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Biomedical subjects

B Gribben

Publications and source records attributed to B Gribben.

At least 19 recordsLinked to original sources
PubMed2002

Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access?

BACKGROUND: Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. AIM: To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. DESIGN OF STUDY: A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. SETTING: Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. METHOD: Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. RESULTS: The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. CONCLUSION: A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.

Adult↗
PubMed2001

Non-invasive methods for measuring data quality in general practice.

AIM: To develop non-invasive methods of measuring the quality of data recorded in general practice. METHODS: Laboratory and pharmaceutical claims data from fourteen practices (44 doctors) from the FirstHealth network of general practices were examined to determine the extent to which valid minimum bounds on expected rates of diagnosis coding could be established. These were compared with recorded rates in patient notes to measure completeness of diagnosis recording. Data completeness was measured for demographic data and a marker for the accuracy of gender coding was developed from diagnosis data. RESULTS: Minimum rates of diagnosis could be established for asthma, diabetes (NIDDM and IDDM), ischaemic heart disease, hypothyroidism, bipolar affective disorder and Parkinson's disease. Minimum bounds for the number of patients requiring monitoring of warfarin and digoxin levels were also established. These expected minimum rates were combined with measures of completeness of age, gender, ethnicity and smoking data, and a gender coding accuracy measure, to produce a set of fourteen data quality indicators. Pass/fail thresholds on each indicator were set and each of the fourteen practices was scored on the number of passes they achieved. The scores ranged from three to nine out of fourteen passses. CONCLUSIONS: Non-invasive data quality measures may be useful in providing feedback to general practitioners as part of a data quality improvement cycle. The sensitivity of this method will decline as data quality improves.

Data Collection↗
PubMed2000

The early experience of general practitioners using Green Prescription.

AIM: Sedentary lifestyle is a significant risk factor for increased morbidity and mortality in many medical conditions. A Hillary Commission initiative, Green Prescription is a written exercise prescription given by general practitioners (GPs) to sedentary patients to encourage physical activity. Our aim was to establish the extent to which GPs in the North Health region in 1997 issued with Green Prescription packages had used them, the circumstances under which they were used, and barriers to their use. METHODS: 433 GPs issued with packs were faxed a one-page questionnaire for immediate completion, with follow-up of non-responders. RESULTS: The response rate was 73%, with 65% of respondents having written Green Prescriptions. Their main reasons for use were patient need for more exercise and presence of high-risk medical conditions such as hypertension, cardiovascular disease, obesity and diabetes. Reasons for non-use were: GP already giving advice about physical activity; concern that Green Prescription was patronising and simplistic; compliance issues and time restraints. Some requested a computerised version. CONCLUSION: Non-responders may be non-users, hence we estimate that 48-65% of targeted GPs used Green Prescription. Barriers identified by GPs have assisted in Green Prescription development, which is now nationwide and assessed by independent researchers tri-annually.

Adult↗
PubMed2000

The "supply hypothesis" and medical practice variation in primary care: testing economic and clinical models of inter-practitioner variation.

Medical practice variation (MPV) is marked, apparently ubiquitous across the health sector, well documented, and continues to be a focus of professional and policy interest. MPV have stimulated two paths of investigation, one economic in emphasis and the other more-clinical in orientation; while health economists have stressed the potential role of income incentives in medical decision-making, health services research has tended to emphasise clinical ambiguity as a factor in practitioner decisions. Both sets of explanations converge in an implicit "supply hypothesis" that posits contextual practitioner and practice attributes as influential in clinical decisions. Data on inter-practitioner variation are taken from a large and representative regional survey of general practitioners in New Zealand, a country in which unsubsidised fee-for-service is the predominant mode of remuneration in primary care. The paper assesses the impact on three important areas of clinical decision-making prescribing, test ordering, request for follow-up -- of three key conceptual dimensions -- income incentives, physician agency, and clinical ambiguity (operationalised as local doctor density, practitioner encounter initiation, and diagnostic uncertainty respectively). Predictions are made about inter-practitioner variations in the rate of clinical activity in the three areas. The results of the analysis using multi-level statistical techniques are: 1. the extent of competition -- local doctor density -- seems to have no effect on the pattern of clinical decision-making; 2. doctor-initiated visits are, if anything, associated with lower rates of intervention; 3. diagnostic uncertainty is associated with higher rates of investigations and follow-up, both of which have clinical plausibility; 4. there is no significant interaction effect between density and uncertainty. It is concluded that, for the clinical activities studied and for the practitioner attributes as operationalised in this investigation, a clinical, rather than an economic, model of practitioner decision-making provides a more plausible interpretation of inter-practitioner variation in rates of clinical activity in general practice. The "supply hypothesis" requires further analytical refinement and empirical assessment before it can be applied as a generic explanatory framework for MPV.

Family Practice↗
PubMed2000

Do physician practice styles persist over time? Continuities in patterns of clinical decision-making among general practitioners.

OBJECTIVES: This study seeks to determine whether there are identifiable differences in patterns of clinical decision-making among family physicians, and whether these patterns persist over time. METHODS: A representative cross-sectional survey of general practice encounters in the Waikato region of New Zealand in 1979-1980 was repeated in 1991-1992. Patterns of clinical decision-making were operationalised as practitioner rates for writing a prescription, ordering a laboratory test or radiological examination and the recommendation of a future follow-up office visit at a specified date. Comparable data were available for a cohort of 50 physicians in both surveys. Multi-level techniques and a simulation exercise were used to study the patterns of decision-making over time. RESULTS: Raw, unadjusted correlations for the 50 family physicians between the two surveys were 0.24, 0.14 and 0.55 for rates of prescribing, investigations and follow-up, respectively. However, these correlations increased substantially, to 0.55, 0.41 and 0.70, once account was taken of case mix, data clustering and inter-practitioner variation in patient sample size. The extent of this recovery of the underlying correlations was confirmed in a parallel simulation exercise. CONCLUSIONS: This study confirms the existence of substantial and durable individual practice styles in primary medical care, with implications for the development and successful implementation of clinical guidelines.

Cross-Sectional Studies↗
PubMed1999

Practice nurses in the Waikato, 1991-1992, I: Occupational profile.

AIMS: To describe the personal characteristics, working conditions, clinical activities and professional development of a representative sample of practice nurses in the Waikato during the period 1991-1992. METHODS: The data are from a survey of practice nurses drawn from a larger study of general practice carried out in the Waikato (the WaiMedCa Study). Eighty-nine percent of the 107 practices in the region participated in the study. The practice nurse survey was carried out on the 189 nurses working in these practices. Of these 149 replied, representing a response rate of 79%. RESULTS: On average, there was one nurse for each solo practice and two in most other practices. Only two practices--both solo--did not employ a nurse. Practice nurses were female and aged between 30 and 50. While only one-third had received a postgraduate qualification, two-thirds had been to recent professional development courses. The majority had worked as a practice nurse for between one and ten years. Nurses averaged just under 15 telephone contacts a day and 28 face-to-face contacts a week. Nurses' workload comprised general measurements and assessments, monitoring and surveillance procedures (such as diabetes, asthma and child development), and counselling and women's health activities. CONCLUSION: Practice nurses are an accepted and essential part of primary health care in New Zealand. However, their potential is probably underdeveloped and they could be more fully utilised for a wider range of nursing functions.

Adult↗
PubMed1999

A future for primary health care in New Zealand.

The attempt to implement a health market in New Zealand by separating funders and providers in 1992 has not delivered improved health outcomes. Indeed there is increasing concern that deprived populations are not accessing appropriate health care. This article describes the models of primary care that have evolved in the new environment and suggests that these new structures, given appropriate support, are ideally placed to increase the focus of primary care on population health. A capitation funding model with patient enrolment and low fee-for-service barriers is proposed as the most promising model for delivering improved health outcomes. The model incorporates a needs-based funding formula, locality health needs assessment, an increased role for primary care nurses and improved responsiveness to local communities, especially Maori.

Capitation Fee↗
PubMed1998

Trends in general practice in the Waikato, 1979-80/1991-92, II: Social variations in service use and clinical activity.

AIMS: To document trends in ethnic group and occupational class differences in the use of general practitioner services and in patterns of clinical activity for the Hamilton Health District of the Waikato over the period 1979-80 to 1991-92. METHODS: The data are drawn from a baseline and a follow-up survey of general practice in the Waikato region representing a one per cent sample of all in-surgery, in-hours, week-day encounters at two points in time. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 9468 and 10,235 patient encounter forms were completed respectively. RESULTS: Over a period in which service availability and rates of medical contact grew, there was a relatively greater increase in utilisation among Maori and lower socioeconomic groups: between the two surveys the ratio of Maori to non-Maori rates increased from 0.8 to 1.0 and the ratio of visits for lower to higher socioeconomic groups grew from a differential of 2.5 to one of 3.1. More serious conditions apart, these changes seemed to occur uniformly regardless of the severity, amenability or susceptibility of the condition presented to the general practitioner. Changes in ethnic group and occupational class patterns of service activity almost exactly mirrored these trends. CONCLUSIONS: A notable relative increase in rates of contact for primary medical care among Maori and lower socioeconomic groups seems to have accompanied the growth in the 1980s of the availability of general practitioner services in this region of New Zealand.

Data Collection↗
PubMed1998

Trends in general practice in the Waikato, 1979-80/1991-92, I: Practitioner availability, service use and clinical activity.

AIMS: To document trends in availability and use of general practitioner services and in patterns of clinical activity for the Waikato over the period 1979-80 to 1991-92. METHODS: The data are drawn from a baseline and a follow-up survey of general practice in the Waikato region representing a 1% sample of all in-surgery, in-hours, week-day encounters at two points in time. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 9468 and 10,235 patient encounter forms were completed. RESULTS: While the number of general practitioners increased by a half over the period, average workload declined by a fifth, the inflation-adjusted value of the usual adult fee increased by nearly 50% and visits went up by an average of a half a visit a year. Clinical activity declined for prescribing but increased for referral and follow-up. CONCLUSIONS: The increase in availability of general practitioners over the last decade has been associated with significant changes in patterns of practice organisation, service utilisation and clinical activity. Further research is required into the potential impact of greater service availability on patient demand and resource use.

Adult↗
PubMed1997

Maori/non-Maori patterns of contact, expressed morbidity and resource use in general practice: data from the Waikato Medical Care Survey 1991-2.

AIMS: To compare patterns of contact, expressed morbidity and resource use in primary care for a representative sample of patients of Maori and non-Maori background. METHODS: The data are drawn from a survey of general practice in the Waikato region representing a one per cent sample of all week day encounters. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 12,833 patient encounter forms were completed. RESULTS: Annual rates of general practitioner contact for Maori are slightly lower than those for patients of non-Maori background. The case-mix pattern of general practitioner contact is very similar between the two groups. There is a limited correspondence between ethnic patterns of general practitioner usage and health need (as measured by mortality levels and rates of public hospital discharge). CONCLUSIONS: The near equivalence in ethnic rates of general practitioner contact revealed in this study contrasts strikingly both with the level of hospitalisation for Maori, which is nearly double that of non-Maori, and with the difference in mortality rates (30% higher for Maori). Attention devoted to improving access to general practitioner services among Maori may be necessary if important areas of ill health and hospital resource use are to be addressed effectively.

Adolescent↗
PubMed1997

Patterns of general practitioner usage among Pacific people: indicative results from the Waikato Medical Care Survey 1991-2.

AIMS: To report patterns of medical contact in a representative sample of Pacific people attending the general practitioner. METHODS: The data were drawn from a survey of general practice in the Waikato region representing a one per cent sample of all weekday encounters. In total, 12,833 patient encounter forms were completed. Just over one per cent of all encounters were recorded for patients of Pacific Islands background. RESULTS: Rates of medical contact for Pacific patients were lower-3.4 visits per year versus 4.5 for the whole sample-fewer follow up visits were requested (71% versus 76.2%), presentation was delayed (4.9 days from onset versus 3.7 for the sample) and there was an apparently lower level of rapport achieved. CONCLUSION: Overall levels of medical contact and return visits among Pacific patients appear to be lower and presentation delayed in this Waikato sample.

Adolescent↗
PubMed1996

The community services card and utilisation of general practitioner services.

AIMS: To examine the relationship between holding a community services card and the utilisation of general practitioner services. METHODS: A 1 year retrospective notes review from a random sample of 5637 general practitioner records. RESULTS: CSC holders consulted their family doctor an average of 0.9 more times per year than non card holders. The CSC remained a significant predictor (p<0,0001) of consultation rate after controlling for age, gender, high user status and five common chronic conditions. Although holding a CSC had no significant effect on prescribing rate, CSC holders received significantly more prescription items per annum (6.74 items vs 4.89 items). CONCLUSIONS: The CSC is a significant predictor of utilisation. The CSC identifies people who use more resources than people who do not hold the card, in terms of number of consultations and number of prescription items per year.

Adolescent↗
PubMed1995

Geographical variations in the organisation of general practice.

AIMS: To describe organisational characteristics of New Zealand general practice and to investigate inter-regional variations in these characteristics. METHODS: Data were collected by standardised questionnaires from general practitioners in Auckland, Waikato and Taranaki. The Waikato data were collected in July-August 1991 by postal survey, the Taranaki data were collected May-June 1992 by postal survey and the Auckland data were collected December 1990 to January 1991 by face-to-face interview. RESULTS: The response rates were Auckland 98% (167/171), Waikato 84% (185/220) and Taranaki 79% (79/100). There were significantly more overseas trained graduates in rural areas than in urban areas. Average practice size was 2.3 full time equivalent doctors, with each 100 doctors employing 71 nurses and 77 receptionists. The number of patients seen per week ranged from 109-141. Almost all (95%) general practitioners operated appointment systems. One in five general practitioners had patients in private hospitals, and more than half (58%) had patients in rest homes. At the time of interview, 29% of Auckland general practitioners used computers in their practices compared with over 50% in Waikato and Taranaki (p < 0.05). A smaller proportion of Auckland general practitioners had access to age/sex registers and fewer Auckland general practitioners had a recall system. Of Auckland general practitioners with recall systems, a greater proportion used them for mammograms, blood pressure and lipid measurements compared with elsewhere. CONCLUSIONS: There are some significant regional variations in the functional characteristics of general practice in New Zealand which should be taken into account when planning primary care services in different regions. Should budget holding and managed care be introduced, computerised practices will be required. This will have significant resource implications.

Adult↗
PubMed1995

Rational prescribing and interpractitioner variation. A multilevel approach.

There are marked geographical variations in rates of medical and surgical intervention at every level of aggregation and in every aspect of medical practice. These data raise a range of important theoretical, methodological, and policy issues. Much the same pattern of variation characterizes the prescription and consumption of therapeutic drugs. Data from a survey of general practice in New Zealand confirm the existence of extensive variability in prescribing. Multilevel techniques are deployed to isolate the specific interpractitioner element in this variability. Controlling for patient, diagnostic, and practitioner variables improves the predictive power of the model but does not reduce the extent of interpractitioner variability in prescribing rates. The existence of such variability raises questions about the role of clinical uncertainty and professional autonomy in the promotion of rational therapeutics in medical practice.

Adolescent↗
PubMed1994

The Waikato Medical Care (WaiMedCa) Survey 1991-1992.

Objective. The main objective of this study is to provide a comprehensive description of general practice in the Waikato, an area which represents many aspects of New Zealand. Accurate, detailed and up to date information in this area is needed for future planning of medical education and the provision of health services. Survey method. The survey was conducted over one year, from September 1991 to August 1992. Participating general practitioners and practice nurses recorded details of a sample of patient encounters in the surgery or on home visits. Each participant was assigned four single weeks for data gathering over the course of the year. A one in five sub-sample of patients was also given questionnaires to complete immediately and two weeks after the consultations. This component of the study was reported elsewhere. Participants. A list of all active general practitioners working within the area covered by the Waikato Area Health board was constructed. All were contacted during May and June 1991 and asked to contribute to the study. During this initial, recruiting stage the practitioners and their practice nurses were asked to provide details of their professional background and to outline the structure, functions and size of their practices. Data collection. The variables studied included: provider characteristics (age, gender, qualifications, type of practice and services offered); patient attributes (age, gender, ethnicity, benefit category and occupation); patient reasons for encounter (up to four per encounter); doctor diagnoses (again up to four per encounter); drugs prescribed and or other treatments provided; tests and investigations ordered and referrals made; planned follow up and subjective view on the encounter. Data were centrally coded by trained staff. Patient reasons for encounter were coded according to NAMCS, practitioner diagnoses were classified into OXMIS, and drugs prescribed were allocated into the ATC classification system. Participation rate. 87% of practitioners (182/209), 89% of practices (95/107), and 80% of practice nurses (150/189) completed the initial recruitment survey. The participation rate at the first phase of the encounter survey was 80.5% (169/210), but this had dropped to 65.7% (136/207) by the fourth collection week. An overall response rate of 68.6% was achieved, representing successful collection of encounter data in 562 of 819 potential doctor recording weeks. On average, general practitioners recorded 109 encounters per week, from which they selected on average a sample of 23 patients for the survey. They described 141 problems per 100 encounters, of which 49 were new. On average general practitioners made less than three home visits per 100 encounters.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1993

Satisfaction with access to general practitioner services in south Auckland.

AIMS: To describe satisfaction with access to general practitioner services in south Auckland. METHODS: A random population survey of established residents was undertaken with the sample drawn from electoral rolls. A questionnaire was administered face-to-face by trained interviewers. Satisfaction was graded using a five point scale, with standard "smiley faces" as visual cues. RESULTS: Overall satisfaction levels are high, ranging from 3.00 to 4.41 out of a maximum of 5. The lowest satisfaction is reported with charges (3.00), home visiting (3.31), weekend services (3.39), after hours services (3.48), and waiting times (3.55). Satisfaction is lowest amongst Polynesians and the 18-29 age group. CONCLUSIONS: General practitioners could increase patient satisfaction with access by reducing patient charges and waiting times, and by improving access to services not provided at their usual premises during normal hours. Further research is needed into reasons for low satisfaction in the nonEuropean and younger age groups.

Adolescent↗
PubMed1992

Do access factors affect utilisation of general practitioner services in south Auckland?

AIMS: To describe basic features of access to general practitioner services in south Auckland, and to examine the effect of different factors on utilisation of general practitioner services with particular attention to access issues. METHODS: A random population survey of relatively established residents was undertaken with the sample drawn from electoral rolls. A questionnaire was administered face-to-face by trained interviewers. RESULTS: Ninety-eight percent of respondents claimed to have a regular family doctor. The median travelling time to a respondent's general practitioner was 10 minutes. Ninety-five percent of respondents' general practitioners operated appointment systems. The median waiting time was 20 minutes, 30% felt the doctors fees stopped them going to the doctor sometimes. The average reported visiting rate was 6.9 visits per year. Poor perceived health, longer times with a given doctor and long waiting times were associated with decreased utilisation. Demographic factors were not associated with utilisation. Patient fees were not associated with utilisation in the sample. Only 23% of the variation in utilisation could be explained by the model. CONCLUSIONS: Long waiting times are associated with decreased utilisation in this population. Although there is significant dissatisfaction with general practitioner fees, this does not manifest itself in decreased utilisation. Only a small proportion of the variation in utilisation can be explained by linear models of the variables studied.

Adolescent↗