Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

Positive and negative factors in defensive medicine: a questionnaire study of general practitioners.

OBJECTIVES--(a) To investigate defensive medical practices among general practitioners; (b) to compare any such practices with general practitioners'' understanding of certain aspects of the terms of service and medical negligence and practitioners'' concerns about the risk of being sued or having a complaint lodged. DESIGN--Postal questionnaire survey. Each questionnaire was followed by a reminder. SUBJECTS--500 systematically selected general practitioners on the membership list of the Medical Defence Union. MAIN OUTCOME MEASURES--Answers to questions on defensive medical practices, understanding of certain aspects of the terms of service and medical negligence, and concerns about the risk of being sued or having a complaint lodged. RESULTS--300 general practitioners returned the questionnaire (response rate 60%). 294 (98%) claimed to have made some practice changes as a result of the possibility of a patient complaining. Of the defensive medical practices adopted, the most common (over half of doctors stating likely or very likely) seemed to be increased diagnostic testing, increased referrals, increased follow up, and more detailed patient explanations and note taking. Respondents practised defensive medicine as a possible consequence of concerns about the risks of being sued or having a complaint lodged. This association was particularly strong for negative defensive practices. Defensive medical practice did not correlate with any misunderstanding about the law of negligence or the general practitioners'' terms of service. CONCLUSIONS--General practitioners are practising defensive medicine. Some defensive practices such as increased patient explanations or more detailed note taking are clearly beneficial. However, implementing the findings of the Wilson report may increase negative defensive medical practices.     

AIDS and the general practitioner: views of patients with HIV infection and AIDS.

An unselected series of outpatients infected with the human immunodeficiency virus (HIV) who attended two London hospitals were interviewed to assess their relationship with their general practitioner. Although most of the 192 patients were registered with a general practitioner, the doctors of only one half knew of the diagnosis. Patients feared a negative reaction from their general practitioner or were concerned about confidentiality. Although those who had told their doctor had received favourable reactions, few general practitioners attempted to counsel or educate their patients. The patients who previously had been open about their homosexuality were not more likely to have told their general practitioner of their HIV infection. Although most did not think that general practitioners were well informed about AIDS, half of the patients wished that general practitioners could take a bigger part in their care.     

Computerisation of primary care in Wales.

OBJECTIVE--To obtain information about the computerisation of general practice in Wales, and to enable more effective planning of educational provision for doctors and other primary health care workers. DESIGN--Postal questionnaire sent to all general practices in Wales. SUBJECTS--553 general practices, of which 401 (73% replied). RESULTS--The level of computerisation varied from 11 (85%) of practices in Powys Family Health Services Authority to 22 (40%) in Mid Glamorgan. Less than half of practices had a computer in only two authorities. The commonest uses of the computer were for patient registration (208 practices), repeat prescribing (180), call and recall of patients (165), and partial clinical records (122). The main suppliers were VAMP (78 practices), AAH Meditel (46), and AMC (23). 102 of 226 practices with a computer had a terminal on each doctor''s desk. Just 33 practices had full patient notes on computer and 51 had modems for electronic communication. CONCLUSION--Mechanisms to encourage greater and more sophisticated use of computers and information technology need to be explored.     

Questioning behaviour in general practice: a pragmatic study.

OBJECTIVE: To study the extent to which general practitioners'' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine. DESIGN: Self recording of questions by doctors during consultations immediately followed by semistructured interview. SETTING: Urban Australian general practice. SUBJECTS: Random sample of 27 general practitioners followed over a half day of consultations. MAIN OUTCOME MEASURES: Rate of recording of clinical questions about patients'' care which doctors would like answered; frequency with which doctors found answers to their questions. RESULTS: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning. CONCLUSIONS: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.     

Survey of general practitioners' attitudes to AIDS in the North West Thames and East Anglian regions

As the numbers of people suffering from human immunodeficiency virus infection and the acquired immune deficiency syndrome (AIDS) increase, so will the contribution to care required from general practice. A postal questionnaire survey was therefore carried out among general practitioners in the North West Thames and East Anglian regions to determine their attitudes to AIDS and the issues it raises for them. One hundred and thirty seven questionnaires were returned (response rate 57%) and four factors underlying the doctors'' attitudes identified; these concerned disease control, general practitioner care, patient support, and perception of seriousness. There were wide divergencies of attitude among the general practitioners, younger doctors being more in line with specialist thinking on AIDS than older colleagues, and evidence of important gaps between policies advocated by AIDS specialists and bodies of opinion in general practice.Attitudes to AIDS in general practice may partly be a function of personal experience; further study is required.     

Responses by general practitioners in Avon to proposals for general practice in the white paper Working for Patients.

OBJECTIVE--To determine the views of Avon''s general practitioners about the general practice proposals within the government''s white paper Working for Patients. DESIGN--Postal questionnaire survey. SETTING--A county in south west England. SUBJECTS--All general practitioner principals (n = 537) under contract with Avon Family Practitioner Committee. MEASUREMENTS AND MAIN RESULTS--492 doctors (92%) responded to the survey. More than three quarters of the respondents were opposed to the government''s proposals on budgets for specific surgical procedures, prescribing, and diagnostic tests; and between 63% and 93% felt negative about advantages that might accrue from the proposals. Over three quarters of general practitioners were in favour of family practitioner committees monitoring work load, prescribing, and referrals. General practitioners in large, potentially budget holding practices held similar views to doctors in smaller practices. CONCLUSIONS--Avon''s general practitioners substantially reject most of the government''s proposals about general practice in the white paper Working for Patients.     

Influences on control in diabetes mellitus: patient,doctor, practice,or delivery of care?

OBJECTIVE--To assess patient, doctor, practice, and process of care variables for their effect on glycaemic control in diabetes mellitus, and to quantify their relative effects. DESIGN--Search of general practice medical records, patient questionnaires and examination, doctor questionnaire, videotaping and analysis of consultations, and practice questionnaire. SETTING--12 practices with 32 participating general practitioners in Nottinghamshire. SUBJECTS--318 patients randomly selected from those with diabetes in each practice, 10 for each participating doctor. MAIN OUTCOME MEASURE--Glycaemic control as measured by random glycated haemoglobin A1c estimation (random haemoglobin A1 measurement). RESULTS--Glycaemic control was significantly related to the disease process as measured by years since diagnosis, treatment group, and number of diabetes related clinical events. Females had significantly worse control than males. Other patient factors, such as age, social class, lifestyle, attitudes, satisfaction, and knowledge, had no association with glycaemic control. Of all the doctor factors examined, only doctors who professed a special interest in diabetes achieved significantly better glycaemic control. Bigger and better equipped practices and those with a diabetic miniclinic had patients with significantly better glycaemic control, as did those with access to dietetic advice. Patients attending hospital clinics had worse glycaemic control, but this seemed to be attributable to the case mix and practice characteristics. Shared care did not contribute to the multiple linear regression model. CONCLUSION--Glycaemic control among diabetic patients in the community is related to such factors as treatment group, sex, and years since diagnosis; it is also related to the organisation and process of care. The findings support concentrating diabetic care on partners with special interests in diabetes in well equipped practices with adequate dietetic support.     

General practitioners and management of infection with HIV

General practitioners will have an increasingly important role in the management of patients with the acquired immune deficiency syndrome (AIDS) and infections with human immunodeficiency virus (HIV) as the numbers of cases increase. Altogether 280 general practitioners working in Oxfordshire were sent a postal questionnaire inquiring about their education, knowledge, current practice, and attitudes in relation to managing infections with HIV. Of the 235 (84%) general practitioners who replied, nine out of 10 were giving advice about infection with HIV to their patients. One in two were testing patients for such infection, and one in four were caring for infected patients. Nevertheless, uncertainty remained about the risks of transmission of infection with HIV and general practitioners'' knowledge of educational activities for their patients could be improved.The introduction of a facilitator to work with general practitioners in managing patients with AIDS or infection with HIV is planned, especially to help general practitioners develop the skills needed for prevention.     

Immunisation against influenza among people aged over 65 living at home in Leicestershire during winter 1991-2.

OBJECTIVES--To assess the size of the elderly population for whom influenza vaccine is indicated and how many are vaccinated. DESIGN--Cohort questionnaire study. SETTING--Leicestershire general practices. SUBJECTS--800 elderly subjects selected a random from the Leicestershire family health services authority list who were not living in residential care, 565 of whom returned a questionnaire. MAIN OUTCOME MEASURES--Patient profile, vaccine offers, vaccination status, and reasons for not accepting vaccine. RESULTS--170 of 334 (51%) people aged 65-74 years and 106 of 205 (52%) aged > or = 75 years had one or more medical indications for influenza vaccine. 195 people were offered vaccine, 49 of whom had no risk factor. 152 offers were made opportunistically during visits to the practice and only six were made in writing or by telephone. Overall 113 of 266 patients with known medical indications were immunised. Vaccine was accepted by 148 of 189 (78%) offered it, and, as judged by acceptance in sequential years, influenza vaccine was well tolerated. The main reasons for not being vaccinated were misconception about risk status and inadequate advice from doctors. CONCLUSIONS--The prevalence of medical indications for vaccine is not large enough to justify a policy of universal immunisation. Most patients offered vaccine accept it and tolerate it well. Improved targeting and education is needed to increase immunisation of people at risk.     

Employment experiences of vocationally trained doctors.

OBJECTIVES--To investigate the expectations and employment experiences of male and female doctors who completed vocational training in East Anglia during 1981-7 and to examine the factors which had influenced those who had changed direction early in their careers. DESIGN--Survey conducted by confidential postal questionnaire. SETTING--Britain. SUBJECTS--281 doctors, 233 (83%) of whom responded. MAIN OUTCOME MEASURES--Ideal choice of work on completion of vocational training; present employment; factors which had restricted present choice of work; factors associated with reported satisfaction with job. RESULTS--77/83 (93%) men and 130/150 (87%) women had hoped to work in general practice (p = 0.75). A smaller proportion of women (71%; 106) than men (89%; 74) were in general practice posts (p less than 0.01); only 6% (nine) of women were on maternity leave or caring for children without paid employment. More women than men were working in medical jobs other than general practice (18% (27) women v 4% (three) men; p less than 0.01). 44/91 (49%) women with children had achieved their employment goals compared with 47/59 (80%) women without children and 55/71 (78%) men with children. 87% (72/83) of men and 65% (98/150) of women had achieved the status of principal (p less than 0.01). 162/193 (84%) doctors who had worked in general practice reported satisfaction with their jobs. Dissatisfaction was linked with doing a job different from that hoped for and with perceiving that the share of practice income did not accurately reflect their share of the practice workload. CONCLUSIONS--Steps need to be taken to retain women in general practice, including a statutory part time pay allowance and incentives for practices to allow flexible working hours for doctors with young children.     

Are general practitioners ready to prevent the spread of HIV?

General practitioners are excellently placed to assess a person''s risk of being infected with the human immunodeficiency virus (HIV) and to give advice on reducing that risk. Their attitudes to the acquired immune deficiency syndrome (AIDS) and infection with HIV are, however, unknown. A questionnaire survey of 196 general practitioners in East Berkshire Health District was used to assess general practitioners'' readiness to undertake opportunistic health education to prevent the spread of infection with HIV. Altogether 132 replied. Sixty four of them expressed little interest in health education about HIV, and one in six would not dissent from the notion that AIDS could be controlled only by criminalising homosexuality. Only 75 of them had initiated discussions about HIV with patients. Moreover, many underestimated the risks from heterosexual sex while exaggerating the risks from non-sexual contact.Advice from general practitioners if given extensively might reduce the spread of infection with HIV. How best this may be achieved needs to be considered urgently.     

Information systems for general practitioners for quality assessment: I. Responses of the doctors.

A questionnaire was sent to all general practitioner principals in Leicestershire and Lincolnshire (n = 669) to determine (a) the extent to which they would participate in quality assessment activities based on objective evidence of performance and (b) the personal and professional characteristics of interested doctors. The overall response rate to the questionnaire was 76% (508 replies). The highest response rates were recorded by trainers (100%), principals in training practices (94%), and younger doctors (80-86%), the lowest by overseas graduates (59%) and older doctors (65%). Distinctive patterns of interest and participation in three types of audit activities were clearly evident. Overall, 61% (310) of respondents wished to be provided with profiles of practice activity from their family practitioner committees, 36% (183) volunteered to participate in a prescribing study, and 34% (172) expressed interest in carrying out an audit in depth. Proportionately, the most enthusiastic and active groups were trainers 88%, 70%, 62%), principals in training practices (74%, 49%, 47%), and members or fellows of the Royal College of General Practitioners (71%, 50%, 45%). Also active were younger doctors, vocationally trained doctors, and principals in large group practices. These figures suggest that roughly 15 000 general practitioners in the United Kingdom would be prepared to participate in performance review activities using information provided by external agencies, 10 000 would if they had to generate some of the information, and 7500 would if they had to produce all the information themselves.     

Decontamination of instruments and control of cross infection in general practice.

OBJECTIVE--To assess the effectiveness of decontamination procedures in general practice. DESIGN--Anonymous postal questionnaire survey of 600 general practitioners randomly selected from the national register. SETTING--General practices throughout the United Kingdom. SUBJECTS--382 General practitioners, a response rate of 65%. RESULTS--186 General practitioners had autoclaves but 125 used hot water disinfectors or chemical disinfectants to reprocess instruments. 22% (474/2132) Of high risk instruments were inadequately decontaminated. Decontamination was performed by the practice nurse or receptionist in 306 practices. Knowledge of treatment of spillages of blood fluids was uncertain, and only 114 general practitioners used effective methods for dealing with spillages. CONCLUSIONS--A comprehensive central code of practice for control of infection is needed for primary health care staff.     

Survey of equipment in general practice.

Partners in general practice have to buy any equipment they want themselves. As a result partners in high investing practices have lower net incomes. Of the 297 practices in Devon and Cornwall, 265 responded to a questionnaire listing 115 possible items of practice equipment. Overall, practices seemed to be fairly well equipped. Key findings were that 193 of those who responded had an electrocardiograph, 206 had a kit for minor operations, 119 owned a computer, and less than one third owned a microscope. Most of these practices were high investors. There seems to be a shift away from some traditional instruments towards expensive information technology. Government policies are encouraging the use of computers and such equipment, though funds are not necessarily being made available for this purpose.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Occupational Post-Exposure Prophylaxis (PEP) against Human Immunodeficiency Virus (HIV) Infection in a Health District in Cameroon: Assessment of the Knowledge and Practices of Nurses

Background

Health care providers are at risk of acquiring human immunodeficiency virus (HIV) infection from occupational exposure, with nurses being the most vulnerable. There is no data on the awareness of post-exposure prophylaxis (PEP) among nurses in Cameroon. This study aimed to assess the knowledge, practices of nurses regarding PEP for HIV and their determinants in Cameroon.

Methods

A cross-sectional study was conducted between April and July 2013, and involved 80 nurses in a rural health district in the North West Region of Cameroon. Data was collected using a structured questionnaire and analysed using the SPSS software version 20.

Results

In all, 73.7% of the participants had poor knowledge about PEP for HIV. Though many (83.8%) had heard about PEP, just 10 (12.5%) had received formal training on PEP for HIV. Only 24 (30%) and 20 (25%) knew the correct drug regimen and duration of treatment respectively. The majority (85%) considered themselves to be at risk of acquiring HIV at work, with 54 (67.5%) having experienced an exposure in the past, mainly while setting up intravenous lines (57.4%), recapping needles (37.0%) and during delivery (24.1%). Of those exposed, ten (18.9%) received PEP, which was started after 24 hours in 50%. In multivariable regression analyses, awareness of hospital policy [OR: 0.043 (0.005–0.404), p-value = 0.006] was associated with Good knowledge on PEP for HIV.

Conclusions

The knowledge and practice of nurses on PEP for HIV in Cameroon is low. There is urgent need for training programmes and workshops to increase awareness, improve practice, and reduce the risk of HIV acquisition from work related activities among health care providers.     

To tell or not to tell: HIV disclosure to family members in China

Laws in China relating to HIV disclosure are inconsistent. After a patient has tested HIV-positive, service providers struggle to decide who should be informed first: patients, family members, or both. To understand service providers' attitudes and practices regarding the HIV notification process in China, 1101 service providers from a southwestern province of China were surveyed. Opinions were gathered from providers at five different levels of health care facilities (provincial, city, county, township and village). A mixed methods approach was used to analyze perceptions of informing family members of a patient's HIV status. Quantitative analysis was used to examine whether providers held a favorable attitude toward notifying family members first and qualitative analysis was used to explore the reasons and consequences of notifying family members first. Nearly half of service providers felt family members should be informed of a patient's HIV status first. Providers who were older, had contact with HIV patients, or had less medical education were more likely to agree with a family-first notification practice. Psychological pressure, concern about protecting family members, the need for family support, and consideration for local regulations were cited as the main reasons for this practice. There is an immediate need to re-examine HIV notification policies so that there are consistent guidelines and procedures for providers throughout China.