Leone Ridsdale

After I had been in general practice for several years, I joined a local sports club. This brought me into sometimes problematic contact with past, present and future patients. There were lots of older men at the club, who continued to play sport, despite gradual physical decline. They usually liked to play tennis with other men, and mostly they accepted their declining performance gracefully. Many of them made up for lack of mobility by employing long-practised skills, charm and humour. One man was an exception. He evidently had been a good athlete in the distant past. He was thin, spidery and bent at the ankles, knees and back, making it difficult to walk. He had completely lost his sense of humour about his declining abilities. Everyone tried to avoid playing with him. Local general practitioners (GPs) occasionally would ask my advice on their patients, knowing of my training in neurology and with such long neurology outpatient waiting times. On one occasion, I was asked to do a domiciliary visit for a neighbouring practice on an older man who was behaving increasingly irascibly, particularly towards his wife. Apparently her husband had been locking her out of the house and had written letters accusing her of having lovers. The deterioration in behaviour had occurred over such a long time, that it was difficult to know quite when it had started. The man was becoming impossible to live with. Her husband did not agree that there was anything wrong with him. I could see that getting the patient to agree to see me at his home was going to be challenging. It was then that I recognised his name, and realised that this was the bad tempered man from the club. I saw him, and managed to gain a limited interview. It was difficult to do more, as he was keen to assert that he was fine. I did persuade him to have some blood tests, and requested a B12, T4 and VDRL. Although these investigations are intended to identify treatable causes of memory decline and abnormal behaviour in adults, in my experience they were almost invariably negative. I performed them almost as a ritual, in the faint hope of finding something. Sometime later I attended a grand round at the neurological centre. The Registrar presented the history of an older patient who had become paranoid, and had been admitted to a psychiatric hospital under a Sectioning Order. The patient's GP had telephoned shortly after the admission with results of blood tests taken on a domicil-iary visit. The VDRL was positive, and his wife's was weakly positive too. I heard my patient's story spun as 'classical' tertiary syphilis, with Charcot joints. There was general wonderment…a textbook case…almost never seen nowadays. At the end, the group quickly concurred, penicillin was indicated for the patient, and for his wife. I continue to test for syphilis but moved to a sports club a greater distance from my home.

Headache is being viewed more commonly in a biopsychosocial framework, which introduces the possible utilisation of psychological treatment options, such as cognitive behavioural therapy and relaxation. No such treatments have been trialled in the UK. We conducted a randomised controlled pilot trial, comparing a brief guided self-help CBT and relaxation treatment with standard medical care (SMC), in a UK NHS setting. Participants were recruited from specialist headache clinics across London. Participants were randomised to receive either treatment or standard medical care. Our objective was to provide design information necessary for a future definitive trial of the SHE treatment, including, recruitment/retention rates, acceptability of randomisation, treatment fidelity and estimations of mean and variances of outcome measures. From the initial 275 patients identified, 73 were ran-domised. There was no difference in drop-out rates between SMC and treatment groups. Of the 36 participants randomised to receive treatment, 72 % attended all sessions. Findings show that a future definitive trial of the SHE treatment is feasible, with small modifications of protocol, within a UK NHS context.

Background: Migraine headache has a high prevalence and a severe impact on personal, social and work life, forming a significant burden on patients, service providers and society. There is some evidence of the effectiveness of behavioural interventions to supplement drug therapy but a recognised need to identify an effective minimal contact approach to enhance access and provide a model for use in publicly funded health systems. This study uses in-depth interviews to examine patients' experience and responses to a behavioural intervention with relaxation and CBT components delivered in three individual therapist sessions with follow-up. Methods: Qualitative study of 20 adults aged 18–75 years in London, UK, with clinically diagnosed migraine and at least four headache days per month. Semi-structured and tape recorded interviews were held post intervention based on a topic guide. Transcripts were coded and charted for all participants and analysed thematically.

Migraine causes major health impairment and disability. Psychological interventions offer an addition to pharmacotherapy but they are not currently recommended by the National Institute of Clinical Excellence (NICE) or available in the National Health Service. We aimed to systematically review evidence on the efficacy of psychological interventions for migraine in adults. A search was done of MEDLINE, psychINFO, http://www.opengrey.eu, the meta-register of controlled trials and bibliographies. Twenty-four papers were included and rated independently by two people using the Yates scale, which has 35 points. Cochrane recommendations are that high quality reports score above the mid-point (18 points). Methods used in 17/24 papers were rated 'high quality'. However, frequently descriptions of key areas such as randomisation methods were omitted. Eighteen studies measured effects of psychological interventions on headache-related outcomes , fifteen reporting significant improvements, ranging 20–67 %. Interventions also produced improvements in psychological outcomes. Few trials measured or reported improvement in disability or quality of life. We conclude that evidence supports the efficacy of psychological interventions in migraine. Over half of the studies were from the USA, which did not provide universal health care at the time of the study, so it is difficult to generalise results to typical populations in receipt of publically funded health services. We agree with the NICE recommendation that high quality pragmatic randomised controlled trials are needed in the UK.

Background: There is a need to test the effectiveness of new educational interventions for people with poorly controlled epilepsy. The SMILE (self-management education for adults with poorly controlled epilepsy) trial evaluates a complex service intervention that involves a 2-day self-management course with the aim of improving quality of life and clinical outcomes. This article describes the statistical, economic, and qualitative analysis plan for the trial.

Background: Teaching people with epilepsy to identify and manage seizure triggers, implement strategies to remember to take antiepileptic drugs, implement precautions to minimize risks during seizures, tell others what to do during a seizure and learn what to do during recovery may lead to better self-management. No teaching programme exists for adults with epilepsy in the United Kingdom although a number of surveys have shown patients want more information. Methods/Design: This is a multicentre, pragmatic, parallel group randomised controlled trial to evaluate the effectiveness and cost-effectiveness of a two-day Self-Management education for epILEpsy (SMILE (UK)), which was originally developed in Germany (MOSES). Four hundred and twenty eight adult patients who attended specialist epilepsy outpatient clinics at 15 NHS participating sites in the previous 12 months, and who fulfil other eligibility criteria will be randomised to receive the intervention (SMILE (UK) course with treatment as usual-TAU) or to have TAU only (control). The primary outcome is the effect on patient reported quality of life (QoL). Secondary outcomes are seizure frequency and psychological distress (anxiety and depression), perceived impact of epilepsy, adherence to medication, management of adverse effects from medication, and improved self-efficacy in management (mastery/control) of epilepsy. Within the trial there will be a nested qualitative study to explore users' views of the intervention, including barriers to participation and the perceived benefits of the intervention. The cost-effectiveness of the intervention will also be assessed. Discussion: This study will provide quantitative and qualitative evidence of the impact of a structured self management programme on quality of life and other aspects of clinical and cost effectiveness in adults with poorly controlled epilepsy.

SUMMARY This study looked at the effect of different appointment time intervals on process and outcome measures in the consultation. Over a five-month period patients attending a two-partner surgery were non-systematically allocated to appointments at five, 10 or 15 minute intervals. Consultations were audiotaped and analysed. When appointments were scheduled at longer intervals, doctors asked significantly more questions and made significantly more statements explaining the problem and its management, while patients asked significantly more questions and made significantly more statements of their own ideas about the problem. In consultations booked at shorter intervals patients were significantly more likely to report in satisfaction questionnaires that they had little or far too little time available. The implications of the results for future planning are discussed.

Headache accounts for up to a third of new specialist neurology appointments, although brain lesions are extremely rare and there is little difference in clinical severity of referred patients and those managed in primary care. This study examines influences on GPs' referral for headache in the absence of clinical indicators. Qualitative interview study. Eighteen urban and suburban general practices in the South Thames area, London. Purposive sample comprising GPs with varying numbers of referrals for headache over a 12-month period. Semi-structured interviews with 20 GPs were audio taped. Transcripts were analysed thematically using a framework approach. All GPs reported observing patient anxiety and experiencing pressure for referral. Readiness to refer in response to pressure was influenced by characteristics of the consultation, including frequent attendance, communication problems and time constraints. GPs' accounts showed variations in individual's willingness or &...

Anecdotal reports suggest that clopidogrel may prevent migraine attacks. We undertook a pilot randomised trial. We randomised consecutive migraineurs with four to 15 headache days per 28-day month to receive clopidogrel 75 mg or placebo daily for three months. Headache was primarily assessed with a headache diary. There were no statistically significant treatment effects. The number of headache days fell by 1.9 on clopidogrel and 1.6 on placebo (adjusted difference 0.02, CI -2.07 to 2.12). Headache severity rose by 0.14 points (out of 10) on clopidogrel, and fell by 0.63 on placebo; treatment effect 0.7 points (CI -0.11 to 1.57). The main treatment effect did not depend on the presence or absence of migraine with aura at baseline, a patent foramen ovale (PFO) or atrial septal aneurysm. The evidence is inconclusive, but a multicentre trial would be feasible recruiting from primary care.

People with chronic epilepsy (PWE) often make costly, and clinically unnecessary emergency department (ED) visits. Some do it frequently. No studies have examined interventions to reduce them. An intervention delivered by an epilepsy nurse specialist (ENS) might reduce visits. The rationale is it may optimize patients' self-management skills and knowledge of appropriate ED use. We examined such an intervention's clinical- and cost-effectiveness. Eighty-five adults with epilepsy were recruited from three London EDs with similar catchment populations. Forty-one PWE recruited from two EDs received treatment-as-usual (TAU) and formed the comparison group. The remaining 44 PWE were recruited from the ED of a hospital that had implemented a new ENS service for PWE attending ED. These participants formed the intervention group. They were offered 2 one-to-one sessions with an ENS, plus TAU. Participants completed questionnaires on health service use and psychosocial well-being at baseline, 6- and 12-month follow-up. Covariates were identified and adjustments made. Sixty-nine (81%) participants were retained at follow-up. No significant effect of the intervention on ED visits at 12 months or on other outcomes was found. However, due to less time as inpatients, the average service cost for intervention participants over follow-up was less than for TAU participants' (adjusted difference £558, 95% CI, -£2409, £648). Covariates most predictive of subsequent ED visits were patients' baseline feelings of stigmatization due to epilepsy and low confidence in managing epilepsy. The intervention did not lead to a reduction in ED use, but did not cost more, partly because those receiving the intervention had shorter hospital admissions. Our findings on long-term ED predictors clarifies what causes ED use, and suggests that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency-savings generated.

Can an epilepsy nurse specialist-led self-management intervention reduce attendance at emergency departments and promote well-being for people with severe epilepsy? A non-randomised trial with a nested qualitative phase L Ridsdale,1* P McCrone,1 M Morgan,1 L Goldstein,1 P Seed2 and A Noble1 1Institute of Psychiatry, King's College London, London, UK 2Division for Women's Health, King's College London, London, UK *Corresponding author leone.ridsdale@kcl.ac.uk Objectives: To (1) describe the characteristics and service use of people with established epilepsy (PWE) who attend the emergency department (ED); (2) evaluate the economic impact of PWE who attend the ED; (3) determine the effectiveness and cost-effectiveness of an epilepsy nurse specialist (ENS)-led self-management intervention plus treatment as usual (TAU) compared with TAU alone in reducing ED use and promoting well-being; (4) describe patients' views of the intervention; and (5) explore their reasons for attending the ED. Design: Non-randomised trial with nested qualitative study. Setting: The EDs of three inner London hospitals. The EDs each offer similar services and support a similar local population, which made a comparison of patient outcomes reasonable. Participants: Adults diagnosed with epilepsy for ≥ 1 year were prospectively identified from the EDs by presenting symptom/discharge diagnosis. We recruited 85 of 315 patients with 44 forming the intervention group and 41 the comparison group. Intervention: Intervention participants were offered two one-to-one outpatient sessions delivered by an ENS who aimed to optimise self-management skills and knowledge of appropriate emergency service use. The first session lasted for 45–60 minutes and the second for 30 minutes. Main outcome measures: The primary outcome was the number of ED visits that participants reported making over the 6 months preceding the 12-month follow-up. Secondary outcomes were visits reported at the 6-month follow-up and scores on psychosocial measures. Results: In the year preceding recruitment, the 85 participants together made 270 ED visits. The frequency of their visits was positively skewed, with 61% having attended multiple times. The mean number of visits per participant was 3.1 [standard deviation (SD) 3.6] and the median was two (interquartile range 1–4). Mean patient service cost was £2355 (SD £2455). Compared with findings in the general epilepsy population, participants experienced more seizures and had greater anxiety, lower epilepsy knowledge and greater perceived stigma. Their outpatient care was, however, consistent with National Institute for Health and Clinical Excellence recommendations. In total, 81% of participants were retained at the 6- and 12-month follow-ups, and 80% of participants offered the intervention attended. Using intention-to-treat analyses, including those adjusted for baseline differences, we found no significant effect of the intervention on ED use at the 6-month follow-up [adjusted incidence rate ratio (IRR) 1.75, 95% confidence interval (CI) 0.93 to 3.28] or the 12-month follow-up (adjusted IRR 1.92, 95% CI 0.68 to 5.41), nor on any psychosocial outcomes. Because they spent less time as inpatients, however, the average service cost of intervention participants over follow-up was less than that of TAU participants (adjusted difference £558, 95% CI –£2409 to £648). Lower confidence in managing epilepsy and more felt stigma at baseline best predicted more ED visits over follow-up. Interviews revealed that patients generally attended because they had no family, friend or colleague nearby who had the confidence to manage a seizure. Most participants receiving the intervention valued it, including being given information on epilepsy and an opportunity to talk about their feelings. Those reporting most ED use at baseline perceived the most benefit. Conclusions: At baseline, > 60% of participants who had attended an ED in the previous year had reattended in the same year. In total, 50% of their health service costs were accounted for by ED use and admissions. Low confidence in their ability to manage their epilepsy and a greater sense of stigma predicted frequent attendance. The intervention did not lead to a reduction in ED use but did not cost more, partly because those receiving the intervention had shorter average hospital stays. The most common reason reported by PWE for attending an ED was the lack of someone nearby with sufficient experience of managing a seizure. Those who attended an ED frequently and received the intervention were more likely to report that the intervention helped them. Our findings on predictors of ED use clarify what causes ED use and suggest that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency savings generated. Trial registration: Current Controlled Trials ISRCTN06469947. Funding: This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 1, No. 9. See the HSDR programme website for further project information.

The paper describes the evidence on potential effects of specially trained nurses working in primary care for patients with epilepsy. The method used was a search and review of evidence published from 1992 to 1999. It was found that where nurses have been trained in epilepsy care, there is good evidence that it is feasible for them to set up and run clinics in family practice. Where this has been undertaken, there is level I evidence that this is acceptable and satisfactory to patients. Where clinics have been set up in primary care, there is level I evidence that there has been an increase in the information and advice recorded as being provided to patients. Structured checklists may additionally prompt service providers to increase the level of information provided to patients, and this hypothesis is being tested currently. In conclusion, epilepsy nurses can set up clinics for patients in primary care which are well attended, satisfy patients, and which are associated with better recording of advice given. There is little published evidence on outcome as opposed to process measures. Trials with adequate sample size and long-term follow-up are necessary to identify whether nurse monitoring with advice and counselling can benefit patients in terms of epilepsy self-management in the long run.

Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings. Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment. This study estimates this impact. Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study. Service use over a 3 month period was measured and lost employment recorded. These data were used to estimate economic costs. Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled. The mean total cost of services and lost employment across the sample was Pound Sterling1906 for the 3-month period with formal services accounting for 9.3% of this figure. Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone. Total 3-month costs were on average higher for chronic fatigue syndrome (Pound Sterling3515 v. Pound Sterling1176) but when sample differences were taken account of the mean difference was reduced to Pound Sterling1406 (P = 0.086). Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment. Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment. Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment. Treatments need to be developed which recognize these impacts.

There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue. To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue. A randomised controlled trial incorporating a cost-consequences analysis. One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months. An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale. Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score). Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.

Summary: Purpose: To describe a group of people with newly diagnosed epilepsy and to test the effect of an epilepsy nurse specialist on patients' knowledge of epilepsy, satisfaction with the advice provided, and psychological well-being.Methods: Neurologists in the United Kingdom (U.K.) recruited adults with newly diagnosed epilepsy. Patients were randomized to receive the offer of two appointments with an epilepsy nurse specialist or usual medical care. The main outcome measures were a questionnaire assessing patients' knowledge of epilepsy, the Hospital Anxiety and Depression Scale, and patients' reported satisfaction with the advice and explanations provided on key epilepsy-related topics.Results: Ninety people with new epilepsy completed the trial. At baseline, fewer than half the patients reported having been given enough advice on epilepsy, and there were important differences in patients' knowledge of epilepsy. Lack of a U.K. school-leaving examination pass (General Certificate School Examination) was associated with lower knowledge of epilepsy (p = 0.03). At follow-up, the patients randomized to see the nurse specialist were significantly more likely to report that enough advice had been provided on most epilepsy-related topics compared with the control group. There were no significant differences in knowledge of epilepsy scores. However, there were significant differences in the group who, at baseline, had knowledge scores in the lowest quartile; those randomized to the nurse had higher knowledge scores (42.7 vs. 37.2; p < 0.01). Compared with doctors, the nurse was highly rated for providing clear explanations.Conclusions: Patients who have less general education have less knowledge of epilepsy. The introduction of a nurse specialist in epilepsy is associated with a significant increase in patient reports that enough advice has been provided. Nurse intervention appears to help those with the least knowledge of epilepsy improve their knowledge scores.

There is a burgeoning literature on communication in general practice. It is often assumed that trained GPs know and practice the techniques described, but that time is a major constraint. In two experimental studies patients were given shorter or longer appointments, and the doctors&amp;#39; use of different verbal interventions was measured. Our analysis focused on how individual doctors varied in their use of interviewing techniques according to the time available. When more time was available some interventions were used more frequently by all doctors, but for other interventions the response was variable. For example, GPs who normally used facilitation frequently used it more often when greater time was available, whereas doctors who used this technique less frequently tended not to change when more time was available. This suggests that, at least in the short term, there is a differential response to changes in the time available in the consultation, with increased time being a necessary but not sufficient condition to promote the greater use of the communication techniques which doctors use less frequently.

Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care. To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care. Randomised trial with parallel group design. Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas. Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients&amp;#39; satisfaction with care. One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al&amp;#39;s standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months&amp;#39; follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups. Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

This paper aims to estimate the service and social costs of headache presenting in primary care and to identify predictors of headache costs. Patients were recruited from GP practices in England and service use and lost employment recorded. Predictors of cost were identified using regression models. Service and social costs were available on 288 and 282 patients, respectively. Average service costs over 3 months were £117 whilst total costs (including lost production) were £582. Patients referred to neurologists had service costs that were £82 higher than those not referred (90% CI £36–£128). Costs including lost employment were higher by £150, but this was not significant (90% CI -£139–£439). The annual mean service and social costs, weighted to represent population rates of referral, were £468 and £2328, respectively. Higher costs were significantly related to pain. Age was linked to higher service costs and lower social costs. The figures extrapolated to the whole of the UK suggest £956 million due to service use and £4.8 billion including lost employment. These are likely to be underestimates because many people experiencing headaches do not consult their GP.

This fellowship led to a project investigating ways to better deliver neurology care in the community. Neurology teaching was evaluated in the USA, Canada, Singapore and New Zealand, and strategies for delivering better neurology care in the community were suggested.