Showing papers in "Family Practice in 1994"

Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions.

Abstract: One-hundred and ninety-eight elderly subjects attending their general practitioners (GPs) were asked to complete the 15 item Geriatric Depression Scale (GDS15). Analysable results were obtained from 194 (98%). Of these, 67 (34%) scored above the GDS15 cut-off (4/5) for significant depressive symptomatology. 87.6% found the questionnaire to be acceptable and only 3.6% found it very difficult or very stressful. The GDS15 had a high level of internal consistency (Cronbach's alpha = 0.80). All the individual items of the GDS15 associated significantly (P < 0.01) with total score and 'caseness'. A single question "do you feel that your life is empty?" identified 84% of 'cases'. In an attempt to devise short scales to screen elderly primary care patients for depression, the data were subjected to logistic regression analysis. Ten (GDS10), four (GDS4) and on (GDS1) item versions were generated. Agreement between these short scales and the GDS15 in the original sample was 95, 91 and 79% respectively. Cronbach's alpha was 0.72 for the GDS10 and 0.55 for the GDS4. The short scales were then validated in an independent sample of 120 patients in whom both GDS data and the results of a detailed psychiatric interview (the Geriatric Mental Status Schedule, GMS) were available. The sensitivity and specificity of the GDS10 against GMS caseness were 87 and 77% (cut-off 3/4); those of the GDS4 were 89 and 65% (cut-off 0/1) and 61 and 81% (cut-off 1/2). Sensitivity and specificity for the GDS1 were 59 and 75%. It is concluded that these short scales may be useful in helping GPs and practice staff to identify elderly patients with significant depressive symptoms.

Dietary Intervention in Primary Care: Validity of the DINE Method for Diet Assessment

Abstract: Primary health care staff are involved increasingly in the provision of dietary advice for health promotion, often without adequate training in nutrition assessment or counselling. At present no brief diet assessment methods are available which have been validated for this purpose in the UK. We report on the accuracy of the Dietary Instrument for Nutrition Education (DINE) in classifying dietary fat and fibre intakes. This structured questionnaire can be administered and scored in under 10 minutes by primary care staff without specialized nutritional knowledge, and includes a dietary counselling component. The classification of fat and fibre intakes as low, medium or high by the DINE method was compared to that of a detailed 4-day diet record in a population of 206 factory workers. There was exact agreement of categorization for 53% of fat intakes and 52% of fibre intakes, and only 6% of fat intakes and 5% of fibre intakes were grossly misclassified (placed in a high category by one method and a low category by another). Pearson correlation coefficients between the two methods were 0.51 for fat, 0.46 for fibre and 0.43 for the polyunsaturated:saturated fat ratio. The DINE method is a brief and inexpensive tool for diet assessment in primary care health promotion programmes.

Scientific Rigour in Qualitative Research—Examples From a Study of Women's Health in Family Practice

Abstract: The increase in qualitative research in family medicine raises a demand for critical discussions about design, methods and conclusions. This article shows how scientific claims for truthful findings and neutrality can be assessed. Established concepts such as validity, reliability, objectivity and generalization cannot be used in qualitative research. Alternative criteria for scientific rigour, initially introduced by Lincoln and Guba, are presented: credibility, dependability, confirmability and transferability. These criteria have been applied to a research project, a qualitative study with in-depth interviews with female patients suffering from chronic pain in the locomotor system. The interview data were analysed on the basis of grounded theory. The proposed indicators for scientific rigour were shown to be useful when applied to the research project. Several examples are given. Difficulties in the use of the alternative criteria are also discussed.

Primary care, financing and gatekeeping in western Europe

Abstract: Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.

Quality of Life and Patient Satisfaction Following Treatment for Menorrhagia

Abstract: This prospective cohort study of patients who consulted general practitioners complaining of excessive menstrual bleeding measured changes in quality of life and patients' satisfaction following different forms of treatment for menorrhagia. Three hundred and forty-eight patients were followed-up for 18 months using self-completion questionnaires which included generic measurements of health-related quality of life (SF-36) and a disease-specific questionnaire to measure the social impact of menstrual symptoms. Only 15 patients (4%) received no active treatment, 132 (38%) underwent surgical treatment (hysterectomy or endometrial resection), and the remainder were prescribed drugs. Those in the surgical group with both moderate and severe symptoms experienced significant improvements in their quality of life. Patients with moderate symptoms who did not undergo surgery improved in the social functioning and energy dimensions of the SF-36, but those with severe symptoms who received drug treatment only experienced no significant quality-of-life benefits. Patients who had not had surgery were significantly more likely to be dissatisfied with their treatment (21%) than those in the surgical group (5%). Since menorrhagia can have adverse effects on many aspects of a patient's daily life, it is important to measure the effects of treatment on quality of life. This study has demonstrated the feasibility of doing so.

Major determinants of consumer satisfaction with primary care in different health systems.

Abstract: It is becoming increasingly recognized that patient or 'consumer' views should be taken into account as part of a comprehensive assessment of quality of care. This paper reports a study carried out in four European countries about consumer satisfaction with primary care. The results showed that higher levels of general satisfaction with general practitioner services were found in Canterbury (95%) and Ioannina (87%) than Belgrade (85%) and Moscow (62%). Further analysis of the data showed that in all four cities the key dimensions of satisfaction with general practitioner care are both the nature in quality of the doctor-patient relationship and the GP's professional skills. The implications of these findings are discussed.

Patients' Preferences and General Practitioners' Decisions in the Treatment of Menstrual Disorders

Abstract: The aim of this study was to investigate the treatment preferences of patients consulting their general practitioners (GPs) for heavy menstrual bleeding and the influence of these preferences and other factors on GPs' management decisions. One-hundred and twenty-nine GPs recruited 483 eligible patients into the study, of whom 425 (88.0%) returned completed questionnaires. 35.6% of patients indicated that they had a strong treatment preference. Logistic regression analysis revealed that the strongest independent predictors of the likelihood of having a treatment preference were higher education and previous consultations for gynaecological problems. Among those who expressed a preference for either drug therapy or surgery, those with severe symptoms and those who had not received higher education were more likely to prefer surgical treatment. The likelihood of referral was related to a preference for surgery, as expressed by the patient and as perceived by the GP. Patients were much more likely to be referred to a gynaecologist if they had a history of prior surgery (odds ratio 3.21) and if their GP was male (odds ratio 1.76).

Is the Potential of Teenage Consultations Being Missed?: a Study of Consultation Times in Primary Care

Abstract: There is a paucity of knowledge regarding teenage health even though it features as one of the priority areas in the government's health plans. There have been few reports of adolescent contacts with primary care teams, although there are impressions of a suboptimal service. As a prelude to understanding more about communication between general practitioners and teenage patients, this study aimed to look at the time spent on teenage consultations, which can be used as one method of describing the quality of care provided to teenage patients. Nine-hundred consultations involving six doctors in one surgery were timed over a 3 month period by one observer using a validated method. One-hundred and nineteen consultations with patients aged 11-19 were compared with the 781 consultations for other age groups and showed a statistically significant mean shortfall of nearly 2 minutes (23%). This trend was confirmed for all six doctors, despite a broad range of average consulting times. The study also demonstrated some other characteristics of teenage consultations. Several implications of these results are discussed as well as possible reasons for these findings. The study emphasizes the need for further research in this area.

Quality assurance in general practice: the state of the art in Europe.

Abstract: Quality assurance' (QA) is an important new development in general practice. In order to describe the state of the art in this field a preliminary survey was performed by the WONCA European Working Party on Quality in General Practice (EQuiP) in 17 European countries. The results revealed considerable differences in the systems and organization of general practice care [such as practice form, list size, the role of the general practitioner (GP), remuneration], which will have an impact on setting up QA. The preliminary findings demonstrated that most countries are only just beginning the implementation of QA. Nevertheless, there are many valuable developments and experiments concerned with the methodology, procedures and structures for it. In order to accelerate the speed of adoption of QA and to avoid the repetition of mistakes, policy makers and GPs from different parts of Europe should study examples in their fellow countries. A clearing house of QA projects in general practice can help to inform them on valuable developments.

The role of social support in the pathogenesis of coronary heart disease. A literature review.

Abstract: A possible effect of social support on the pathogenesis of coronary heart disease (CHD) would have practical implications, especially from a general practitioner's point of view. This paper reviews studies on the relationship between social support and CHD/CHD risk factors. Several prospective studies show a negative correlation between the level of social support and CHD mortality/CHD morbidity. These associations may be due to a protective effect of social support. This conclusion is supported by several investigations indicating that social support is capable of moderating potentially harmful negative emotions and the potentially harmful cardiovascular response to psychological challenge. However, a lack of control with personality factors in most of the studies makes this conclusion uncertain.

General Practitioner Appointment Systems, Patient Satisfaction, and use of Accident and Emergency Services—a Study in One Geographical Area

Abstract: This study examines the relationship between (i) measures of how appointment systems work; (ii) patients' views of the arrangements for seeing their general practitioner; and (iii) practice self-referral rates to accident and emergency departments (AE (ii) patient views on practice appointment systems (reported dissatisfaction with arrangements for being seen, proportion of patients reporting they normally wait in excess of 15 minutes when attending to be seen, the perceived availability of a doctor to deal with (a) urgent and (b) non urgent problems); (iii) practice self-referral rates to local A&E department. Practices varied widely in their rate of provision of appointments, in the proportion of appointments which were unbooked at the start of the working day and in the proportion of patients identified as 'extras' by reception staff. These measures of appointment system operation correlated with patient dissatisfaction with the arrangements of seeing a doctor in their practice and with the perceived availability of a doctor to deal with non urgent problems. The measures did not, however, correlate with A&E self-referral rates after they had been corrected for distance between practice and hospital, or with the perceived availability of a doctor to deal with urgent problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequent attenders of Finnish public primary health care: sociodemographic characteristics and physical morbidity.

Abstract: In this article results of a Finnish study on frequent attender patients of public primary health care are reported. These patients (n = 96) were compared with other patients (n = 466) attending the same surgeries. Frequent attender patients tended to have lower vocational training and to belong to lower social groups than other patients. The frequent attender patients also had more physical diseases, were more often on disability pension and had more mixed (physical-psychiatric) complaints than the control patients. The results indicate that many frequent attender patients complaints form a complicated network departing from different levels (physical, psychological and social). The implications of the findings are discussed.

General practitioner diagnosis of depression and dementia in the elderly: can academic detailing make a difference?

Abstract: The objective was to improve the ability of general practitioners (GPs) to diagnose depression and dementia compared with standard screening measures. The setting was a retirement village on the outskirts of Sydney, Australia. The study used a prepost design with a 6 month follow-up. The intervention involved a visit to the GP by an academic detailer who spent 15 minutes discussing the diagnosis of depression and dementia. Ratings of depression and dementia on two occasions by GPs, and by independent interviews were made using the Geriatric Depression Scale, Mini-mental State Examination and Canberra Interview for the Elderly. In the case of depression, the level of agreement (Kappa) between the GPs and all instruments increased significantly by a factor of between 2.3 and 3.3. The doctors did not significantly improve in their agreement with the instruments on the diagnosis of dementia. An academic detailing approach to improving GPs' abilities in the diagnosis of depression can be effective. A controlled trial would be justified to confirm this finding.

The Effectiveness of Waiting Room Notice-Boards as a Vehicle for Health Education

Abstract: To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not increase the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (< 10%) read or took health promotion leaflets. These results suggest that the role of waiting room notice-boards should be reassessed. More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation.

Do Clinicians Tell Each Other Enough? An Analysis of Referral Communications in Two Specialties

Abstract: Referral letters and replies are an important vehicle for conveying information about patients and for creating and sustaining professional relationships. Studies of communication between hospital specialists and GPs, however, suggest that improvements could be made to the content of letters. In this study, which is part of a larger study of referral expectations, a sample of 39 letters to and from the ENT and Rheumatology departments at Sunderland Royal Infirmary was analysed to find out what objectives were being achieved through the correspondence between consultants and GPs. An analytical framework of letter content was derived from a review of 25 letters to and from each specialty and from a separate study of doctors' opinions of letter content conducted by two of the authors. Doctors recruited to the present study were involved in devising a weighted scoring system for letter content. Analysis showed that the letters accomplish the basic objective of transferring clinical and administrative information. They were less likely to contain items of a socio-psychological type. There was very little difference in the standardized letter scores between the two specialties. While the level of detail recorded in this sample may be adequate for straightforward referrals, there are indications that clinicians' letters are frequently not addressing nonclinical matters that can be a complicating factor in a proportion (perhaps a fifth) of referrals. This may be a possible topic for audit in multidisciplinary groups.

Benzodiazepine prescribing and withdrawal for 3234 patients in 15 general practices

Abstract: Benzodiazepines are still widely prescribed in general practice, despite repeated warnings about the problems associated with their use. Other studies have shown that a variety of interventions can reduce prescribing, but these have been restricted to relatively few general practices or patients. We co-ordinated an audit of benzodiazepine prescribing and withdrawal in 15 practices caring for 87,900 patients across a district. In total 3234 patients (37 per 1000 registered patients) were discovered to be taking the drugs at the start of the programme, and 16% of these people stopped taking the drugs by the conclusion of the audit 8 months later. There was no relation between success at benzodiazepine cessation and initial levels of prescribing, nor with practice size. Younger patients were significantly more likely to stop benzodiazepines than those over the age of 65.

Job satisfaction, mental health and job stress among general practitioners before and after the new contract--a comparative study.

Abstract: In order to compare measures of job satisfaction, mental health and job stress among general practitioners (GPs), the results of a 1993 survey were compared with that obtained in the previous study in 1987. Eight-hundred and fifty GPs were selected at random by seven Family Health Service Authorities in England, 380 of whom returned questionnaires suitable for statistical analysis. There were significant differences between the 1987 and 1993 surveys. GPs experienced less job satisfaction, poorer mental health and more stress in 1993 than in 1987. These changes may have occurred as a result of the introduction of the new contract.

How do General Practitioners Diagnose Dementia

Abstract: By means of a qualitative study, we set out to generate hypotheses about the way general practitioners (GPs) diagnosed dementia. We looked for triggers for the diagnosis of dementia. Ten GPs were interviewed about four dementia cases taken from their own practices. GPs are more concerned with treatment than with the diagnosis of dementia as such, as diagnosis is performed in relation to treatment. The most important aid was the evolution of the clinical tables based on the information of caregivers. Important triggers were changes of activities of daily life function, behaviour and cognition. Acute illness and loss of the key caregiver were relevatory moments. Recommendations are made for the improvement of the diagnostic abilities of GPs.

Antibiotics prescription in primary care: a 5-year follow-up of an educational programme

Abstract: An educational programme on the use of antibiotics for respiratory tract infections (RTIs) in primary care, initiated among district physicians at the Community Health Centre of Hoor, Sweden in 1985, resulted in an overall reduction in prescriptions for antibiotics, particularly broad-spectrum antibiotics. The aim of the present study was to evaluate the long-term effects of the programme on antibiotic prescription patterns at the centre. Since 1985, computerized records have been kept of every consultation at the centre, including details of the attending physician, the patient, diagnosis and type of antibiotic prescribed. Moreover, during a 3-month period in 1991, each pharmacy in the region recorded details of all prescriptions for antibiotics dispensed. Estimated immediately after the programme, the proportion of RTI patients prescribed antibiotics had fallen to 44%, a figure virtually unchanged 5 years later. During the subsequent five-year period, antibiotics dispensed at the pharmacy in Hoor were further reduced from 14.1 to 13.2 defined daily doses 1000 inhabitants-1 day-1. As compared with district physicians at other community health centres in the region, those at Hoor prescribed more penicillin V (80% of all antibiotic prescriptions) and less broad-spectrum antibiotics. The educational programme, combined with an active interest among district physicians at Hoor in current research into antibiotic usage, has thus wrought enduring changes in the pattern of antibiotic prescription. A probable contributory factor was the district physicians' awareness that the computerized registration of diagnosis and treatment enables prescription patterns to be audited at an individual level.

Prevalence of Depressive Symptoms and Depressive Disorder in Primary Care Patients Over 65 Years of Age

Abstract: The aim of this study was to estimate the prevalence of depressive symptoms and depressive disorder (ICHPPC-2-defined) in patients over 65 years of age. A cross-sectional, partly two-phased, study was performed in general practices in The Netherlands. A total of 384 consecutive patients aged 65 and above, 116 men and 268 women were included, both during practice visits and home visits. Depressive symptoms were recorded with the Zung Self-rating Depression Scale, the Geriatric Depression Scale, and with physician ratings. Assessments of depressive disorder were based on an adaptation of interview ratings with the Montgomery Asberg Depression Rating Scale. The proportion of patients considered to have depressive symptoms ranged from 11 to 29% of patients, depending on the self-report instrument and the cut-off point. According to interviews a depressive disorder was estimated to be present in 17%. The high prevalence of depressive symptoms and depressive disorder suggest a higher index of suspicion of depression in elderly general practice patients.

Is smoking intervention in general practice more successful among pregnant than non-pregnant women?

Abstract: The objective of this study was to evaluate the effect of a simple smoking intervention programme, carried out by a large number of general practitioners (GPs) among pregnant and non-pregnant women. Four groups of women were defined by the dichotomies pregnant versus non-pregnant and intervention versus control. The intervention was semistructured, using a flip-over and a booklet, and it was implemented in an ordinary sequence of consultations. The study involved 187 GPs in western Norway. The subjects were 350 daily smoking pregnant women and 274 daily smoking non-pregnant women, 18-34 years of age. The point prevalence abstinence rate at 18 months was 15 and 20% for pregnant and non-pregnant women, respectively, in the intervention groups, and 7% in the control groups (Ppregnant = 0.06, Pnon-pregnant = 0.006). Twenty-five per cent of the pregnant women and 34% of the non-pregnant women reported that they had reduced their cigarette consumption, but had not stopped smoking entirely. If we include all drop-outs as smokers, the continuous abstinence rate during 15 months was 6%/0% among pregnant women (intervention/control) and 5%/1% among non-pregnant women. Stopping smoking was associated with having a non-smoking partner (P = 0.001), and being encouraged to do so by their partner (P = 0.004). The prevalence of both pregnant and non-pregnant women who stopped smoking was higher in the intervention than in the control groups. Pregnant women stopped smoking as frequently as non-pregnant individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient demand for prescriptions: a view from the other side.

Abstract: This paper describes patients' ideas about doctor's prescribing habits, their expectations for prescriptions and their self-reported behaviour in cashing prescriptions. It is based on semistructured interviews with 30 adult patients from two general practices. Views about doctors' prescribing habits ranged from those wanting more help with their symptoms saying that doctors underprescribe to those aware of doctors' pressure of work saying that they overprescribe. The desire for a prescription in a consultation can be related to the stage of the illness at which a patient consults; not all patients wanted a prescription or collected it if they received one. It is suggested that in appropriate cases, doctors could ask patients directly if they were expecting a prescription.

Asthma in adolescents and young adults: screening outcome versus diagnosis in general practice.

Abstract: The objectives of this study were to investigate underdiagnosis of asthma in adolescents and young adults in general practice and to examine the influence of patient characteristics. The results of screening on asthma (questionnaire, spirometry) were compared with the diagnosis made in general practice. Screening results served as the reference standard. Four general practices forming the Continuous Morbidity Registration, Nijmegen were used. Five-hundred and fifty-one subjects aged 10-23, registered since their birth till the year of the study (1989) on the practice lists of these practices were involved in the study. The data collected included: (i) all episodes of respiratory morbidity in their life presented in general practice; (ii) socioeconomic level and family history of asthma; and (iii) current respiratory status, allergy to inhalant allergens and smoking behaviour (questionnaire, spirometry, histamine-challenge test and Phadiatop-test). The screening identified asthma in 19% of the study subjects, of whom 56% not had been recognized in general practice. Of the asthmatics recognized in general practice, significantly more were boys, had presented acute bronchitis in the last 5 years preceding this study and had a family history of asthma than those not recognized. Of the latter, 30% had not presented any respiratory disease in the last 5 years to their general practitioner (GP). This study suggests underdiagnosis of asthma in adolescents and young adults. Asthmatics are more likely to be recognized by their GPs in case of male sex, previous diagnosis of acute bronchitis and a family history of asthma. Reluctance of some patients to consult their doctor and low perception of symptoms may play a role in underdiagnosis.

General practitioners' experience of research.

Abstract: In 1993, a Men's Health Study was conducted in five mainland capital cities of Australia to determine prevalence of urinary symptoms among male patients. Patients completed a questionnaire in the waiting room before seeing the general practitioner who later completed a checklist. Various strategies were used to encourage participation by general practitioners in the research and to maintain the quality of data collection, including the use of local co-ordinators seconded from a pharmaceutical company. The aim of the study was to obtain feedback from participants about strategies used to encourage their participation, ways to improve the study and future research topics. One hundred and thirty-four general practitioners completed self-administered questionnaires (82% response rate). The three most encouraging factors were the research topic itself, a telephone call from a medical member of the research team before receiving a letter about the research and a face-to-face visit by the local co-ordinator to explain the study before consent. Reactivity of patients and practitioners themselves to research requirements was perceived both positively and negatively. To improve the study, respondents suggested providing more information about the study to participating doctors and designing a patient questionnaire to involve non-English-speaking patients. Fifty-two per cent suggested topics for future research. The most frequently suggested topics were smoking, other cardiovascular risk reduction interventions, hormone replacement therapy, alcohol and exercise. It was concluded that general practitioners are influenced less by the names and track record of the research team than the research topic itself and the personal approaches used to obtain consent.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening, detection and management of depression in elderly primary care attenders. II: Detection and fitness for treatment: a case record study.

Abstract: Mullan E, Katona P, D'Ath P and Katona C. Screening, detection and management of depression in elderly primary care attenders. II: Detection and fitness for treatment: a case record study. Family Practice 1994; 11:267-270. Case note data were obtained for 186 elderly primary care attenders who also completed the 15 item Geriatric Depression Scale (GDS15). The presence or absence in the case notes of a current or past diagnosis of depression, of current treatment of depression, and of a number of clinical features of depression were noted. Case notes were also rated for the presence or absence of contraindications to the use of tricyclic antidepressants (TCAs) and to serotonin-specific reuptake inhibitors (SSRIs). Whereas 65 (35%) patients were rated as 'cases' of depression on the GDS15, only 28 (15%) had a current case note diagnosis of depression and 37 (20%) had one or more current symptoms of depression recorded in the case notes. Patients rated by their GP as having one or more current symptoms of depression scored higher on the GDS15 (P < 0.05) and were more likely to be categorized as a GDS case (P = 0.05). There was no significant relationship between GDS caseness and a current case note diagnosis of depression. Seventy-three patients (39%) had a past history of depression and 53 (28.5%) patients had previously been treated with antidepressants. The former was significantly associated with GDS caseness (P < 0.05). Twenty-four patients (13%) were currently on antidepressants, 19 of them receiving adequate doses (equivalent to at least 75 mg of amitriptyline). Current antidepressant treatment was not associated with GDS 'caseness'. A significantly higher proportion of patients (both in the sample as a whole and in the subgroup of GDS15 depression 'cases') had a medical condition or were taking a drug that mitigated against the use of TCAs than was the case for SSRIs.

Accessibility and Use of Health Care Services in the British Asian Community

Abstract: British Asians make up 3% of the population. There is evidence that Asians have difficulty obtaining good quality health care, appropriate to their needs. This article examines some of this evidence, with examples of specific communities in Britain. In the past, specific health education programmes for Asians have targeted their 'special' needs such as rickets, tuberculosis and thalassaemia. In fact the population itself perceives its needs differently--improved communication, easier access to services, and more information on asthma, diabetes, ischaemic heart disease and skin disorders. It is important to appreciate that the 'Asian' community is made up of disparate groups with widely differing needs and expectations, and that each community should be considered by health service planners as unique within the context of the health authority within which they lie. Reasons for the mismatch between need and service provision are discussed in the light of the recent reforms in the National Health Service and recommendations for change are given.

Analysing General Practitioners' Referral Decisions II. Applying the Analytical Framework: Do High and Low Referrers Differ in Factors Influencing Their Referral Decisions?

Abstract: An analytical framework of the referral decision was applied to the question of whether general practitioners (GPs) with relatively high and relatively low referral rates differed in the types of factors that influenced their referral decisions. Interview data from six high referring and six low referring GPs were compared at all levels of the framework, using both quantitative and qualitative content analysis. High referrers were found to mention significantly more negative factors than low referrers, i.e. they referred 'in spite of' reasons against referral. In particular, they referred patients in spite of having doubts about treatment effectiveness. Low referrers mentioned factors related to interpersonal processes significantly more often than high referrers, for example, GP-patient communication as an influence. Possible interpretations of these findings are discussed.

Can the Dartmouth COOP/WONCA Charts be Used to Assess the Functional Status of Chinese Patients?

Abstract: This is the first study on the use of the Dartmouth functional health assessment charts COOP/WONCA in the assessment of the functional status of Chinese patients. The Chinese are the world's largest ethnic group and make up more than one-fifth of the world's population. We have developed a Chinese translation of the Dartmouth COOP/WONCA charts that satisfies the two minimal and one intermediate criteria on translation of scales and instruments set by the European Research Group in Health Outcome (ERGHO). We tested the charts on 84 Chinese patients with previous strokes when they attended follow-up at the General Practice Unit of the University of Hong Kong from 1 August to 30 November 1992. We found that the Dartmouth COOP/WONCA charts in Chinese were easy to administer and were well accepted by our patients. All but one patient understood all the charts. There was good face validity in the results obtained by the charts. The consulting doctors found that the information detected by the charts was moderately useful in 64% of the patients and was very useful in 5% of the patients. Our translation can be applied to other Chinese in Hong Kong as well as other countries, because there is only one written Chinese language. It is hoped that our pilot study will stimulate further research to establish the reliability, validity and clinical application of the COOP/WONCA charts in Chinese.

Measuring Patient Satisfaction in Primary Care: a Joint Project of Community Representatives, Clinic Staff Members and a Social Scientist

Abstract: We describe the process of planning and developing a questionnaire and conducting a patient satisfaction survey in a neighbourhood clinic in Beer-Sheva, Israel. The project was conducted by the clinic staff members, patient representatives and a medical sociologist. The satisfaction survey was conducted in patients' homes, with a 67% response rate. General satisfaction and satisfaction with specific components of service are described. Patient satisfaction was higher among men than among women, and negatively correlated with family size. The strongest predictor of general satisfaction was satisfaction with physicians' services. Implications of the survey results were decided upon by active collaboration between the clinic staff and the patient representatives. The inferences drawn from the patients' replies and the changes introduced as a result of them, are discussed. Health care consumers should be active participants in carrying out surveys of satisfaction on a regular basis.