PubMed HealthSearch

Biomedical subjects

I D Steven

Publications and source records attributed to I D Steven.

At least 19 recordsLinked to original sources

Collecting data on potentially harmful events: a method for monitoring incidents in general practice.

OBJECTIVE: The prediction and subsequent prevention of errors, which are an integral element of human behaviour, require an understanding of their cause. The incident monitoring technique was developed in the study of aviation errors in the Second World War and has been applied more recently in the field of anaesthetics. This pilot study represents one of the first attempts to apply the incident monitoring technique in the general practice environment. METHOD: A total of 297 GPs across Australia anonymously reported details of unintended events which harmed or could have harmed the patient. Reports were contemporaneously recorded on prepared forms which allowed a free text description of the incident, and structured responses for contributing and mitigating factors, immediate and long-term out-comes, additional costs etc. RESULTS AND DISCUSSION: The first 500 reports were analysed using both of qualitative and quantitative methods and a brief overview of results is presented. The methodological issues arising in the application of this technique to such a large, widely spread profession, in which episodes of care are not necessarily confined to a single consultation, are discussed. This study demonstrated that the incident monitoring technique can be successfully applied in general practice and that the resulting information can facilitate the identification of common factors contributing to such events and allow the development of preventive interventions.

Australia

Feasibility of conducting cardiovascular outcome research in Australian general practice: results from the ANBP2 pilot study. Australian National Blood Pressure Study.

1. The present study aimed to determine the feasibility of conducting a 5 year cardiovascular outcome trial of the treatment of 6000 elderly hypertensive patients in Australian general practices. 2. General practitioners (GPs) were invited to participate by mail and personal follow-up. Patient records were reviewed to identify subjects for a blood pressure (BP) screening programme. Blood pressure was measured on three occasions and eligible subjects were included if the average BP was > or = 160 mmHg systolic or > or = 90 mmHg diastolic if systolic BP was > or = 140 mmHg. 3. Seven hundred and forty-one GPs were approached and 89 were enrolled in the study (12% of mail invites and 75% of those receiving a personal contact). In 16 practices where screening was completed, 82,000 records were reviewed to identify 4% patients eligible for screening. Twenty-two per cent of eligible subjects attended screening. Of 1938 subjects screened, 180 (9%) had BP > or = 160/90 mmHg. Forty-seven per cent of subjects (n = 916) were receiving antihypertensive therapy and 184 (20%) were withdrawn from therapy. One hundred and sixteen (63%) of these subjects had BP return to study entry levels within 6 weeks. Fifty-seven newly diagnosed and 81 previously treated subjects were randomized (7% of the screened population). 4. Based on the high participation rate of GPs, the response rate of patients to attend a BP screening programme and the 7% randomization to screening ratio for entry into the study, the ANBP2 pilot study has demonstrated that it is feasible to recruit subjects from Australian general practices to a cardiovascular outcome trial.

Aged

Assessing case records using monitor criteria developed from consensus guidelines.

OBJECTIVE: To develop criteria to enable the monitoring of general practitioner (GP) case records using consensus guidelines for conditions commonly managed in general practice and to measure how well the case records of a non random sample of GPs conformed to these criteria. METHOD: An iterative process was used to develop criteria from consensus guidelines for 19 conditions. Criteria were also developed to enable monitoring of the structure and content of the patient case record. A non random sample of GPs in Adelaide was approached to allow measurement of the content of their case records against these criteria. This measurement was undertaken by allied health professionals. An overall percentage score of conformity with the criteria was created for 10 acute, and six chronic conditions and for the patient case record review. These were rank ordered and Kendall's rank order correlation coefficients were used to compare the results in these three areas of practice. RESULTS: Criteria were successfully developed for each condition. Thirty-one GPs had their patient case records assessed. There was substantial variability between these practitioners in their conformity to the criteria. Kendall's rank order coefficients found statistically significant correlation between the results for acute and chronic conditions, and between acute conditions and the patient case record review section. CONCLUSION: It is feasible to develop criteria that enable measurement of the conformity of GP case records to these criteria. The overall level of conformity, together with the substantial variability found between practitioners suggest that there is a need for GPs to address this area of their practice.

Clinical Competence

Clinical practice guidelines. Particular reference to the management of pain in the lumbosacral spine.

Clinical practice guidelines and protocols are a seductive way of trying to improve the standard of clinical practice. If these are to be most effective, they must evaluate rigorously the evidence supporting a particular management strategy and make appropriate recommendations based on this information. This process needs to be objective, should engage and obtain endorsement from the disciplines that are involved in providing the care, and be accompanied by appropriate implementation strategies. Subsequently, the impact of these strategies should be measured. Existing guidelines for the management of lumbosacral pain largely conform to criteria for guidelines development. It can therefore be expected that they will benefit practitioners and the community.

Costs and Cost Analysis

Development of consensus guidelines for conditions commonly managed in general practice. Royal Australian College of General Practitioners.

OBJECTIVE: Initially, the project objective was to develop audit protocols for commonly managed conditions in general practice. However, as the nature of the project evolved these objectives changed to developing consensus guidelines. METHOD: An iterative process was undertaken using mail-outs to gain items for potential inclusion in an audit protocol. This resulted in a change of direction to management guidelines. Consensus, as to the validity of inclusion of items in each guideline, was then achieved by continuing to use an iterative process. RESULTS: Guidelines for 30 presenting complaints were developed. Because a number of differential diagnoses were possible for each complaint, a total of 105 guidelines were developed. A total of 263 general practitioners participated. CONCLUSION: The concept of discriminant actions was developed. It was agreed that this described the clinical decision making that occurs in the general practices of participating practitioners. It is feasible to use an iterative method undertaken by mail to develop consensus guidelines for conditions that are commonly managed by general practitioners.

Australia

Opioid dependence in 15 patients after a work injury.

OBJECTIVE: To document aspects of the management of 15 patients with workers' compensation injuries which led to opioid dependence and suggest preventive strategies. METHOD: Details of general practitioner and deputising service visits for a 38-week period, 1 May 1991 - 22 January 1992, were obtained from WorkCover case files and general practitioners' patient records, and claims for reimbursement for afterhours home visits (Item 97) were obtained from the Health Insurance Commission (HIC) for the years 1991, 1992 and 1993. RESULTS: Fourteen of the patients had a lumbosacral injury. A total of 2489 deputising service visits were provided on 3227 days (0.77/day). A statistically significant 20% higher visit rate occurred on Sundays and public holidays compared with the rate for the rest of the week. Deputising service practitioners provided 4.7 times as many services as general practitioners. In 1299 visits to 12 of these patients, parenteral drugs administered included 108 385 mg pethidine, 2680 mg morphine, and 20 400 mg promethazine. All 15 patients were independently assessed as having features indicating opioid dependence. In only one patient was there evidence of opioid dependence before injury. An alternative management plan not requiring deputising service visits was instituted early in 1992. The number of claims from the HIC for afterhours visits to these 15 patients rose from 125 in 1991 to 630 in 1992, while 409 were provided in 1993. CONCLUSION: Appropriate strategies, such as restricting the ability of deputising services to bill directly for the services they provide, and a sharing of information between the HIC and other statutory authorities, should prevent a similar occurrence in the future.

Adult

Changes to recommended immunisation procedures.

The fifth edition of the Australian Immunisation Procedures Handbook updates what has become an important reference and practical guide to immunisation practice in Australia. A number of significant changes have been incorporated into this edition. The purpose of this paper is to alert and remind general practitioners of these changes.

Adolescent

Hepatitis C.

Hepatitis C is particularly prevalent among injecting drug users. The infection is asymptomatic over 50% of the time. A significant proportion of those infected ultimately develop cirrhosis or carcinoma of the liver or both. While prevention is the best form of treatment, alpha interferon may benefit up to 30% of those with active infection.

Hepatitis C

Reported diabetes mellitus management among South Australian general practitioners.

Diabetes mellitus is a chronic disease commonly managed in general practice. This article reviews the findings of a questionnaire survey of 173 randomly chosen South Australian general practitioners and their reported management in the areas of detection, diagnosis, assessment, monitoring and GP knowledge. Substantial differences between respondents were found in all areas, suggesting the need for improved educational methods aimed at all general practitioners.

Adult

Knowledge of and reported asthma management among South Australian general practitioners.

AIM: This study, carried out in 1989, set out to assess general practitioners' knowledge of asthma management and their reported management practices. METHOD: Of 153 randomly selected South Australian general practitioners 127 (83%) completed a questionnaire designed to explore issues relating to the management of asthma. RESULTS: The survey revealed substantial differences between general practitioners in their knowledge and management practices including the assessment of the severity of asthma, the need for objective monitoring, that is by the use of spirometry and peak flow meters, and the use of medication. Overall, the sampled general practitioners believed that patient-related factors were the main barriers to effective treatment of asthma. CONCLUSION: The findings of this study suggest that ideal asthma management was not being attained. More research is required to ascertain why such variability among practitioners exists and how best to remedy these differences.

Adult

The effect of prazosin on patients with symptoms of benign prostatic hypertrophy.

OBJECTIVE: To evaluate the effect of prazosin on the symptoms of benign prostatic hypertrophy for patients of general practitioners. SETTING AND PATIENTS: Eighty-two general practitioner patients from 317 who were identified as being eligible for inclusion in the trial. They were randomly allocated to receive either prazosin or placebo for the first 3 month arm then crossed-over for the second 3 months. RESULTS: Seventy-six patients completed the trial. An analogue scale of patient rating of symptoms showed a statistically significant decrease in symptoms for patients taking prazosin when compared with patients taking placebo, regardless of the order in which they had been administered. A total symptom score and an obstructive symptom score for benign prostatic hypertrophy showed a statistically significant difference between the two treatments at 4 weeks. A difference was still apparent at 8 and 12 weeks but it was not statistically significant. No difference was detected for irritative symptoms. CONCLUSION: Prazosin may have a limited place in the management of benign prostatic hypertrophy.

Aged

A pattern of decline in general practice obstetric care in Adelaide.

Some educational, training and politico-economic reasons for the decline in GP obstetrics in Adelaide, South Australia, are described. It is recommended that similar studies be done in other centres in Australia to evaluate the general nature of the findings.

Clinical Competence

Facilitation for demonstration practice grant holders.

Our results indicate that most demonstration practice grant holders in South Australia and the Northern Territory accept and regularly access facilitator services. Grant holders had little experience with granting body procedures and most frequently discussed administrative matters regarding their individual projects with the facilitator. Concerns about project progress and evaluation issues were other popular topics discussed during grant holder facilitator interactions. The present study did not seek to measure the impact of facilitation on the success of projects. A further study should be undertaken to examine the efficacy and effectiveness of facilitation on project outcome.

Family Practice