Showing papers in "British Journal of General Practice in 1991"

Long to short consultation ratio: a proxy measure of quality of care for general practice.

Abstract: Eighty five general practitioners in the Lothian region recorded information on all surgery consultations on one day in every 15 for a year. On the basis of their mean consultation times with patients the working styles of the general practitioners were described as 'faster' (n = 24), 'intermediate' (n = 40) or 'slower' (n = 21). The 21,707 consultations which they carried out over this period were defined as 'short' (five minutes or less), 'medium' (six to nine minutes) or 'long' (10 minutes or more). Independent of doctor style, 'long' consultations as against 'short' consultations were associated with the doctor: (1) dealing with more of the psychosocial problems which had been recognized and were relevant to the patient's care; (2) dealing with more of the long term health problems which had been recognized as relevant; and (3) carrying out more health promotion in the consultation. Patients also reported greater satisfaction with longer consultations. The ratio of long:short consultations was found to be 0.28:1 for 'faster' doctors as against 2.3:1 for 'slower' doctors. When doctors in either group had more heavily booked surgeries or were running late, the long:short consultation ratio fell, in some cases by over 50%. This paper suggests that the ratio of long to short consultation length for a general practitioner might become the basis of a simply proxy measure of quality of care; and that its use might help monitor the effect of recent and proposed changes in the way in which general practice care is delivered.

Lay epidemiology and the rationality of responses to health education.

Abstract: Health education has long been seen as an important component of primary care, and under the new contract has become routine. It is important to consider the likely impact of general practitioners' endeavours in the light of the experience of health education to date. Despite decades of efforts directed towards reducing the population's adherence to practices deemed harmful to health, it must be acknowledged that the impact of such activity has been disappointing. This paper considers some cultural origins of public scepticism to health education messages, and argues for a more balanced presentation of current knowledge concerning the causes of disease and the probability that individuals will benefit by changing their behaviour.

Consultation length in general practice: a review.

Abstract: Although there is evidence that consultation length has increased in the UK over the last 20 years, it is still short by international standards, and is blamed in part by both general practitioners and the public for failure to deliver high quality care. Consultation length is determined by both doctor and patient variables and these need to be looked at when interpreting observational studies linking longer consultations to beneficial outcomes. Studies of the same doctors consulting at different rates suggest that while many aspects of a doctor's behaviour do not change, longer consultations may be associated with greater patient satisfaction and increased health education/prevention measures.

Controlled trial of pelvic floor exercises in the treatment of urinary stress incontinence in general practice.

Abstract: The aim of this study was to assess the usefulness of pelvic floor exercises in the treatment of urinary incontinence in women and to analyse the factors which determine a successful outcome. The study involved 66 women who had reported 'genuine stress incontinence' to their general practitioner. They were assigned at random to the treatment or control group. The treatment group received instructions in pelvic floor exercises from a general practitioner. The control group received no therapy. At the start of the trial the severity of the patients' incontinence was assessed objectively. This assessment was repeated after three months and patients were also asked for their own perception of whether their incontinence had improved. After the three months' evaluation the patients in the control group were also given instructions in pelvic floor exercises. After another three months they were assessed in the same way. About 60% of the patients in the treatment group were dry or mildly incontinent after three months compared with only one patient in the control group; the mean weekly frequency of incontinence episodes fell from 17 to five in the treatment group but remained virtually unchanged in the control group; and about 85% of the women in the treatment group felt that their incontinence had improved or was cured compared with no one in the control group. These results were later corroborated by those for the control group. The most important factor in the success of the treatment was the patients' motivation, as demonstrated by their adherence to the daily exercises.(ABSTRACT TRUNCATED AT 250 WORDS)

Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice.

Abstract: The aim of this study was to assess the effect of a nurse run asthma clinic on practice workload and the morbidity of patients in a four partner general practice. One hundred and fifteen asthmatic patients were studied and comparisons were made between the 12 months prior to the introduction of the clinic and the first 12 months after the clinic started. Morbidity was measured in terms of: the number of courses of oral steroids, the number of emergency salbutamol nebulizations, and the number of days lost from work or school. The number of consultations with the general practitioners were recorded. The repeat prescribing register was also monitored throughout the study to examine the effect of the clinic on prescribing in the practice. Consultations with general practitioners fell from a total of 818 to 414 during the study period (P less than 0.001). This was offset by 496 consultations with the nurse in the first 12 months of the clinic. As a result of attending the nurse clinic significant reductions (P less than 0.01) were found in the patients' requirements for courses of oral steroids, acute nebulizations and days lost from work or school. The results for the 46 children were similar to those for the 69 adults, confirming that the asthma clinic was effective for all ages. The clinic coincided with an increase in the number of patients receiving regular bronchodilator therapy and prophylactic medication. Eighty per cent of patients had their medication modified as a result of attending the clinic. The cost of prescribing remained remarkably stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Spirituality, healing and medicine.

Abstract: The natural science base of modern medicine influences the way in which medicine is delivered and may ignore the spiritual factors associated with illness. The history of spirituality in healing presented here reflects the growth of scientific knowledge, demands for religious renewal, and the shift in the understanding of the concept of health within a broader cultural context. General practitioners have been willing to entertain the idea of spiritual healing and include it in their daily practice, or referral network. Recognizing patients' beliefs in the face of suffering is an important factor in health care practice.

Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners.

Abstract: A postal questionnaire was used to assess general practitioners' knowledge, attitudes and current practice of treatment regarding obesity and weight problems. Overall, 299 responses (75%) were received from general practitioners randomly selected from family practitioner committee lists in Portsmouth and Norwich. Currently 27% of the doctors were overweight and a further 3% obese. Many doctors (69%) had tried to lose weight at some time and 40% had been overweight and a further 12% obese in the past. The most popular methods used to educate overweight and obese patients were one to one counselling and giving out diet sheets and leaflets on healthy eating. The treatment advice to patients from the majority of doctors was to eat less in general (78%) (specifically to eat fewer calories 75%); to exercise (77%); or to attend a slimmers group (54%). Doctors thought that they were less effective than the media or the family in persuading overweight patients to lose weight. Doctors said they were prepared to counsel on weight reduction but felt they had little success in achieving weight loss in patients. Experience was ranked as the most important contributor to knowledge about managing obesity, and medical school was rated as least important. Further study is needed to discover how different practices and attitudes affect patient management and which ones are associated with greatest success. Medical schools and postgraduate centres could play a more important role in educating doctors about nutrition.

Assessment of the performance of general practitioners by the use of standardized (simulated) patients.

Abstract: A study was undertaken whereby a set of standardized (simulated) patients visited general practitioners without being detected, in a health care system where doctors had fixed patient lists Thirty nine general practitioners were each visited during normal surgery hours by four standardized patients who were designed to be indistinguishable from real patients The objective of the study was to see whether the actual performance of general practitioners, as assessed by standardized patients, met predetermined consensus standards of care for actual practice The patients presented standardized accounts of headache, diarrhoea, shoulder pain and diabetes The mean group scores of the doctors on the predefined standards of care for the different complaints ranged from 33 to 68% The results show that standardized patients may be the method of choice in the assessment of the quality of actual care of doctors It is hypothesized that the substandard scores of the doctors do not reflect inadequate competence, but are a result of the difference between competence and performance

Assessment of elderly people in general practice. 1. Social circumstances and mental state.

Abstract: A survey of patients aged 75 years and over registered with general practitioners in north and north west London was carried out by trained interviewers to investigate cognitive impairment. A random sample of 239 patients was selected for the more detailed home assessment. General practitioners had seen nearly two thirds (65.3%) of their patients aged 75 years and over in the three months prior to the study, the majority of these consultations (82.1%) being initiated by the patient and occurring at the surgery. Half of the patients lived alone (50.2%), nearly one in three had no living siblings (31.9%), a similar proportion had no living children (29.5%), and contact with neighbours and relatives was relatively infrequent. One in five elderly patients had evidence of depression (22.0%) although this appeared to be severe in only two cases, and 36 participants (15.1%) had scores on the mini-mental state examination suggesting cognitive impairment. General practitioners underdiagnosed both dementia and depression. The population contained a small group of people who consumed alcohol on a daily basis (10.5%). This study showed that an annual assessment of elderly people as required by the new general practitioners' contract would yield much new evidence of depression and dementia and assist in the identification of heavy drinkers. Up to 30% of patients aged 75 years and over are likely to require further assessment on the basis of screening tests for depression and cognitive impairment, although it remains unclear to what extent identification of these patients will lead to improvements in outcome for them or their carers.

Putting on the style: what patients think of the way their doctor dresses.

Abstract: The aim of this study was to determine how acceptable patients found different styles of doctors' dress and whether patients felt that a doctor's style of dress influenced their respect for his or her opinion. A total of 475 patients from five general practices in Lothian were surveyed using photographs of different styles in a male and female doctor and questions about their attitudes to doctors' dress in general. Overall, patients seemed to favour a more formal approach to dress, with the male doctor wearing a formal suit and tie and the female doctor in a white coat scoring the most high marks. This was particularly true of older patients and those in social classes 1 and 2. The male doctor wearing a tweed jacket and informal shirt and tie scored fewer low marks and this was therefore the least disliked of the outfits. There was a marked variation between preferences of patients registered with different practices. When asked, 28% of patients said they would be unhappy about consulting one of doctors shown, usually the ones who were informally dressed. However, some patients said they would dislike their doctor wearing a white coat. Although there are more important attributes for a general practitioner than the way he or she dresses, a majority of patients (64%) thought that the way their doctor dressed was very important or quite important. Given that 41% of the patients said they would have more confidence in the ability of one of the doctors based on their appearance it would seem logical for doctors to dress in a way that inspires confidence.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting women's response to an invitation to attend for a second breast cancer screening examination.

Abstract: A survey was conducted to study the impact of women9s previous experiences of breast cancer screening on their subsequent readiness to reattend. Women aged 45-64 years from three general practices were invited to attend for a second breast cancer screening test at a mobile clinic. Of the 1582 women who were invited, 1408 (89.0%) reattended. A questionnaire about their experience of the previous screening test was completed by 641 women who attended and 124 who did not attend the second test. Twenty six per cent of the women had found the previous test painful, and a minority also reported embarrassment (7%) or distress (6%). Women who did not reattend were significantly more likely than those who did to report the previous screening test as embarrassing or distressing and were significantly less likely to have found the clinic staff helpful or attendance for screening worthwhile or reassuring. No significant difference was found in the reattendance rate of women who had experienced a false positive result at the previous screening test compared with the remaining women. These results show that there may be substantial scope for reducing non-attendance by improving the way the service is provided, thereby enhancing the overall impact of breast cancer screening.

A method for introducing standardized (simulated) patients into general practice consultations.

Abstract: A study has been undertaken to determine whether it is possible for a set of standardized (simulated) patients to visit general practitioners, without being detected, in a health care system where doctors have fixed patient lists. Since sending standardized patients into doctors' offices is a new way to assess the performance of general practitioners; this paper describes in detail the methodology that has been used for visits. The paper looks first at the general preparation for visits and secondly at the specific preparation concerning the fine detail of the individual visit. The method was tested in 156 consultations with 39 general practitioners and in no cases were the standardized patients detected. None of the doctors visited felt offended and all were prepared to cooperate in future studies with standardized patients. It is concluded that the standardized patient method, following the step-by-step procedure described, is feasible in actual practice.

General practitioners' experience of the chronic fatigue syndrome.

Abstract: In order to examine the prevalence of patients with symptoms fulfilling the criteria for the chronic fatigue syndrome an extensive survey was carried out of general practitioners on 10 local government lists in two health boards (91% response rate). At the same time practitioners' attitudes to the syndrome and their experience in terms of workload and the characteristics of patients affected were documented. The majority of general practitioners (71%) accepted the existence of chronic fatigue syndrome, but 22% were undecided. The doctors reported a prevalence among their patients of 1.3 per 1000 patients (range 0.3-2.7 for the 10 areas) with a peak in the 30-44 years age group. Female patients were more commonly affected than males (sex ratio 1.8:1.0), but the severity of illness and the use of general practitioner's time was the same among male and female patients. Patients in occupations where they were exposed to infection were affected (teachers and students, 22% of sample; hospital workers, 7%), but many patients were unskilled (8%) and skilled workers (9%). Patients suffering from the chronic fatigue syndrome appear to be a real and distinct group for general practitioners and may represent a substantial part of the workload of doctors in particular areas.

Attitudes to carrier screening for cystic fibrosis: a survey of health care professionals, relatives of sufferers and other members of the public.

Abstract: The gene which is mutated in cystic fibrosis has now been identified, thus permitting the detection of carriers in the general population. This paper reports pilot surveys in the North West Thames region of the health service to assess knowledge of people about cystic fibrosis and their attitudes towards screening. Three groups were surveyed: a group of relatives of those with cystic fibrosis (n = 268), a sample of the community (school pupils and family planning clinic attenders, n = 363), and a group of health care professionals (general practitioners and family planning clinic staff, n = 227). The relatives of cystic fibrosis sufferers were unanimously in favour of the introduction of cystic fibrosis screening, and the results indicate that there is likely to be support from the relevant health professionals: approximately 75% of respondents in the group of health care professionals believe the introduction of screening would be worthwhile. Data from the community sample suggest that, although knowledge of cystic fibrosis within the general community is low (less than 50% of respondents realized that cystic fibrosis affects the lungs and that no cure is available), there is likely to be considerable demand for carrier testing from the general public. Approximately 75% of the community sample indicated that they would like to be tested. There was no clear consensus, either from the professionals or the public, as to the best time to offer screening.

Understanding the uptake of cervical cancer screening: the contribution of the health belief model.

Abstract: The health belief model, explaining health and illness behaviour, is 25 years old. Criticisms of the model have included its abstract nature and its emphasis on the rationality of patients' behaviour. Its lack of predictive power means it provides a useful framework rather than a true model. The health belief model is used here to review the literature that has advanced our understanding of the factors affecting uptake of cervical screening. The influence of age and social class on perceptions of vulnerability, and the costs and benefits of screening are highlighted. The body of work reviewed has helped expose inherent limitations of screening programmes. The main obstacles to the success of cervical screening are organizational, for example, the inaccuracy of address registers. Numerous ways of encouraging uptake are identified. These include appropriately worded invitations and educational material, personalized approaches from members of the primary health care team and flexible surgery hours. The incentives introduced under the 1990 general practitioner contract are likely to help increase uptake.

Prevention in general practice: the views of doctors in the Oxford region.

Abstract: A postal questionnaire was sent to all 1291 general practitioners in the Oxford region to determine the pattern of preventive care and their beliefs about its effectiveness. Replies were received from 1014 doctors (79%). Doctors' attitudes to their role in prevention and health promotion were very positive and a large majority claimed to discuss health related topics with their patients when indicated. Fewer respondents said they made a point of discussing smoking habits (64%), alcohol intake (26%), diet (12%), or exercise (11%) as a matter of routine with all their adult patients. Most general practitioners said they usually offered simple advice, leaflets, or other aids when they had identified a problem, but few said they would refer these patients to the practice nurse. With the exception of cervical screening (45%), few respondents said they maintained statistics on the distribution of risk factors in their practice population. Despite considerable enthusiasm for their role in preventive health care, before the imposition of the new contact most general practitioners in the Oxford region had not yet embraced the model of prevention which the contract aims to encourage: systematic screening for risk factors and lifestyle advice for all patients.

Balance of care for the dying between hospitals and the community: perceptions of general practitioners, hospital consultants, community nurses and relatives.

Abstract: A survey was made of the general practitioners, hospital consultants and community nurses who had cared for a random sample of people dying in 1987. Their views and experiences of the balance of care between hospital and the community are reported. All three groups wanted more people to be looked after in their homes rather than in hospital if adequate care could be arranged at home. But they perceived inadequacies in home help and district nursing services and many wanted other community services expanded or introduced. The main shortcomings of the hospital service were seen as inadequate numbers of hospice beds, difficulty obtaining admission for people needing long term care, discharge too early and some over-treatment of people who were dying. There was some evidence from relatives that pain control was better in hospital than at home, and the district nurses also reported that pain was not controlled satisfactorily for patients dying at home as often as it could be. It is concluded that inadequacies in community services may discourage some people from taking on the care of their relatives at home.

The menopause and hormone replacement therapy: views of women in general practice receiving hormone replacement therapy.

Abstract: Women's views on the menopause and hormone replacement therapy were explored using a questionnaire given to women attending one general practice who were having hormone replacement therapy under the supervision of their doctor. Sixty four women (67%) responded. Although only 5% of women had requested hormone replacement therapy from their general practitioner the majority of women indicated that they had been helped by hormone replacement therapy. Eight per cent of women were using hormone replacement therapy primarily to treat menopausal symptoms with only 6% of women using it primarily as prophylaxis against osteoporosis. Many women were correctly informed about the effects of hormone replacement therapy but mistaken beliefs about its side effects may indicate the need for further health education. The desire for further information was striking: 59% of women wanted further information about hormone replacement therapy, and 80% of women would have liked to have had more information about the menopause before its onset. The media appeared to be an important source of information about health matters: 61% of women obtained information about hormone replacement therapy from either the television, magazines or newspapers. The role of the media and health workers in health education is discussed.

Case finding in elderly people: validation of a postal questionnaire.

Abstract: A continuing concern of primary care is to produce economical methods of case finding among elderly patients to reduce unmet need in practice populations. This paper reports the use of a postal questionnaire to identify high dependency groups and the use of statistical methods to produce a formula which weights the relative importance of different items in identifying patients with a high level of dependency. It appears possible to identify such high dependency cases reliably at the cost of assessing between one half and two thirds of the population aged 75 years and over.

Link between the ability to detect and manage emotional disorders: a study of general practitioner trainees.

Abstract: Independent ratings were made of videotaped consultations involving six general practice vocational trainees, of whom three were poor identifiers and three were able identifiers of emotional illness. Taped consultations were selected so that each trainee was rated interviewing five patients with low general health questionnaire scores, and five patients with high scores. It was found that able identifiers of emotional illness were more likely than poor identifiers to offer patients information, advice and treatment relevant to their illness, and that they did so in a manner likely to maximize patient satisfaction and cooperation. This was true for both distressed and non-distressed patients. It is argued that both the ability to identify emotional disturbances and the ability to manage emotional illness are characteristics of a generally superior interview style. This may reflect a common variable: the possession of good communication skills.

Factors influencing waiting times and consultation times in general practice.

Abstract: Using data collected from 85 general practitioners in Lothian, large variations were found in the time patients wait for and spend with their doctor. This study, which sets consultations into their administrative framework, examines factors which cause this variation. Consultation time was found to be affected by the total number of patients attending a particular surgery, while waiting time was found to be affected by an individual patient's place within that surgery queue. Taking these two results together suggests that patients seen at the end of large surgeries are likely to get a different service from their doctor than they would have done earlier in the session, or when attending a less busy surgery. Possible strategies are discussed for reducing average waiting times, thereby decreasing the relative cost of consultation to patients.

Change in the established prescribing habits of general practitioners: an analysis of initial prescriptions in general practice.

Abstract: The aim of this study was to describe the types of drugs prescribed by general practitioners in a sample of initial (rather than repeat) prescriptions, the additions and deletions made to a doctor's repertory and the factors influencing these changes. The method used here enabled repeat prescriptions to be excluded as these are an inaccurate reflection of the current habits of the prescriber. A total of 201 (74%) of the principal general practitioners in the Grampian region participated. Data were obtained by substituting special prescription pads containing duplicate forms which allowed additional data to be recorded at the time of prescribing, including perceived influences that had resulted in changes from established choices of drug therapy. A sample of 100 forms were collected on seven occasions from each doctor over a one year sample period. Prescribers on average selected a preparation that they had only started to use within the last 12 months (that is newly adopted to their repertory) in 5.4% of initial prescriptions. These changes mostly involved antibiotics and analgesics and were occasioned mainly by the influence of the 'limited list' regulations, pharmaceutical company representatives and hospital specialists. We conclude that general practitioners were not unduly influenced by commercial sources of information, and that their prescribing habits were stable and conservative. The paper presents a case for the separate analysis of initial and repeat prescriptions as an essential step in producing more informative data on prescribing.

Self help programme for anxiety in general practice: controlled trial of an anxiety management booklet.

Abstract: Behavioural methods of treating anxiety have been shown to be highly effective but are not widely available in general practice where most people suffering from anxiety are treated. This study reports a development in service delivery which is simple, inexpensive and does not make great time demands on general practitioners or require them to extend their training and expertise. The study shows that for patients suffering from panic disorder or generalized anxiety disorder the use of an anxiety management booklet in addition to their usual treatment from their general practitioner produces clinically and statistically significant improvements. Of particular importance is the speed of response to the booklet. Within the first two weeks those patients who received the booklet were significantly less anxious than the controls. The booklet was acceptable to patients and recommendations are made about how to incorporate it into clinical practice.

Use of regression analysis to explain the variation in prescribing rates and costs between family practitioner committees.

Abstract: There are proposals to set up prescribing budgets for family practitioner committees (now family health services authorities) and indicative prescribing amounts for practices. An intelligible model is therefore required for specifying budgetary allocations. Regression analyses were used to explain the variation in prescription rates and costs between the 98 family practitioner committees of England and Wales in 1987. Fifty one per cent of the variation in prescription rates and 44% of the variation in prescription costs per patient could be explained by variations in the age-sex structure of family practitioner committees. The standardized mortality ratio for all causes and patients in 1987, and the number of general practice principals per 1000 population in 1987, but not the Jarman under-privileged area score were found to improve the predictive power of the regression models significantly (P less than 0.01). The predictions of the model for the 10 family practitioner committees with the highest and lowest prescription rates or costs are reported and discussed. Potential improvements in models of prescribing behaviour may be thwarted by two problems. First, the paucity of readily available data on health care need at family practitioner committee and practice levels, and secondly, the increasing complexity in the statistical techniques required may render the procedure less intelligible, meaningful and negotiable in a contentious field.

Development and randomized controlled trial of a booklet of advice for parents.

Abstract: A booklet was developed in the author's practice that provided advice for parents on the home management of cough, fever, sore throat, diarrhoea and vomiting in children, and included specific recommendations about when to seek medical help. The effect of distributing this booklet on the frequency of parent-initiated consultations was evaluated in a randomized, controlled trial. The overall effect of the booklet was a statistically non-significant reduction in consultations for the symptoms that it addressed ('booklet symptoms'). However, this finding masked a statistically significant reduction in daytime home visits for booklet symptoms (especially for cough, fever and sore throat) and a significant increase in out of hours consultations (for fever, diarrhoea and vomiting). Had all the households in the practice been sent a copy of the booklet then it was estimated that over the following year some 28% fewer home visits and some 173% more out of hours consultations would have been undertaken for booklet symptoms than if none of the households had been sent a copy.

Assessment of elderly people in general practice. 2. Functional abilities and medical problems.

Abstract: A random sample of 239 patients aged 75 years and over registered with general practitioners in north and north west London was selected for home assessment to determine the functional abilities and medical problems of this group of patients. Nearly one in five of the patients were incontinent of urine (18.4%), although this was on a daily basis for only 4.1%. Around one in 20 patients were incontinent of faeces (5.9%), yet only one patient had laundry service support. Unassisted mobility outdoors was reported as possible by 81.2% of the patients. Fourteen different types of aids were present in the participants' homes, the commonest being walking sticks, bath aids and stair rails. Only a small proportion of aids seemed to be currently unused. The major functional problems were bathing, housework, shopping, washing and ironing, and cooking main meals, but the level of demand for extra help was low. One in five patients had a hearing aid (19.8%) but for only 30% of these patients was it in continuous use. Polypharmacy was common, with 29.7% of patients taking three or more prescribed medicines. The workload implications of this approach to anticipatory care of elderly people are considerable. In an average practice of 2000 patients with 130 patients aged 75 years and over the primary care team would need over 150 hours of face-to-face contact per year with these patients to fulfil the new contractual obligation and the yield of new information leading to effective medical or social intervention is limited.(ABSTRACT TRUNCATED AT 250 WORDS)