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Biomedical subjects

R C Fraser

Publications and source records attributed to R C Fraser.

At least 37 records · Page 2Linked to original sources
PubMed1994

Consultation competence in general practice: testing the reliability of the Leicester assessment package.

BACKGROUND: An acceptable assessment must be both valid and reliable; the face validity of the Leicester assessment package has already been established. AIM: This study set out to test the reliability of the Leicester assessment package, and the factors influencing it, when used by multiple assessors to assess performance in general practice consultations. METHOD: Six randomly selected course organizer assessors simultaneously used the package to conduct independent assessments of the performance of five doctors of widely varying abilities in consultation with six simulated patients. The scores allocated were subjected to generalizability analysis. RESULTS: The mean scores allocated for consultation performance of individual doctors ranged from 51% to 70%, with the lower scores being allocated to the less experienced doctors. Scores of each assessor across the cases were examined for internal consistency and five of the six assessors consistently scored the doctors with an alpha coefficient of the minimum accepted level of 0.80 or greater. The other assessor had a consistency of only 0.22. Measurements of consistency within cases between markers indicated that the first case produced unreliable results (alpha coefficient 0.25) but all other cases were scored consistently. Two independent assessors scoring eight consultations are the requisite numbers to achieve acceptable levels of reliability in a formal assessment process; seven consultations produce the minimum acceptable generalizability coefficient of 0.80 plus the first 'non-counting' consultation. CONCLUSION: Required levels of reliability can be achieved when the package is used by multiple markers assessing the same consultations over a wide range of consultation performance. To achieve reliability only two hours of assessment time are required using the Leicester package compared with the previously regarded minimum of 32 hours. Although assessors can produce reliable scores with minimal training, intra-assessor reliability cannot be taken for granted and all assessors should be trained and calibrated before being sanctioned to conduct assessments, particularly for regulatory purposes. The Leicester assessment package has now been shown to be valid, reliable, feasible and easy to use in practice. It can, therefore, be recommended for use in both formative and summative assessment of consultation competence in general practice.

Communication↗
PubMed1994

Consultation competence in general practice: establishing the face validity of prioritized criteria in the Leicester assessment package.

AIM: This study set out to test the face validity of prioritized criteria of consultation competence in general practice as contained in the Leicester assessment package. METHOD: A questionnaire was sent to a geographically stratified random sample of 100 members of the United Kingdom Association of Course Organisers to seek their views on the categories, components and weightings contained in the Leicester assessment package and to determine the proportion of respondents who rejected or suggested a new category, component or weighting or reallocated components to other categories or amended weightings. Their views were sought on a six-point scale (strongly approve, approve, tend to approve, tend to disapprove, disapprove and strongly disapprove). RESULTS: There was a 73% response rate. Of the respondents 99% either strongly approved or approved of the overall set of categories of consultation competence. Only two respondents (3%) expressed any disapproval of individual categories. Thirty five of the 39 suggested components of consultation competence were supported by more than 80% of respondents. There was minimal support for excluding any categories or components of consultation competence, for moving any components to different categories or for the inclusion of new categories or components. Eighty eight per cent of respondents were in favour of the need to identify priorities between any agreed categories of consultation competence and 79% expressed approval of the suggested weightings. Although 42% of respondents indicated a wish for some alteration in weightings, the mean values for all consultation categories suggested by all respondents were almost identical to the original weightings in the Leicester package. CONCLUSION: The face validity of the categories and components of consultation competence contained in the Leicester assessment package has been established, and the suggested weightings of consultation categories have been validated. Consequently, the criteria contained in the Leicester package can be adopted with confidence as measures against which performance can be judged in formative or summative assessment of consultation performance in general practice.

Clinical Competence↗
PubMed1993

Sequestration of the left coronary artery from the aorta.

A patient with the left coronary artery isolated from the ascending aorta is discussed. This is the seventh case described and the third diagnosed preoperatively. In contrast to other patients she had predominant aortic incompetence and was much older (52 years compared with the other patients, all younger than 25 years). She also had two angiograms demonstrating progressive isolation of the coronary artery with time. The patient was managed by aortic valve replacement. It is our belief that the condition is acquired and resulted from fusion of the free edge of the aortic valve leaflet to the supravalvar ridge secondary to an inflammatory process.

Aorta↗
PubMed1993

High risk of coeliac disease in Punjabis. Epidemiological study in the south Asian and European populations of Leicestershire.

The purpose of this study was to measure the incidence of coeliac disease in different ethnic communities and investigate the hypothesis that the incidence is decreasing in most European countries and the role incomplete retrieval of data may play. In a retrospective study of histologically confirmed cases of coeliac disease between 1975 and 1989 in the City of Leicester, 106 patients with coeliac disease were identified. Of these 86 were European and 20 Asian. The overall incidence of coeliac disease in Europeans was 2.5/10(5)/year (95% CI 2-3.2), in Gujaratis 0.9/10(5)/year (95% CI 0.4-1.8), and in Punjabis 6.9 (95% CI 3.2-12.3). These differences were independent of religious belief. The relative risk to Punjabis compared with Europeans is 2.9 (95% CI 1.5-5.3; chi 2 = 12.5, p < 0.01) and to Gujaratis 8.1 (95% CI 3-22.4; chi 2 = 25; p < 0.001). Gujaratis were at 0.4 risk of Europeans (90% CI 0.2-0.8; chi 2 = 6.7; p < 0.01). The incidence in the urban populations of Leicester was 6/10(5)/year (95% CI 1.3-1.9) which was significantly lower than the 3.2/10(5)/year (95% CI 2.7-3.8; chi 2 = 5.6; p < 0.001) in surrounding rural areas. This study shows that the incidence of coeliac disease in Punjabis (Sikhs, Hindus and Muslims) is 8 times higher than in Gujaratis (Hindus and Muslims) and 4 times higher than in Europeans in Leicester.

Adult↗
PubMed1993

Teaching and assessment in the consultation. A workshop for general practice clinical teachers.

A faculty development programme for general practice clinical teachers offered a skills development workshop which specifically addressed the skills needed when teaching and assessing students consulting with patients. The course was sequential, that is, a group moved on to a new skill only when its members could demonstrate mastery of a lower-order skill. Participants practised skills and received feedback on their performance from peers and learners (students and trainees). Participants comments about the course were highly favourable and the majority foresaw a general improvement in their own personal consultation skills as a result. They recognized that the use of a valid and reliable set of criteria (the Leicester Assessment Package) was essential in order to make correct judgements about consultation performance before instituting remedial teaching.

Educational Measurement↗
PubMed1990

Prognostic value of peritoneal cytology in endometrial carcinoma.

To determine whether positive peritoneal cytology is an independent poor prognostic factor in patients with endometrial carcinoma the records of 381 patients were reviewed. Positive peritoneal cytology was found in 24 of 381 (6.3%) patients. In clinical stage I disease, 16 of 322 (5.0%) patients had positive peritoneal cytology. Patients with positive cytology were more likely to have higher-grade tumors and extrauterine disease at the time of surgery (45% vs 2.3%) than were patients with negative cytology. Five-year survival was significantly less for patients with positive cytology than negative (50% vs 81.2%). For patients with surgical stage I disease (no extrauterine spread at surgery) there was no significant difference in 5-year survival between groups with positive and negative cytology (80% vs 86.3%). The majority (70.8%) of patients with endometrial cancer and positive peritoneal cytology have extrauterine disease at the time of surgery. Although overall 5-year survival is less for patients with positive cytology, when other risk factors are controlled for, there is no difference in survival for patients with no demonstrable extrauterine disease despite positive cytology. We conclude that positive peritoneal cytology is not an independent prognostic indicator for patients with endometrial cancer.

Adenocarcinoma↗
PubMed1990

Teaching the teachers at Leicester: the general practice approach.

This article describes a systematic induction programme devised for newly appointed lecturers in general practice. The programme aims to help them develop skills in both teaching and assessment and to encourage self-appraisal. The progress of participants is monitored by direct observation and video-recording with the regular provision of feedback a prominent characteristic. All the lecturers have found participation in the programme an effective way of developing their teaching capabilities.

Education, Medical↗
PubMed1989

Pelvic radiation therapy for gynecologic malignancy in geriatric patients.

Thirty-one patients, aged 75 years or older, who received pelvic radiation therapy as part of primary treatment for a gynecologic malignancy, were reviewed. Ten patients (32%) failed to complete their treatment and 4 patients (13%) died of treatment-related complications. The treatment-related complications were independent of increasing age, but did correlate closely with the patients' pretreatment ECOG performance status. Ten patients with performance levels of 2 or higher had a mortality rate of 30%, while 70% failed to complete treatment. Treatment fractions of greater than 220 cGy per day also resulted in unacceptably high complication rates. Alternative treatment formats should be considered in geriatric patients with poor initial performance levels.

Age Factors↗
PubMed1988

Adriamycin and cisplatin in the treatment of stage III and IV epithelial ovarian carcinoma.

A total of 342 eligible, previously untreated patients with Stage III or IV epithelial ovarian carcinoma were treated with Adriamycin and cisplatin, both at 50 mg/m2, for nine courses. Of the 210 patients who had clinically detectable disease after initial surgery, 85 (41%) had a complete clinical response and 45 (21%) had a partial clinical response. A total of 197 were clinically free of disease at the completion of chemotherapy and 175 of these had a second-look laparotomy; 55 had no macroscopic or microscopic evidence of residual disease after multiple random biopsies were examined histologically (complete surgical/histologic response). The major determinants of complete surgical/histologic response were diameter of largest residual tumor prior to treatment, ECOG performance status, and grade, patients with grade 3 tumors having a higher complete response rate than those with grade 1 or 2 tumors. The major determinants of survival were ECOG performance status and diameter of largest residual tumor prior to treatment. Median survival of the total group was 1.8 years.

Adult↗
PubMed1987

A predictive index of cure versus no cure in advanced ovarian carcinoma patients--replacement of second-look laparotomy as a diagnostic test.

Three hundred forty-two Stage III and IV epithelial ovarian carcinoma patients received cytoreductive surgery followed by Adriamycin and cisplatin, 50 mg/m2 each, q 4 weeks for 9 courses. One hundred ninety-seven were clinically NED at completion of treatment and 173 of these 197 had a second-look laparotomy. One hundred twenty had persistent disease. Fifty-three were second-look negative and had no further treatment. Thirty of these latter patients relapsed--all (with one exception) within 2 years. Those not relapsing after negative second-look are considered "cured" (median follow-up 42 months, range 24-68 months) and all others "failures." Stage was a significant predictor of treatment failure--there were no Stage IV "cures." In Stage III patients, age and largest residual tumor diameter post initial surgery were significant predictors of failure. Performance status was marginally significant. In our series, any patient with Stage IV disease or Stage III disease with at least two of the following three poor prognostic factors had a chance of cure of 2.2% (2 "cures" out of 90 patients): age greater than 60 years, macroscopic residual initially, or initial performance status of 2 or 3. Under normal circumstances a second-look procedure to identify persistent disease in this group of patients does not appear justified.

Adult↗
PubMed1987

Second-line chemotherapy of stage III-IV ovarian carcinoma: a randomized comparison of melphalan to melphalan and hexamethylmelamine in patients with persistent disease after doxorubicin and cisplatin.

A total of 205 women with stage III or IV ovarian cancer who had persistent disease after initial treatment with doxorubicin and cisplatin were randomized to receive melphalan (8 mg/m2 orally for 4 days) or the combination of melphalan (6 mg/m2 for 4 days) and hexamethylmelamine (120 mg/m2 for 14 days) every 4 weeks. Only one of 64 patients with measurable disease had an objective response. The major determinants of survival after randomization were the amount of residual disease after initial chemotherapy and the type of response to initial chemotherapy. There was no overall difference in survival between the two chemotherapy regimens, but the small group of patients whose disease progressed on initial chemotherapy survived significantly longer when treated with the two-drug combination. Neither of these regimens provided effective therapy for women whose disease was not eliminated by first-line treatment. However, the superior results obtained in one subgroup with the addition of hexamethylmelamine suggest that the place of this agent in treating ovarian cancer should be carefully evaluated.

Adult↗
PubMed1987

Comparative trial of azapropazone and indomethacin plus allopurinol in acute gout and hyperuricaemia.

This study compared the effects of azapropazone and indomethacin plus allopurinol in the management of acute gout and hyperuricaemia. A group of 93 patients predominantly based in general practice were randomly allocated to the two treatment regimens (azapropazone (days 1-225) or indomethacin (1-28) followed by allopurinol (29-225)) on a double-blind double dummy basis. Azapropazone produced a substantial reduction in serum uric acid levels by day 4 compared with day 1 (P<0.002) and was superior to indomethacin with regard to recorded levels of serum uric acid at day 4 (P<0.01) and day 28 (P<0.05). From day 28 onwards allopurinol produced and azapropazone maintained similar reductions in serum uric acid. Both treatments rapidly controlled the initial acute attacks of gout and both produced side effects similar in frequency and nature. Fewer breakthrough attacks of gout occurred in the azapropazone group (12) than the indomethacin/allopurinol group (21).Although the results achieved in both treatment groups were similar it has been shown that azapropazone is effective monotherapy for controlling both acute attacks of gout and hyperuricaemia.

Adult↗
PubMed1985

Information systems for general practitioners for quality assessment: III. Suggested new prescribing profile.

The information that is supplied to general practitioners by the Prescription Pricing Authority and family practitioner committees has severe limitations if used for self audit of prescribing. We studied the demand for and the extent to which general practitioners would collaborate in developing a system for providing more pertinent information about patterns of personal and practice prescribing. One hundred and eighty two doctors (36% of respondents to a questionnaire) who wished to learn more about their repeat prescribing were invited to help to generate this information and to create profiles of their personal prescribing rates based on a denominator of doctor-patient contacts. Nearly all of them translated intention into participation and also recruited 28 more doctors, since all partners in a practice had to take part. Overall, 202 doctors (40%) took part, 83% of whom participated in the combined study of repeat prescribing and rate of prescribing and 17% in the repeat prescribing exercise only. The examples of the new profiles that are provided show a more accurate representation of personal and practice prescribing patterns, differentiate between face to face contacts and repeat prescriptions, and are likely to stimulate improvements in personal or practice prescribing. We believe that this system should be offered to all practices in the United Kingdom.

Drug Utilization↗
PubMed1985

Information systems for general practitioners for quality assessment: II. Information preferences of the doctors.

In this part of the study we intended to determine (a) the extent to which currently supplied information was used by general practitioners to assess their performance and (b) the preferences of the doctors for new information. Four aspects of professional activity were investigated: prescribing, practice activity as shown by family practitioner committee quarterly returns, hospital use, and audit in depth. The results are from 508(76%) questionnaires returned from the 669 general practitioners circulated in Leicestershire and Lincolnshire. The prescribing habits of most doctors are influenced both by factual information about drugs from many sources and by feedback on their personal prescribing or that of their practice, which is supplied by the Prescription Pricing Authority, particularly regarding prescribing costs. Little use is made of data from the family practitioner committee. A distinct pattern of preferences for particular items of information emerged. Most doctors wished to receive information that would enable them to compare their personal performance or that of their practice with their local colleagues from the Prescription Pricing Authority (66%), the family practitioner committee (58%), and hospital sources (57%). Because doctors chose particular items of information that they would like to have, systems that are developed to provide such information are likely to be used. The need to incorporate comparison with peers is particularly important.

Drug Prescriptions↗