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PubMed2001

Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population.

BACKGROUND: Early identification of alcohol abuse or dependence is important in general practice because many diseases are influenced by alcohol. General practitioners, however, fail to recognise most patients with alcohol problems. AIM: To assess the diagnostic performance of the CAGE and AUDIT questionnaires, their derivatives, and laboratory tests in screening for alcohol abuse or dependence in a primary care population (male and female patients), attending their general practitioner (GP). DESIGN OF STUDY: A diagnostic cross-sectional study. SETTING: A random sample of patients who were over 18 years of age (n = 1992) attending 69 general practices situated in the same region in Belgium. METHOD: Alcohol questionnaires (CIDI 1.1, section I, CAGE, AUDIT, AUDIT-C, Five-Shot, and AUDIT Piccinelli) were completed, demographic information was recorded, and patients underwent conventional blood tests, including mean corpuscular volume, liver function tests, the gamma-glutamyl transferase test, and carbohydrate-deficient transferrin (CDT, estimated using %CDT). Calculations of sensitivity, specificity, positive predictive value, negative predictive value, odds ratios with their 95% CIs, and receiver operating characteristic (ROC) curves for different scores of the questionnaires and laboratory tests, using DSM-III-R as the reference standard. RESULTS: The past-year prevalence of alcohol abuse or dependence in this population was 8.9% (178/1992) of which there were 132 male and 45 female patients attending a general practice. The GPs identified 33.5% of patients with alcohol abuse or dependence. Among male patients, all questionnaires had reasonable sensitivities between 68% and 93% and hence at lower cut-points than recommended. Only the sensitivity of the CAGE, even at its lowest cut-point of > or = 1 was lower (62%). In female patients the sensitivities were lower; however, odds ratios were higher for different questionnaires. The receiver operating characteristic (ROC) curves did not differ between the questionnaires. The laboratory tests had low diagnostic accuracy with areas under the ROC curves (AUCs) between 0.60 and 0.67 for female patients and 0.57 and 0.65 for male patients. CONCLUSIONS: This is one of the largest known studies on alcohol abuse or dependence among family care practices. We confirm earlier results that the AUDIT questionnaire seems equally appropriate for males and females; however, screening properties among male patients are higher. Nevertheless, the Five-Shot questionnaire is shorter and easier to use in a general practice setting and has nearly the same diagnostic properties in male and female general practice patient populations. We confirm that conventional laboratory tests are of no use for detecting alcohol abuse or dependence in a primary care setting. Also, the %CDT cannot been used as a screening instrument in this general practice population.

Alcoholism↗
PubMed1995

Using referral letters to measure quality and performance in general practice.

Although quality assurance is a concern of professional Colleges of General Practice and researchers in primary care, there are practical difficulties in measuring performance in general practice. Reliance on medical record audits in general practice has many shortcomings. Referral letters hold many advantages as a tool for audit or quality assessment in general practice: accessibility; acceptability; objectivity; consensus in standard setting for letters; and a positive impact on the quality and cost of management. Professional consensus standards will continue to be developed. If they are to be used for performance measurement, rather than simply serve an educational function, more use can and should be made of referral letters to assess and improve general practitioner performance.

Family Practice↗
PubMed1992

What do medical students seek to learn from general practice? A study of personal learning objectives.

With the aim of stimulating learning which is more self directed, fourth year medical students in Liverpool are encouraged to set personal learning objectives for the general practice attachment. On average, a student defines seven objectives for the three week attachment. A classification of objectives derived from the 1989 cohort of students is presented and the objectives could be seen as focusing on the practice population and its health problems, the role of the general practitioner, the work of general practice, the management of general practice, general practice as a career, and general learning. The validity and reliability of the classification are considered. Along with the advantages of this approach in motivating students to learn, the findings are considered in relation to impending changes in undergraduate medical education and the future role of general practice teaching by departments and by practice based colleagues.

Curriculum↗
PubMed1997

Measuring quality in general practice. Pilot study of a needs, process and outcome measure.

1. As part of the Scottish Shadow Fundholding Evaluation (1990-92), quality of care was assessed in 6 practices with 49 general practitioners using a pre-consultation health needs questionnaire, consultation length as a process measure (previously shown to be a proxy measure for quality) and a post-consultation satisfaction/outcome measure which contained a subset of six questions assessing whether patients felt enabled by their consultation. This report describes secondary analysis of the available dataset undertaken to explore whether the approach used to evaluate quality of care for patients with specific clinical problems could be extended to the generality of general practice consultations. 2. Chapters 1 and 2 of the report describe earlier work developing both the concepts and instruments used in the Shadow Evaluation, and general findings already reported. The reliability and the construct validity of the measure of enablement are examined and found to be satisfactory. 3. Strong correlations between more time at consultations and more enablement for more patients are found at population level for patients with psychological problems, with social problems and with physical problems. More complex problems require more time to achieve equal benefit. 4. Mean consultation length and mean enablement score correlate well with each other and can be used as summary statistics of quality. Where trends require explanation or exploration, other measures of the use of time and the level of benefit gained are more helpful; both sets of analyses can be derived from the same datasets (Chapter 3). 5. Analyses at practice level show that practices which spend more time at consultations enable patients more whatever the nature of problems presented. The rank orders of time spent at consultation and of enablement are highly correlated (Chapter 4). 6. Analyses at doctor level show that doctors who spend more time at consultations enable patients more and that those who spend less time enable patients less. The numbers of patients available for study were not sufficient to explore this association within subgroups of clinical presentations. As in previous studies, we found that doctors who take longer time are likely to be more patient centred, and those who take less time are likely to be less patient centred. Case-mix varies between doctors, but seems to be independent of whether a doctor is more or less patient centred (Chapter 5). 7. The methods developed in this study give useful insights into the definition and delivery of quality of care in general practice (Chapter 6). The measures now need to be tested in different clinical, cultural and organizational settings and results compared with those found using routinely available NHS data on prescribing and achievement of other clinical and management targets (Chapter 7).

Communication↗
PubMed2000

The state, the market, and general practice: the Australian case.

This article examines the development of general practice in the latter half of the 20th century, documenting the issues of concern to both the profession and the state. General practice developed hand in hand with the welfare state in Australia. As the structural changes associated with restructuring of the welfare state have advanced, so have the fortunes of general practice declined, despite significant attempts in the 1970s and 1980s to "save" general practice by both the profession and the state. These structural changes have operated on two fronts, the economic and the cultural. On the economic, changes to the employment of general practitioners clearly indicate ongoing proletarianization, particularly in a changing environment of labor-capital relations. At the cultural level, development of the self-help and the women's movements and the elective affinity of these groups with the individualism of the new right are leading to deprofessionalization. The author advances this argument in a review of general practice over the last 40 years and in a case study of community health services. Theoretically he argues for a combination of the proletarianization and the deprofessionalization theses.

Australia↗
PubMed1994

Careers in academic general practice: problems, constraints, and opportunities.

Changing priorities in the NHS have underlined the crucial importance of academic general practice in providing quality training and research to underpin developments in general practice. Unfortunately, several problems and constraints mean that the full potential of general practitioners to make a contribution to teaching and research has not been realised. These issues are examined and recommendations for improvements are made. Obstacles to career development for academics in general practice should be removed. The funding of academic general practice should be the same as for other medical disciplines. Vocational training for general practice should be extended to include research and audit methods, particularly for doctors interested in an academic career. Above all, the long term objective should be to integrate undergraduate and post-graduate general practice to increase the overall effectiveness of teaching and research and hence the quality of service general practice.

Academic Medical Centers↗
PubMed2006

General practice nursing education in Australia.

The quality of care delivered by nurses working in Australian general practices rests on a strong foundation of nursing educatlon and training. A national study of nurses working in general practice was conducted using qualitative and quantitative research techniques to explore their role and educational needs. Results from this research suggest that education for general practice nurses is seen by nurses and General Practitioners to be largely non-formal in nature and is seen by GPs and nurses to be tailored towards general practice nursing needs. Such education is often available locally through general practice support organisations; is strongly focused on National Health Priority Areas and clinical care; and is more appropriate for registered rather than enrolled nurses. The educational opportunities currently available to support nursing in general practice are largely ad hoc and vary in relation to quality, appropriateness and accessibility. Nurses working in general practices in Australia need a system of ongoing training and education to support their responsibilities and foster the development of the position as a viable career option for nurses.

Accreditation↗
PubMed2006

Fewer medical graduates are choosing general practice: a comparison of four cohorts, 1980-1995.

OBJECTIVE: To compare general practice career choices of four cohorts of medical graduates. DESIGN AND SETTING: Retrospective longitudinal study of medical graduates. Data on employment since graduation, nature of current employment, and postgraduate qualifications were collected by postal survey in 2003. PARTICIPANTS: Four cohorts of Monash University Medical School graduates who completed their degrees in 1980, 1985, 1990 and 1995 (n = 386). MAIN OUTCOME MEASURE: Proportion of each cohort pursuing a general practice career. RESULTS: At 8 years after graduation, half of the graduates in the 1980 and 1985 cohorts were working in general practice, compared with 38% of 1990 graduates and 33% of 1995 graduates. Differences were mainly attributable to fewer female graduates working as GPs: female GPs comprised 62% of the 1980 cohort compared with 31% of the 1995 cohort. Graduates in more recent cohorts also entered the general practice workforce at a later stage than those in earlier cohorts. CONCLUSION: A rapidly declining proportion of new graduates from Monash University Medical School, particularly female graduates, are choosing general practice as a career. This will exacerbate future shortages in the general practice workforce.

Adult↗
PubMed1997

Effectiveness of dietary intervention in general practice.

The scope for dietary intervention in general practice is substantial. The three most prevalent conditions for which general practitioners are likely to give dietary advice are hypertension, functional digestive disorders, and ischemic heart disease. As well as clinical diseases, risk factors such as raised plasma cholesterol concentrations also provide opportunities for dietary intervention. But resources are limited. If a general practitioner or nurse spends 5 min of a 10-min consultation on dietary advice, there is 5 min less to spend on the rest of the consultation. Research studies in general practice show that small changes in plasma cholesterol concentrations can be achieved by dietary interventions. Intensive intervention can also influence salt intake to a small extent. However, the most important, potentially cost-effective roles for the general practitioner in health promotion are the legitimization and reinforcement of public health information by brief advice and the distribution of written material. Secondary and tertiary prevention is a priority in general practice and may entail use of drugs, but drugs are not a desirable solution for the unhealthy diets of healthy people.

Adult↗
PubMed1985

Validation of the Italian version of the GHQ in a general practice setting.

The 30-item General Health Questionnaire (GHQ) and the Clinical Interview Schedule (CIS) were administered to 120 consecutive attenders at a general practice in Northern Italy run by a doctor who had a formal psychiatric training. The Italian versions of both the GHQ and the CIS were found to be feasible instruments for general practice studies in Italy. GHQ misclassification rates, sensitivity and specificity values are presented for different cut-off scores, a total score of 5 or more being the best discriminator between 'cases' and 'non-cases'. The prevalence of confirmed cases in this sample was 47.5%, a rate higher than those reported so far in developed and developing countries.

Adolescent↗
PubMed1993

Alternative or additional medicine? An exploratory study in general practice.

In a South London general practice a substantial proportion of patients in some age groups (35 and 45 yr) had tried alternative treatment. Satisfaction with the outcome was limited. The use of alternatives was associated with higher general practice consultation rates, especially among women. Qualitative interviews with users suggested that rapid cures for chronic conditions were rarely expected; rather, an alternative explanation for health problems was sought and a greater sense of autonomy in dealing with them. Negative attitudes towards modern medicine arose from perceptions of excessive technological intervention and iatrogenic disorders arising from long term drug treatment.

Adult↗