworth (22 September 2008)
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Extending opening hours of general practices: the tip of an iceberg?
- Isabelle Pitrou (23 September 2008)
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Wrong conclusion
- Giles Field (7 October 2008)
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TIA or Stroke with Transient Overt Signs?
- Desmond O'Neill, Ronan Collins, Tara Coughlan (8 October 2008)
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Reassurance!
- Helen Young (13 October 2008)
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Confused statistics on brain attacks
- Mark Howson (14 October 2008)
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Response from the Authors
- Daniel S Lasserson, Arvind Chandratheva, Matthew F Giles, David Mant, Peter M Rothwell (20 October 2008)
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Trefor Roscoe, GP partner Sothall Medical Centre, S20 1HQ
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Lasserson and colleagues seem to have fallen for the Government propaganda that it is always the GPs fault. Their conclusion "General practitioners’ opening hours influence patients’ healthcare seeking behaviour after TIA and minor stroke. Current opening hours can increase delay in assessment. Improved access to primary care and public education about the need for emergency care are required if the relevant targets in the national stroke strategy are to be met." is illogical and not supported by common sense. In order for this to be reversed, thus saving 500 strokes per year as the BBC web site (http://news.bbc.co.uk/1/hi/health/7623000.stm) would have it, all GPs would need to be available round the clock, 365 days per year. That would be the only way that patients would be sure of being able to see their registered GP out of hours or at weekends. There has never been such access to individual GPs and before the Government interfered, the out of hours service for the majority of the population was superb. I am not sure this paper adds anything, and would question whether it should have been published with this conclusion. What is needed, as they also point out is a public health campaign to get patients to seek the urgent secondary care they require, not to yet again berate GPs for something they cannot do even in an ideal world. Competing interests: GP opposed to working around the clock |
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Amit Patel, NIHR Academic Clinical Fellow Imperial College London, Hammersmith Hospital, Du Cane Rd, London, W12 0NN
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I read Lasserson’s[1] population-based study on healthcare seeking behaviour in the first twenty-four hours of a TIA or minor stroke with interest. It is not clear why access to general practice was chosen in particular over access to suitable healthcare overall as a study objective. However, it strikes me that these patients require urgent hospital assessment, either by a TIA service available out of ‘office hours’, or as is the case in most of the UK, the emergency department. The very basic questions that require attention in a patient assessment may be regarding anti-platelet/coagulant therapy, in-patient admission for assessment and/or investigations, urgent imaging and/or potential thrombolytic therapy, and potential surgery. Although other aspects of secondary prevention can be managed in general practice, rapid access to investigations and follow-up are not readily available. Therefore, these more pressing questions require urgent secondary (specialist) care. Indeed, to reduce the risk of subsequent stroke and length of in-patient stay, it is may be more useful to offer twenty-four hour access to an acute TIA service[2] or an acute neurologist/stroke physician,[3] as they will eventually assess the patient anyway. Rather than focus on access to the general practice, which arguably may not have had a major impact on management other than urgent referral to secondary care, one of the most striking messages in the paper is that awareness of the available services to this population needs to be improved, a concerning finding previous reported in this group.[4] Also of interest is that NHS Direct was utilised by only 0.03% of patients, suggesting very few people (with TIA or minor stroke) use the service, and of those that did, 70% may have been incorrectly managed after assessment.[1] Perhaps this could be improved with a basic scoring system, such as ABCD2.[5] References [1] Lasserson DS, Chandratheva A, Giles MF, Mant D, Rothwell PM. Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study. BMJ 2008;337:a1569. [2] Lavallée PC, Meseguer E, Abboud H, Cabrejo L, Olivot JM, Simon O, Mazighi M, Nifle C, Niclot P, Lapergue B, Klein IF, Brochet E, Steg PG, Lesèche G, Labreuche J, Touboul PJ, Amarenco P. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953-60. [3] Brown DL, Lisabeth LD, Garcia NM, Smith MA, Morgenstern LB. Emergency department evaluation of ischemic stroke and TIA: the BASIC Project. Neurology. 2004;63(12):2250-4. [4] Giles MF, Flossman E, Rothwell PM. Patient behavior immediately after transient ischemic attack according to clinical characteristics, perception of the event, and predicted risk of stroke. Stroke. 2006 May;37(5):1254-60. [5] Josephson SA, Sidney S, Pham TN, Bernstein AL, Johnston SC.Higher ABCD2 Score Predicts Patients Most Likely to Have True Transient Ischemic Attack. Stroke. 2008 Aug 7. [Epub ahead of print; accessed 20 September 2008] Competing interests: None declared |
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Daniel P. Edgcumbe, GP ST1 Cambridge
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The work by Lasserson et al would seem to miss an important point: even if a GP is consulted by a patient on Friday evening who has had a transient ischaemic attack (TIA), there are unlikely to be sufficient secondary care resources available to manage them in an optimal way. Patients who are at high risk of suffering a stroke after a transient ischaemic attack frequently go on to have strokes within days of the TIA. Rothwell et al.1 found that 31.4% of patients stratified as high risk on the ABCD score had a stroke within 7 days. Even if a GP correctly identifies the Friday evening patient as being in this high risk group and arranges for them to be admitted, it is unlikely that they will have full access to appropriate investigations (echocardiography, carotid doppler) let alone treatment (such as carotid endarterectomy) until the next working week - a delay of at least two and a half days - by which time they may have well gone to have had a stroke. Without appropriate resources in secondary care to back up GPs referring their patients for investigation and treatment, it doesn't matter if GPs are open 24 hours a day, 365 days a year - patients may still die unnecessarily because of the delays in providing comprehensive hospital care. 1. Rothwell et al. (2000) A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet Jul 2-8;366(9479):29-36.Competing interests: None declared |
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Amit Patel, NIHR Academic Clinical Fellow Imperial College London, Hammersmith Hospital, Du Cane Rd, London, W12 0NN
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In the following sentance, the figure is 3% rather than 0.03%. Apologies. "Also of interest is that NHS Direct was utilised by only 3% of patients, suggesting very few people (with TIA or minor stroke) use the service, and of those that did, 70% may have been incorrectly managed after assessment." Competing interests: None declared |
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Andrew J Ashworth, GP Principal Davison's Mains Medical Centre, 5 Quality Street, Edinburgh EH4 5BP
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The title of this paper implies that it analyses opening hours as an intervention and delay in seeking help as an outcome. It does not: it analyses delay in seeking help (an outcome) and then speculates on the potential intervention of changing GP hours. The following are quotes, in order, from the results section of this paper that does not address the question apparently posed by its title. “Of 359 patients with TIA and 434 with minor stroke, we excluded from
the analysis 25 patients who were outside the study area at the time of
their event…..
Notwithstanding any undeclared conflict of interest favouring a particular model of out of hours primary care provision, the “analysis” of extending opening hours of General Practice (amazingly General Practice is suddenly shifted into “centres” for this “analysis”) is at best speculative and at worst propaganda when included as “results”. These “results” have already been used for a political purpose and are quoted in the general press. Had the results been discussed objectively rather than being subjected to speculative “analysis” then patient care might have been improved: Are we not horrified that only 10 of 244 patients with events requiring prompt specialist attention out of GP contracted hours called the appropriate service and that that service was so inadequate as to fob off 70% with the bad advice to attend routinely? Surely the solutions to the real problem (patients don’t take TIA seriously enough) is patient education via media advertising not giving news media an unjustified pop at General Practitioners. The BMJ is published by the BMA. While the Editor should have editorial freedom (this is not Canada) she should at least read papers before publication (where did "such centres" arise from?)and declare her own position on political matters that the BMJ uses, albeit passively, the pseudoscience of speculative analysis to press a political agenda. Perhaps the Editor should defend her decision to publish this paper with a misleading title at the next meeting of the BMA’s General Practice Committee. Competing interests: I am a GP who does performs his extended hours before not after contracted hours. |
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Isabelle Pitrou, Public Health Practitionner (MD) Fondation MGEN pour la Santé Publique, 3 square Max Hymans, 75015 Paris, France
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I read with interest the original work of Lasserson et al. [1]. The results show elevated delay in seeking help after a TIA or minor stroke in case of out of hours or weekend events. Less than one third of patients used emergency departments (A&E) or called NHS Direct. Those results have immediate implications for emergency service provision and public education. In my opinion it is less a question of extended opening hours of general practices than a question of regulating emergencies in general. The authors in the part Method reported that socio-demographic data were collected but did not take into account those potential confounding factors in their analyses. What would have been of interest is to assess the influence of socio-demographic characteristics (e.g; age, sex, nationality, educational level, occupational activity, marital status, financial resources) on the delay of help seeking and the attendance of general practices, A&E or NHS direct service. Previous findings showed that patient characteristics are predictive of healthcare seeking behaviours [2]. Identifying profile of patients could help targeting the right population group for the delivery of public health awareness campaigns. Also further follow-up is required to determine long-term outcome (e.g; recurrent stroke, mortality rate). [1] Lasserson DS, Chandratheva A, Giles MF, Mant D, Rothwell PM. Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study. BMJ 2008;337:a1569. [2] Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003; 41:309-18. Competing interests: None declared |
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Giles Field, Salaried GP Churchdown, Glos GL2 2DB
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The authors clearly demonstrate that people trust their own GPs more than NHS Direct or PCT organised OOH. No surprise there. But their conclusions are quite clearly wrong. Strokes and TIAs cannot be investigated or treated in a standard General Practice surgery, most of us do not have a CT scanner nor access to IV thrombolysis. The best place for these patients is a hospital and as quickly as possible. Arranging to see your GP is merely a delay when time is of the essence. The correct conclusion is that we need to educate people about the symptoms of a stroke/TIA (now sometimes referred to as a brain attack) and encourage them to head directly to hospital. In the current atmosphere of government lead GP bashing the authors conclusion is at best mistaken. Competing interests: None declared |
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Desmond O'Neill, Consultant Physician in Stroke and Geriatric Medicine Stroke Service, Adelaide and Meath Hospital, Dublin 24, Ireland, Ronan Collins, Tara Coughlan
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It is increasingly clear that rapid and direct assessment by secondary care services is the key to successful management of both transient ischaemic attack (TIA) and stroke (1). In this sense, a continuing challenge is the persistence of the notion that such critical events should be channelled through primary care, with attendant delays, in a way that would be unthinkable for a 'major' stroke. A radical rethink of our descriptors of stroke disease is timely. Unhelpful terminology can obstruct treatment and cloud priorities (2). In addition to dropping the misleading couplet 'minor stroke', we should also abandon TIA, a term dating from the 1950’s which predates modern knowledge of stroke and sophisticated neuro-imaging (3). Increasingly, the benefit of urgent assessment and intervention (1), and evidence of subtle persistent neurological deficits after TIA (4), are eroding the distinction between stroke and TIA. Stroke with transient overt symptoms (STOS) would provide a better match with patient needs, accurate definition of the syndrome, and ideally prompt urgent assessment and management directly with stroke specialist services. 1) Kennedy J, Hill MD, Ryckborst KJ, Eliasziw M, Demchuk AM, Buchan AM; FASTER Investigators. Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol 2007;6:961-9. 2) Castro CM, Wilson C, Wang F, Schillinger D. Babel babble: physicians' use of unclarified medical jargon with patients. Am J Health Behav 2007;31 Suppl 1:S85-95. 3) Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, Sherman DG; TIA Working Group.Transient ischemic attack--proposal for a new definition. N Engl J Med. 2002;347:1713-6. 4) Delaney RC, Wallace JD, Egelko S. Transient cerebral ischemic attacks and neuropsychological deficit. Journal of Clinical and Experimental Neuropsychology 1980; 2: 107 – 114. Competing interests: None declared |
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Helen Young, Clinical Director NHS Direct NHS Direct - SE1 9HA
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The paper by Derkx et al1, outlined their study findings identifying concerns relating to the quality of the clinical aspects of call triaging in out of hours call consultations in the Netherlands. In their conclusion they suggest that the safety of telephone triage might be enhanced by using computer based decision support systems. The corresponding editorial by Josip et al2 reflecting on the findings ask a number of questions about in hours and out of hours telephone triage such as: how can we know if triage protocols are up to date, evidence based, followed or to what extent deviation from protocols is tolerated. We would like to take the opportunity to offer reassurance that NHS Direct telephone triage is underpinned by computer based clinical decision support protocols which are clinically developed and evidence based. Any deviation from the protocols are monitored and reviewed to understand why and what implications this may have for the caller or further refinement of the protocol. We also have a systematic call review process, to ensure call triaging is monitored for quality and appropriateness of outcome and this of course feeds into wider programmes of continuous quality improvement, service evaluation and research. In addition, we have an audit tool which is built into NHS Direct out of hour’s service level agreements to ensure a regular programme of audit activity. 1 Derkx H P, Rethans JJ E, Muijtjens A M, Malburg B H, Winkens R, Rooij H G v, Knottnerus J A. Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study. BMJ 2008; 337:a1264 2 Car J, Koshy E, Bell D, Sheikh A. Telephone triage and safety highlight the need for further evaluation. BMJ 2008; 337:a1167 Competing interests: None declared |
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Mark Howson, GP Registrar Haxby Group Practice YO32 2LL
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I was a little confused by the statistical analysis in the recent article by Lasserson et al.. They presented data in graphical form which showed a distribution of "delay in presentation" versus "time of event" which could be described by three discrete dirac-delta functions seperated from each other by 24 hours. It is inappropriate to describe these by a median and interquartile range, and it is not said how they managed to calculate a p-value from such distributions. A sensible approach would be to transform the distributions so that they could be described by a single lorentzian or gaussian distribution. The p-values could then be calculate using a t-test. I suspect there would be no significant difference between the out-of-hours and in-hours data presented in this way. But the important point to discuss would be in the different transformations required to obtain a single continuous distribution for the in-hours and for the out-of-hours data. I suspect the end result of the analysis would be the same as the qualitative approach of Lasserson et al., but would have some easily achievable mathematical rigour. Similarly I think a more rigorous conclusion is, that "brain attacks" should be treated, not by sticking two hours onto a GP surgery, but in the same way as "heart attacks", with improved secondary care and patient education to seek immediate help. Competing interests: None declared |
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Daniel S Lasserson, Clinical Lecturer Department of Primary Health Care, University of Oxford, Headington, Oxford, OX3 7LF, Arvind Chandratheva, Matthew F Giles, David Mant, Peter M Rothwell
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Patel [1], Field [2] and O’Neill [3] all point out the importance of urgent assessment of patients with TIA and minor stroke (or “stroke with transient overt signs” [3]) in secondary care. Pitrou [4] joins these authors in agreeing with us that public health campaigns need to address the issue of delay in presentation to medical services. Our research merely shows how patients with TIA or minor stroke are currently accessing care. 70% of patients seek help from primary care in the first instance and the majority of patients with events in the out of hours period wait until they can be seen in their registered practice. Urgent secondary care assessment is indeed crucial to prevent recurrent disabling or fatal stroke but in order to achieve this we need to understand how patients currently use healthcare in the emergency setting of TIA/minor stroke. Our findings should therefore help to inform future public health campaigns to ensure urgent specialist assessment. Increased capacity in secondary care may well be required, as Edgcombe [5] describes, so that all patients receive the optimum evidence-based care. Although Roscoe [6] and Ashworth [7] imply political motivation in the topic of the research, understanding how patients interact with healthcare services is crucial in achieving improved healthcare delivery. Organisation of health services has been under a degree of political influence since the foundation of the National Health Service so it is inevitable that research involving the mechanics of healthcare delivery may attract this criticism, which we reject as unfounded. 1. Amit Patel. Patients need improved knowledge and access to services rather than general practice. BMJ, 21 September 2008 2. Giles Field. Wrong conclusion. BMJ, 7 October 2008 3. Desmond O'Neill, Ronan Collins, Tara Coughlan. TIA or Stroke with Transient Overt Signs. BMJ, 8 October 2008 4. Isabelle Pitrou. Extending opening hours of general practices: the tip of an iceberg? BMJ, 23 September 2008) 5. Daniel P. Edgcumbe. Constraints in secondary care not delays in primary care are likely to be a bigger problem BMJ, 21 September 2008 6. Trefor Roscoe GPs to blame again BMJ, 19 September 2008 7. Andrew J Ashworth. Pseudoscience is Political Propaganda BMJ, 22 September 2008 Competing interests: None declared |
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