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PubMed1992

Medical audit in general practice. II: Effects on health of patients with common childhood conditions. North of England Study of Standards and Performance in General Practice.

OBJECTIVE: To estimate the effects of medical audit, particularly setting clinical standards, on patients' health. DESIGN: Before and after study strengthened by a replicated Latin square. SETTING: 62 training general practices in the north of England. PATIENTS: Random sample of 9000 children with any of five conditions--acute cough, acute vomiting, bedwetting, itchy rash, and recurrent wheezy chest--stratified by doctor consulted, condition, and age. INTERVENTIONS: Clinical standard set by each of 10 small groups comprising 84 general practitioner trainers for one randomly selected childhood condition. Each group also experienced a different type of medical audit, randomly selected, for each of the four other study conditions (receiving a clinical standard set by another trainer group, tabulated data comparing clinical performance with that of all other groups, tabulated data from only their own group, and nothing ("control" condition)). MAIN OUTCOME MEASURES: Condition specific, functional, psychological, and educational outcomes; together with parent satisfaction (recorded by home interviews and postal questionnaires). RESULTS: Children consulting trainers for recurrent wheezy chest after those doctors had set a standard for that condition improved both in drug compliance (79% (n = 33) before standard setting v 93% (30) after) and mean number of days of breathlessness (3.8 (SE 1.0) before v 1.7 (0.6) after) and wheeziness (4.7 (0.9) before v 1.8 (0.6) after), compared with those consulting doctors who had not (compliance 74% (144) before v 72% (146) after; breathlessness 2.4 (0.4) before v 2.3 (0.3) after; wheeziness 3.0 (0.4) before v 2.7 (0.4) after). There were no other significant effects of standard setting or audit on patients' health. CONCLUSION: Setting clinical standards improved drug compliance and respiratory function in children with recurrent wheezy chest.

Child↗
PubMedDate not supplied

Non-steroidal anti-inflammatory drug prescribing patterns in general practice: comparison of a general practitioner-based survey and a pharmacy-based survey in France.

PURPOSE: In order to assess biases occurring in primary care prescription studies, we compared non-steroidal anti-inflammatory drug (NSAID) prescribing patterns reported by general practitioners directly (GP-based survey) and from a pharmacy-based survey of general practitioner prescribing (pharmacy-based survey). METHODS: Volunteer GPs of the administrative area of Côte d'Or (France) returned a mailed questionnaire on NSAID prescribing patterns for consecutive patients seen during a 2-month period. In order to obtain a reference basis, pharmacies of the same administrative area provided all prescriptions that included NSAIDs during a 1-week period originating in general practice. RESULTS: The rate of participation was 25% for the GPs and 40% for the pharmacies. Participant GPs were representative of GPs of the area with regard to sex, year of graduation and practice area but pharmacies from rural areas were over-represented. The GP-based survey and the pharmacy-based survey provided respectively 770 and 1050 prescriptions. There were no differences between either survey in the type of NSAIDs prescribed and in the most frequently associated drugs. GPs who volunteered in the GP survey prescribed NSAIDs more frequently orally and at higher doses than GPs involved in the pharmacy-based survey. They also prescribed more gastroprotective drugs, especially in the elderly. None of these results could be explained by differences in patient characteristics and GP practice areas. CONCLUSION: GPs who actively participate in prescription surveys exhibit prescribing patterns that fit better with official recommendations than the average. Although selection biases cannot be ruled out, it is suggested that some changes in GP prescription habits may have been induced by the survey itself.

Adolescent↗
PubMed2003

Deprivation and systematic stroke prevention in general practice: an audit among general practitioners in the Rotterdam region, The Netherlands.

BACKGROUND: To investigate differences in quality of preventive care provided by general practitioners (GPs) to patients at risk of stroke living in deprived and non-deprived neighbourhoods in the Rotterdam region. METHODS: A 'deprivation score' was used to categorize neighbourhoods according to their deprivation status. Data on the process of patient care were collected by means of chart review and interviews with GPs. Cases of stroke (n=188) were retrospectively audited by an expert panel with guideline-based review criteria. To measure differences in quality of patient care between neighbourhoods, deprivation scores were related to scores for sub-optimal care. RESULTS: After adjustment for socio-demographic characteristics, patients in deprived neighbourhoods had an increased risk (OR 1.95 (95% CI: 0.98-3.90)) of having received sub-optimal preventive care if compared with patients in non-deprived neighbourhoods. This excess risk was limited to women (OR 3.57 (95% CI: 1.39-9.16) vs OR 1.01 (95% CI: 0.41-2.48) in men). Adjustment for socio-demographic characteristics and risk factor distribution did not change the OR for women to receive sub-optimal care significantly (OR 3.21 (95% CI: 1.24-8.31)). Sub-optimal care originated mainly from deficiencies in follow-up of treated hypertensive and diabetes patients and evaluation of patients' cardiovascular risk profile. Among treated hypertensive women in deprived neighbourhoods who received sub-optimal care, the mean number of deficiencies related to follow-up was almost double that of the corresponding group in non-deprived neighbourhoods. CONCLUSION: Quality of care to prevent stroke in general practice differs considerably between deprived and non-deprived neighbourhoods. Patients in deprived neighbourhoods, and women in particular, have almost twice the risk of receiving sub-optimal preventive care.

Adult↗
PubMed1992

Perceptions of psychological problems in general practice: a comparison of general practitioners and psychiatrists.

All general practitioners and psychiatrists working in a single health district were sent a questionnaire on their perceptions of the prevalence of psychological problems among patients consulting in general practice. One hundred and twenty-one GPs (75%) and 10 (83%) psychiatrists responded. GPs and psychiatrists agreed that up to 20% of consulting patients were likely to be clinically depressed; they also agreed on the most appropriate management, although GPs tended to be more conservative than psychiatrists would advise on making use of hospital services. GPs, however, believed non-specific psychological problems to be significantly less common than did psychiatrists. This expectation may help explain the reported failure of GPs to diagnose all psychological problems identified by formal psychiatric instruments.

Adult↗
PubMed2000

[Research in general practice. Plea for organized and high quality clinical research by general practice physicians in Switzerland].

The clinical research in the practitioner's office is indispensable for the teaching of the medicine of first recourse. On the basis of the analysis of 109 publications, the authors propose to structure this research under the shape of investigator's networks while guaranteeing an interface between the primary care physicians and the academic specialists. To realise this network, an institutional support is necessary.

Academic Medical Centers↗
PubMed1988

Psychiatric screening in general practice: comparison of the general health questionnaire and the hospital anxiety depression scale.

The prevalence of psychiatric disorder in 100 patients attending their general practitioner was found to be 33% based on the criteria of the DSM-3 diagnostic system. Using the DSM-3 diagnosis as a yardstick, the performance of the hospital anxiety depression scale was compared with that of the general health questionnaire. Relative operating coefficient analysis showed good discrimination between ;cases' and ;non-cases' for both questionnaires, and the optimum threshold score was found to be eight for the hospital anxiety depression scale and five for the general health questionnaire. Using these threshold scores the positive predictive value was 81% for the hospital anxiety depression scale and 77% for the general health questionnaire. The hospital anxiety depression scale appeared more sensitive than the general health questionnaire (90% versus 77%) and simpler to complete. In addition, it does not require a different threshold score for each population studied. The use of screening questionnaires in general practice is discussed.

Adult↗
PubMed1999

Information technology and general practice. A survey of general practitioner attitudes towards computerisation.

AIM: General practitioners in the central Sydney area were surveyed to quantify the extent of, and attitudes towards, computerisation in Australian general practice. METHOD: Two surveys were mailed to all GPs in the central Sydney area, first in 1994, and again in 1996. The majority of questions in both surveys were identical. The results were collated and descriptive and comparative statistics calculated. RESULTS: There was an increase in the use of computers for clinical tasks and, GPs' attitudes towards computerised prescribing systems became more positive. There was a persistent negative attitude towards the actual costs of computerisation. CONCLUSION: Methods are now required to transform the increased use of computers by GPs into improved outcomes for them and their patients.

Attitude to Computers↗
PubMed2005

[Characteristics of solo and group practices in Norwegian general practice].

BACKGROUND: The article describes changes in the size of practices after the introduction of the new Norwegian list patient system for general practitioners (GPs) and how length of patient lists, number of consultations, working hours and waiting time for an appointment vary according to the number of physicians in the practice. MATERIAL AND METHODS: The data were collected by a comprehensive questionnaire survey among general practitioners in the autumn of 2002. A total of 2306 physicians took part (response rate: 70%). RESULTS: Before the list patient system was introduced, 18% of GPs worked in solo practices. With the new system in place, the proportion went down to 15%. About 60% of GPs worked in practices with 2-4 GPs. Out of young GPs in solo practices, 78% wished to work in practices with several colleagues, while 26% of GPs in practices with more than six physicians wished to reduce the size of the practice. The number of patients on the list and the number of curative working hours per GP decreased with increasing practice size. The number of consultations per hour did not vary with the number of GPs in the practice. Waiting time for an appointment for non-emergency treatment increased with increasing practice size. INTERPRETATION: A lower service production per physician in large practices may partly be an effect of a relatively high proportion of women wanting to work fewer hours than their male colleagues. Irrespective of gender, group practices also attract GPs who want slightly reduced working hours.

Adult↗
PubMed1989

Women doctors' career choice and commitment to medicine: implications for general practice.

This study examined the work experiences and plans of a national sample of 150 female medical graduates of 1976, 1980 and 1984. The sample was exhaustively traced and information obtained about 97% of the doctors, including 100% of the doctors ever likely to practise in the UK. The findings show a high recent and planned participation rate in medical practice, especially general practice, among these women graduates and no involuntary unemployment. Increased numbers of women at medical school will result in manpower changes, particularly in general practice, but these increases will not counter possible overproduction of medical graduates. The study also demonstrates that it is possible to achieve a high response rate among medical graduates by using a telephone interview.

Adult↗
PubMed1996

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↗
PubMed2001

Referrals and relationships: in-practice referrals meetings in a general practice.

BACKGROUND: GP referrals to secondary care are an important factor in the cost of running the NHS. The known variation in referral rates between doctors has the potential to cause tension within primary care which will be exacerbated by the latest reorganization of primary care and the trend towards capitation-based budgets. The importance of postgraduate learning for GPs has been recognized; continuing professional development is moving towards self-directed practice-based learning programmes. Educational interventions have been shown to alter doctors' prescribing behaviour. This, together with the pressure on accounting for referral activity, makes the prospect of improving, and possibly reducing, referral activity through educational interventions very attractive. OBJECTIVES: This study complemented a randomized controlled trial (RCT) which investigated whether an intervention of the type which had reduced prescribing costs would have a similar effect on referral activity. METHODS: The context of the study, description of the characteristics of the practice and the issues seen as important by the doctors and practice manager were identified through preliminary semi-structured interviews. The practice then held a series of educational in-practice meetings to discuss referrals and issues arising from referrals. The audio- and videotaped transcripts were interpreted using content and group dynamic analysis. Participants commented upon our preliminary findings. In addition, we used dimensional analysis to induce a preliminary theory describing the effect of the intervention on this general practice which enabled us to review the findings of the parallel RCT. The educational value of the meetings and the learning needs of the participants were also assessed. RESULTS: Our complementary study showed no alteration of practice referral rates following the educational intervention. The qualitative study, unencumbered by the assumptions inherent in the development of the hypothesis tested in the RCT, highlighted the complexity of decision making in general practice and the likely impact of historical background and a variety of internal and external pressures on this self-directive educational intervention. The practice members described the individual and group learning needs identified as a result of the meetings. CONCLUSION: The findings of this study raise important questions for developing practice-based learning. The outcomes of self-directive interventions in practices will be influenced by internal and external events both past and present. Such outcomes may be qualitative and difficult to measure. They are likely to differ from outcomes seen when interventions are applied to groups of doctors who are not all members of the same practice.

Family Practice↗
PubMed1989

National General Practice Study of Epilepsy and Epileptic Seizures: objectives and study methodology of the largest reported prospective cohort study of epilepsy. National General Practice Study of Epilepsy and Epileptic Seizures (NGPSE).

Most available data on the prognosis of epileptic seizures come from hospital-based clinics in which patients with chronic or severe disease are over-represented. The National General Practice Study of Epilepsy and Epileptic Seizures is a large prospective community-based study of people with newly diagnosed seizures which aims to address questions related to the early prognosis of epilepsy. 275 general practitioners throughout the United Kingdom have registered a total of 1,195 patients. In this paper we discuss the background to the study and the methodology used.

Cohort Studies↗
PubMed2001

Valsartan alone and as part of combination therapy in general practice in Brazil.

The objective of this study was to assess the efficacy and tolerability of valsartan (Diovan) when given alone or as part of a combination regimen in normal clinical practice, in general practice patients in Brazil. In an open, multicentre post-marketing surveillance (PMS) study, 7256 hypertensive patients were evaluated. Therapy with valsartan either as monotherapy or in combination with 12.5 mg chlorthalidone was observed for up to six months. Assessments at baseline and study endpoints included analysis of adverse events and measurement of systolic and diastolic blood pressure (BP). A total of 3855 patients (53%) received valsartan as monotherapy (mostly as 80 mg once daily), 1162 (16%) received 80 mg valsartan + 12.5 mg chlorthalidone, and 347 (4.8%) received valsartan together with other antihypertensive agents; 858 patients were not evaluable because of inadequate records. A control group of 1034 patients received other antihypertensives. Overall tolerability was high, with 98.5% of patients receiving valsartan alone, 97.7% of those receiving valsartan + chlorthalidone and 92.4% of those receiving other antihypertensives giving tolerability ratings of 'excellent' or 'good'. In this large PMS study, valsartan alone and in combination with chlorthalidone was associated with excellent safety and tolerability in general practice patients in Brazil with primary hypertension, irrespective of age, sex or concomitant diseases.

Adolescent↗
PubMed2001

[Screening for alcohol overconsumption in general practice. Experiences of general practitioners with a patient questionnaire].

INTRODUCTION: We investigated to which degree a sample of 143 general practitioners in the County of Copenhagen would screen their patients for problem drinking by using The Alcohol Use Disorders Identification Test (AUDIT). Furthermore, among users of AUDIT, we aimed to describe the doctors' perception of using it. METHODS: Eighty-one out of the 143 doctors requested AUDIT. However, after they had had the possibility of using AUDIT, only 38 had handed an AUDIT to at least one patient. These 38 doctors were asked to answer a questionnaire on which this study is based. RESULTS: Thirty-two percent (12/38) of the doctors handed out an AUDIT in more than 14 days, and 21% (8/38) gave at least 100 patients an AUDIT. The general practitioners worked a median of 20 days in their practice during the study period. Only 14% (5/36) would screen all their patients in the future, and 42% (15/36) only when they suspected problem drinking. Sixty-four percent (22/34) of the doctors stated that handing all patients an AUDIT was much too time-consuming, 50% (17/34) stated that financial incentives are necessary, and 53% (18/34) questioned whether the patients wanted an AUDIT. Sixty-six percent (23/35) of the doctors judged that they had improved in detecting patients with alcohol related problems. CONCLUSION: The participating general practitioners were not interested in handing all patients an AUDIT. Major barriers were lack of time and financial incentives and furthermore the doctors questioned whether the patients wanted an AUDIT. However, half of the doctors would use AUDIT for certain patients, especially when they suspected problem drinking.

Adult↗