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ATTRACTing the right questions

Developing a rapid source of advice for GPs in Gwent
Why was the initiative launched?
Finding a way forward
How would ATTRACT operate?
Is ATTRACT helping GPs?
Evaluating the service
What next for ATTRACT?
A challenge for primary care organisations
For more information contact

Why was the initiative launched?


Time is a precious commodity in primary care. GPs are seemingly faced with a never-ending queue of patients waiting for their advice and help. GPs are accustomed to the routine, but unusual situations generate uncertainty. Although they may well know the questions: how to make a diagnosis? what is the most effective treatment? which is the most suitable drug ? They rarely have time to pursue them and find the right answers. Those promoting evidence-based practice talk of five steps, but for many GPs two of these, finding and appraising evidence, are very difficult. If the quality of care is to be improved ways need to be found to promptly answer questions for GPs.

Finding a way forward


Discussions across the primary care practices in Gwent showed that there was a need for an information system geared to GPs' needs. Previous efforts had concentrated too much on providing information in the belief that it was needed. These discussions encouraged the Gwent Primary Care Clinical Effectiveness Team (known as TRIP - Turning Research into Practice) to explore ways in which they could offer timely support to GPs. Their question was Could we answer the sorts of questions posed by GPs and provide answers within a timeframe acceptable to GPs ? In 1997 they set up the ATTRACT (Ask Trip To Rapidly Alleviate Confused Thoughts) project, designed to provide rapid evidence-based summaries to clinical questions.

How would ATTRACT operate?


The service operates through a telephone helpline. GPs were invited to telephone, fax or e-mail their clinical questions to ATTRACT. To get the service going, staff from TRIP arranged a series of practice-based meetings to explain the nature of the new service. The questions would be sent to an experienced information manager who would review them to ensure that they were answerable. Problems would be discussed with the GP for clarification if needed. Assuming that the questions had not been posed before, a rapid search of the literature using the key information sources would be set in hand.

The key sources used would be MEDLINE (both Ovid and PubMed formats), The Cochrane Library, Best Evidence, Embase and the TRIP Database. The expectation was that searches would takes no more than two hours and could be significantly shorter if, for example, a recent systematic review was found. The information was appraised, summarised on one side of A4 and faxed to the GP. The target was a total turn around time of no more than six hours. The plan included the creation of a database of questions and answers on the TRIP website. Answers would thus be available to others and a log would show the number of visits to each answer. How many people were interested in each question?

Is ATTRACT helping GPs?


The service was launched in January 1997 and is proving to be very popular with GPs in Gwent. Since it was set up about 1000 questions have been answered. Use has grown to a steady rate of about 20-25 a month. The material now covers a wide range of issues. As one GP said " It's brilliant for GPs who don't have time or the resources locally to look for information". Indeed, few have the skills required or the equipment needed. The service is proving to be an essential part of the primary care tool-kit.

Its value is demonstrated by comments by some of those who use the service:


It is difficult to measure the impact of the service but it has helped to develop the willingness of GPs to ask questions. GPs are confident that it has helped them improve the quality of their decision making.

The information is essentially addressing the specific situation of an individual patient. But it may also have wider validity. Some practices are starting to look at how they can use the information more generally to improve care to patients.

Evaluating the service


TRIP was keen to gauge the support for the service from GPs: was it worth carrying on? In 1997 they sent a questionnaire to the first 15 general practitioners who used the service about two months after their enquiries. A year later, identical questionnaires were sent to those that had asked the 35 most recent questions. The response is encouraging. Forty-two of the 50 (84%) general practitioners replied. Twenty-nine rated the service very useful while the remaining thirteen (31%) rated the service useful. All the respondents rated the service as very quick or quick and all reported that they would use the service again. A significant proportion (60%) indicated that they changed their practice as a result of the information presented to them. Most of the rest said that they were already practising in line with the evidence supplied.

Another measure of the interest can be seen by the visits to the website. The most popularly visited questions on the website (Table 1) during the first two years have shown the need for information about less glamorous areas (such as proctalgia fugax or eustachian tube dysfunction) rather than the more commonplace topics, such as coronary heart disease, asthma and diabetes.

Table 1. Number of times the most popular questions were accessed on the TRIP website during 1997 and 1998


Question Number
Is there any link between gout and diet? 1483
Is there any information about the effectiveness of Xenical? 616
Which is best depression scoring system? 588
What are the risks of flying while pregnant? 581
Do decongestants help in people with eustachian tube dysfunction? 574
Are there any effective treatments for proctalgia fugax? 464
What is the effectiveness of combined paracetamol and opiates? 459

The initiative has shown that a query-answering service built around a telephone helpline can produce prompt advice based on data from validated sources. The service is labour intensive, but a competent individual can search and summarise approximately 15 questions a week. Experience has shown that the same question is asked by different GPs with the answer now readily available on the database.

Currently NOISE (National Organisation for Information Support for Effectiveness), a group representing query-answering services from across the UK is creating a database of questions and answers. It is helping to avoid the duplication of effort and to improve turn around times. It is exploring whether it could offer a service to validate answers, although experience shows that those running such services do not always like using other people's answers!

What next for ATTRACT?


ATTRACT has secured funding for a further two years to extend the service across Wales. Two full-time searcher/summarisers are being appointed. A squad rotation system is being introduced within TRIP to spread the work and reduce fatigue. A new website will support the extended service with questions classified (e.g. CVD, cancer etc) to allow easier searching. Moreover people will be able to register to receive regular e-mail updates of new questions/answers. There will also be a section to spotlight areas where there is little helpful research. This should prompt researchers to find answers and influence the NHS R&D agenda.

A more in-depth service is also planned, called AIR (ATTRACT Inspired Reviews), to carry out more in-depth reviews on the most frequently visited questions on the website. Ways of taking advantage of the educational value of ATTRACT are also being explored, for example as a reflective tool within peoples' portfolio development.

A challenge for primary care organisations


Providing a service like ATTRACT may be as important in improving the quality of care as the current concentration on systems to force-feed information to unwilling clinicians. Many studies show that unsolicited information is unlikely to change practice. There is a real opportunity now for all new primary care organisations to offer something that has been proven to be helpful to GPs.

ATTRACT, and indeed other similar services, have shown what is possible. But many local services have fallen by the wayside as continuing problems about long-term funding have gone unresolved. It is often seen to be others people responsibility. The support offered by NOISE may make it timely for primary care organisations to think again about how they could provide this type of support for local GPs. NOISE could ensure that this particular wheel is not continually re-invented all over the NHS.

For more information contact


Jon Brassey, Director ATTRACT Wales
Mamhilad House, Mamhilad Park Estate
Pontypool NP4 0YP
Internet www.tripdatabase.com
Telephone 01495 765105
Email jon.brassey@gwent-ha.wales.nhs.uk

 

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