Here - Surrey and Borders Partnership NHS Foundation Trust
Here - Surrey and Borders Partnership NHS Foundation Trust
Here - Surrey and Borders Partnership NHS Foundation Trust
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Research <strong>and</strong> Audit<br />
Table 5 shows how the GPs <strong>and</strong> MHNPs<br />
combined diagnoses (BPD or another<br />
condition) performed against the<br />
psychiatrists final diagnosis, which is used<br />
as the gold st<strong>and</strong>ard in this study.<br />
Thirty-three patients were seen by both<br />
the psychiatrist <strong>and</strong> their GP. Of the 7<br />
patients diagnosed with BPD by the<br />
psychiatrist 5 were correctly identified by<br />
their GP whilst 2 received another<br />
diagnosis. However in 4 patients where<br />
the psychiatrist diagnosed another<br />
condition the GP suggested a diagnosis<br />
of BPD. The corresponding sensitivity <strong>and</strong><br />
specificity of the GPs diagnoses were<br />
71.4% <strong>and</strong> 84.6%. The PPV for the GPs<br />
diagnoses was 55.6% while the NPV was<br />
91.7%. However the LR+ <strong>and</strong> LR- were<br />
4.75 <strong>and</strong> 0.34 respectively which are<br />
outside of the limits of a good diagnostic<br />
test. (Please refer to Fields A, 2009 for a<br />
detailed explanation of these terms.)<br />
Twenty patients were seen by a MHNP<br />
before seeing the psychiatrist. The MHNP<br />
correctly picked up BPD in 2 of the 4<br />
cases diagnosed with BPD by the<br />
psychiatrist. However in 6 out of 16 cases<br />
the MHNP diagnosed BPD whilst the<br />
psychiatrist diagnosed another condition.<br />
The sensitivity, specificity, PPV <strong>and</strong> NPV<br />
for the MHNPs diagnoses were 50%,<br />
62.5%, 25% <strong>and</strong> 80% respectively.<br />
Again the LR+ <strong>and</strong> LR- which are 1.35<br />
<strong>and</strong> 0.8 respectively fall outside of the<br />
limits of an acceptable diagnostic test.<br />
Discussion<br />
There is a growing body of evidence<br />
showing the importance of correctly<br />
identifying <strong>and</strong> treating sufferers of BPD<br />
to improve their quality of life, preserve<br />
their social <strong>and</strong> occupational functioning<br />
<strong>and</strong> to lessen the financial burden of<br />
healthcare costs related to the<br />
mismanagement of this important<br />
condition. Equally, the fact that there is<br />
often a delay of several years before this<br />
condition is correctly identified, highlights<br />
the importance of vigilantly screening for<br />
BPD, especially in the primary care setting.<br />
Our first aim was to establish the<br />
frequency with which our primary care<br />
practitioners screened for BPD. In this<br />
sample of patients presenting with<br />
affective symptoms, only 21.1% of those<br />
referred by their GP showed any evidence<br />
that they had been screened for BPD.<br />
Although this figure rose to 38.9% for<br />
MHNPs, this still represents a rather low<br />
proportion of screening for patients who<br />
are within the at risk category. This is<br />
especially important as tools such as the<br />
MDQ are available, short, <strong>and</strong> easy to<br />
use, <strong>and</strong> could easily be administered in<br />
the context of a primary care assessment.<br />
A potential downfall of this study design<br />
is that it relied on evidence from the<br />
referral letter that the clinician had<br />
screened for BPD <strong>and</strong> therefore it is<br />
possible that where a patient screened<br />
negative, it was not mentioned in the<br />
referral letter. However, a good referral<br />
should mention both positive <strong>and</strong> salient<br />
negative findings <strong>and</strong> routine use of the<br />
MDQ could circumnavigate this issue.<br />
Secondly, we aimed to establish whether<br />
screening for BPD increases the likelihood<br />
of correctly identifying the signs <strong>and</strong><br />
symptoms of this disorder. In our study<br />
both GPs <strong>and</strong> MHNPs almost exclusively<br />
(with the exception of one patient in<br />
each case) only proposed a diagnosis of<br />
BPD when there was evidence that they<br />
had screened for hypomania. These<br />
highly significant results show that it was<br />
highly unlikely that clinicians would<br />
propose a diagnosis of BPD when they<br />
had not screened for the condition. These<br />
results emphasize the great importance<br />
of consistent screening.<br />
Our third question looks at the accuracy<br />
with which GPs <strong>and</strong> MHNPs were able to<br />
rule in or rule out BPD in their patients.<br />
As previously mentioned, a good<br />
screening tool should have both good<br />
sensitivity (low false negatives) <strong>and</strong> good<br />
specificity (low false positives). We also<br />
looked at PPV <strong>and</strong> NPV as well as LR+<br />
<strong>and</strong> LR- as these give additional<br />
information about the quality of a<br />
screening test.<br />
14 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal