Medical audit in general practice. I: Effects on doctors' clinical behaviour for common childhood conditions. North of England Study of Standards and Performance in General Practice.

OBJECTIVE--To estimate the effects of medical audit, particularly setting clinical standards, on general practitioners'' clinical behaviour. DESIGN--Before and after study strengthened by a replicated Latin square. SETTING--62 training general practices in the north of England. SUBJECTS--92 general practitioner trainers, 84 (91%) of whom completed the study; random sample of 3500 children consulting one of these trainers for any of five conditions--acute cough, acute vomiting, bedwetting, itchy rash, and recurrent wheezy chest--stratified by doctor consulted, condition, and age. INTERVENTIONS--Clinical standard set by each of 10 small groups of general practitioner trainers for one randomly selected childhood condition. Each group also experienced a different type of medical audit, randomly selected, for each of the four other study conditions (receiving a clinical standard set by another trainer group, tabulated data comparing clinical performance with that of all other groups, tabulated data from only their own group, and nothing ("control" condition)). MAIN MEASURES--Content of initial consultation divided into: history, examination, investigation, diagnosis, and management (abstracted from medical records and "enhancement forms" completed by doctors). RESULTS--There was increased prescribing of bronchodilators for acute cough, oral rehydration fluids for acute vomiting, antibiotics for itchy rash, and bronchodilators and oral steroids for recurrent wheezy chest and reduced prescribing of antibiotics for acute cough and recurrent wheezy chest and tricyclic antidepressants for bedwetting. Fewer children were "discharged." Each change was consistent with the standard and either limited to doctors who set a standard for that condition or significantly greater for them than all other doctors. CONCLUSION--Setting clinical standards improved prescribing and follow up.     

The practitioner,the patient and resistance to change: recent ideas on compliance.

Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients'' lives. This article focuses on how clinicians'' consulting methods can affect patients'' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients'' intrinsic motivation to make their own decisions. This approach also promotes clinicians'' acceptance of patients'' decisions, even if these decisions run counter to current medical wisdom.     

Using information from asthma patients: a trial of information feedback in primary care.

OBJECTIVE--To test the effects of feedback of information about patients'' asthma to primary care teams. DESIGN--Patients'' reports of morbidity, use of health services, and drug use on questionnaire was given to primary care teams. Randomised controlled trial with general practices as the subject of the intervention was used to test effectiveness of supplying information. SETTING--Primary care in district health authority, London. SUBJECTS--23 general practices, each of which notified at least 20 asthmatic patients aged 15-60 years for each principal. Practices were randomly allocated to an invention group (receiving feedback of information on control of asthma) or a control group (no feedback). INTERVENTION--Information on cards inserted in patients'' medical records; booklet copies of information for team members; formal presentation to primary care teams; poster displays of data on patients in each practice. MAIN OUTCOME MEASURES--Type and frequency of asthma symptoms, use of health services, use of asthma drugs. RESULTS--Reported morbidity at entry to the study was substantial: 45% (818) patients reported breathlessness at least once a week. Less than half these patients were using inhaled steroids regularly. Intervention and control groups did not differ in practice or patient characteristics on entry to the study. In spite of the potential for improvement no differences were observed between the two practice groups at the end of the study--for example, breathlessness at least once a week in last six months was experienced by 36% in intervention group v 35% in control group (t = -0.27, P < 0.79); surgery attendance in last six months by 48% v 48% (t = -0.05, P < 0.96); regular use of inhaled steroids by 60% v 58% (t = 0.51, P < 0.62). CONCLUSION--Feedback to general practitioners of information about patients'' asthma does not on its own lead to change in the outcome of clinical care.     

Experience with indeterminate mammograms.

Most radiologists recommend follow-up mammography in 3 to 6 months for asymptomatic patients with mammographic lesions that do not appear suspicious enough to warrant immediate biopsy. In this retrospective cohort study, the medical records of 776 patients were audited 24 to 35 months after mammography to estimate the frequency of indeterminate lesions, the probability of malignancy, and the rate of patients'' compliance with recommendations. Almost 2% of patients retested after an indeterminate mammogram were found to have breast cancer (95% confidence limits 0.2% and 5.9%). Only 26% of the patients retested during the audit period had the test within the suggested upper limit of 6 months. We conclude that timely follow-up after an indeterminate mammogram is advisable and that for the population we studied, compliance with this recommendation is low.     

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES--To identify those important characteristics of doctors'' and patients'' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners'' performance in their own consultations. DESIGN--Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING--All vocational training schemes for general practice in the Northern region of England. SUBJECTS--First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES--Trainers'' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS--6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION--The instrument produced is reliable for assessing general practitioners'' performance in their own consultations.     

Cost of urology: financial audit in a clinical department.

OBJECTIVES--To cost a clinical unit over one month in 1991, to cost treatment of individual patients from audit data, and to compare this costing method with the hospital charging system. DESIGN--A financial breakdown was obtained for one month''s work. Ward stay, operating time, investigations, and outpatient visits were costed and a formula (episode = days on ward+hours of operating+investigations+outpatient visits) was used to cost patient episodes from audit data. SETTING--The adult urology unit in a teaching hospital. MAIN OUTCOME MEASURES--Costs for each part of patients'' treatment. RESULTS--Total cost was 147,796 pounds for 159 admissions, 738 inpatient days, 131 operations in 29 operating lists, and 615 outpatient visits. An uncomplicated transurethral prostatectomy cost 1140 pounds but complications increased this to 1500 pounds in another patient. The costs of diagnostic cystoscopy were 130 pounds in outpatients, 240 pounds in day surgery, and 430 pounds in inpatients. Hospital charges do not reflect the individual costs of treatment, charges being greater than costs for some patients and lower than costs for others. CONCLUSIONS--Clinicians can produce a financial analysis of their work and cost their patients'' treatment. Audit is strongly advocated as a resource planning tool.     

Improving medication compliance: a randomised clinical trial.

A medical monitor which recorded the date and hour each time a medicine bottle was opened was used to evaluate a programme for improving patients'' compliance with their treatment. Eighty-two patients with glaucoma who had been prescribed pilocarpine eye drops three times daily to prevent visual loss were randomised into two groups. Both groups used the medication monitor during two 20-day periods, but before the second period the experimental group were given an education and tailoring programme in an attempt to improve their compliance. Nine patients missed the second treatment period and were excluded from the analysis. The patients in the experimental group showed significantly improved compliance when compared with the control group. The numbers of missed doses were reduced by about half, as was the proportion of time that exceeded the eight-hour dose intervals. Follow-up studies are needed to determine how long the improved compliance persists, but anyone considering setting up an education and tailoring programme should recognise the extent to which therapeutic efforts are wasted because of non-compliance.     

Effects of self medication programme on knowledge of drugs and compliance with treatment in elderly patients.

OBJECTIVE--To determine whether a programme of self medication for inpatients improves compliance with treatment and knowledge of their drugs after discharge from hospital. DESIGN--Patients were prospectively recruited from four wards: two with a self medication programme and two acting as controls. Ten days after discharge the patients were visited at home. They were questioned about their drugs, and a tablet count was undertaken. SETTING--The pharmacy department and four medical wards with an interest in elderly patients at a district general hospital, and the patients'' homes. PATIENTS--88 patients discharged to their own homes who were regularly taking one or more drugs. INTERVENTION--A hospital self medication programme in which patients are educated about their medicines and given increasing responsibility for taking them in hospital. MAIN OUTCOME MEASURES--Compliance with and knowledge of the purpose of their medicines 10 days after discharge from hospital. RESULTS--The mean compliance score in patients taking part in the self medication programme was 95% compared with 83% in the control group (difference 12%, 95% confidence interval 4% to 21%; P < 0.02). Of the patients in the self medication group, 90% (38/42) knew the purpose of their drugs compared with 46% (17/37) in the control group (difference 44%, 26% to 63%; P < 0.001). CONCLUSION--A self medication programme is an effective aid for improving compliance with and knowledge of patients'' drugs after discharge.     

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

Cost effectiveness of magnetic resonance imaging in the neurosciences.

OBJECTIVES--To measure, in a service setting, the effect of magnetic resonance imaging on diagnosis, diagnostic certainty, and patient management in the neurosciences; to measure the cost per patient scanned; to estimate the marginal cost of imaging and compare this with its diagnostic impact; to measure changes in patients'' quality of life; and to record the diagnostic pathway leading to magnetic resonance imaging. DESIGN--Controlled observational study using questionnaires on diagnosis and patient management before and after imaging. Detailed costing study. Quality of life questionnaires at the time of imaging and six months later. Diagnostic pathways extracted from medical records for a representative sample. SETTING--Regional superconducting 1.5 T magnetic resonance service. SUBJECTS--782 consecutive neuroscience patients referred by consultants for magnetic resonance imaging during June 1988-9; diagnostic pathways recorded for 158 cases. MAIN OUTCOME MEASURES--Costs of magnetic resonance imaging and preliminary investigations; changes in planned management and resulting savings; changes in principal diagnosis and diagnostic certainty; changes in patients'' quality of life. RESULTS--Average cost of magnetic resonance imaging was estimated at 206.20/patient pounds (throughput 2250 patients/year, 1989-90 prices including contrast and upgrading). Before magnetic resonance imaging diagnostic procedures cost 164.40/patient pounds (including inpatient stays). Management changed after imaging in 208 (27%) cases; saving an estimated 80.90/patient pounds. Confidence in planned management increased in a further 226 (29%) referrals. Consultants'' principal diagnosis changed in 159 of 782 (20%) referrals; marginal cost per diagnostic change was 626 pounds. Confidence in diagnosis increased in 236 (30%) referrals. No improvement in patients'' quality of life at six month assessment. CONCLUSIONS--Any improvement in diagnosis with magnetic resonance imaging is achieved at a higher cost. Techniques for monitoring the cost effectiveness of this technology need to be developed.     

Long-term digoxin treatment in general practice.

A questionnaire was sent to several general practitioners and specialists in an attempt to obtain a consensus on standards of care for patients receiving long-term digoxin treatment. The consultants'' suggested standards were slightly more stringent than those of the general practitioners. The records of 42 patients taking digoxin under the care of two general practitioners were studied to see how far their actual care matched up to the suggested standards. The models of management proposed by these patients'' doctors were only slightly different from those suggested by other practitioners, but measured against these models the patients'' care was in some cases inadequate. Nevertheless, there was little relationship between the recorded levels of care and the health of the patient, and it may have been the standard of recording rather than the care that was inadequate. Measuring plasma digoxin levels in these patients proved to be of little value. Medical audit is thus a useful tool in helping the general practitioner to review his work and improve his knowledge, but it may not be a practical or true way of measuring the quality of care.     

A university department's involvement with medical care in the Canadian North.

Both visiting consulting services and resident general practice services to the Churchill Health Centre in northern Manitoba are provided by the University of Manitoba through its northern medical unit. The roles of the university''s department of obstetrics and gynecology with regard to visiting consulting services include patient care, education and medical audit. This paper reviews the several aspects of this involvement over the period 1971 through 1977.     

Effects of computer generated reminder charts on patients' compliance with drug regimens.

OBJECTIVE--To investigate whether a reminder chart improved patients'' compliance with their drug regimen after discharge from hospital. DESIGN--Patients were randomly allocated to one of four groups. Two groups received the reminder chart: one also received routine counselling from a nurse and the other received structured counselling from a pharmacist, which included an explanation of the reminder chart. The other two groups received only counseling, either from a nurse or from a pharmacist. Patients were visited about 10 days later: they were questioned about their drug regimen, and their compliance was measured by tablet counting. SETTING--The pharmacy in a district general hospital and patients'' homes. PATIENTS--197 patients being discharged from hospital who were regularly taking two or more drugs. INTERVENTION--An individualised reminder chart, which listed each person''s medicines and when they were to be taken and was automatically generated by a medicine labelling computer. MAIN OUTCOME MEASURES--Patient''s compliance with and knowledge of their drug regimen. MAIN RESULTS--Of the patients who received the reminder chart, 83% (95% confidence interval 74% to 90%) correctly described their dose regimen compared with 47% (37% to 58%) of those without the chart (p < 0.001). The mean compliance score was 86% (81% to 91%) in both groups not given the reminder chart; 91% (87% to 94%) in the group given the chart without an explanation; and 95% (93% to 98%) in the group given the chart and an explanation. A mean compliance score of > 85% was achieved by 63% (53% to 73%) of patients without a reminder chart and by 86% (78% to 93%) of those receiving the chart (p < 0.001). CONCLUSIONS--An automatically generated reminder chart is a practical and cost effective aid to compliance.     

Invasive external otitis: review of 12 cases.

Invasive external otitis is an infection caused by Pseudomonas aeruginosa that often occurs in elderly people with diabetes. Twelve cases that illustrate the problems associated with the clinical recognition and successful outcome of the condition were reviewed. The patients'' average age was 62.5 years, and they had been ill for an average of 1.8 months before admission to hospital. Predisposing factors included diabetes, swimming in a warm climate and the use of a hearing aid. Radionuclide bone scanning and surgical exploration revealed pathognomonic findings. Initial therapy was often suboptimal: one or more relapses occurred in seven of the patients. All of the patients were cured without relapse after a minimum of 4 weeks of therapy with tobramycin plus an anti-Pseudomonas penicillin. The average duration of the illness was 3.9 months. The outcome in invasive external otitis should be excellent if the condition is diagnosed early and appropriate therapy is instituted.     

传统结肠镜检查法的应用现状

自20世纪六十年代末结肠镜检査术问世以来,无论是其操作手法还是器械改革均得到飞速发展,并广泛应用于临床,使直视病灶、实现活检及治疗成为可能。虽然,结肠镜检查为结直肠疾病的诊断及治疗带来了巨大的帮助并成为结直肠癌诊断的金标准,但其局限性也日渐明显。作为一种侵入性操作,结肠镜检查无法避免的腹部疼痛、难以预知的并发症、无法保证的成功率以及可能存在的漏诊率限制了其临床应用不仅在一定程度上降低了患者的依从性,增加了操作的困难度,且使一部分具有操作指征的患者错失早期诊断及治疗的最佳时机。本文简要阐述了传统注气式结肠镜检查法的一般特点并总结了其应用现状,以期为今后传统注气式结肠镜检查法的合理化应用提供一定的参考依据。     

Response of patients to upper gastrointestinal endoscopy: effect of inherent personality traits and premedication with diazepam.

The influence of personality traits on the reaction of patients to upper gastrointestinal endoscopy was studied prospectively in 86 patients. High N (neuroticism) scores on the Eysenck personality inventory were associated with poor tolerance to and future compliance with the procedure. Although premedication with diazepam did not affect the degree of discomfort and distress during the procedure, it guaranteed acceptance of repeat endoscopy by virtue of its strong amnesic effect. By contrast, not giving premedication to patients who were anxious and had high N scores jeopardized future compliance. These findings suggest that a version of the Eysenck personality inventory should be used to assess patients'' neurotic phenotype and their need for premedication before endoscopy. Alternatively, all patients might be given premedication.     

AIDS in children

The application of medical quality assurance principles to ambulatory patient care using the traditional methods of medical chart audit, process review, and physician education has yielded generally disappointing results in improving patient care and physician performance. Newer methods assist physicians by providing patient and medical reference data at the time of a patient''s visit. Techniques for tracking treatment outcomes and patients'' test results and for providing instructions to patients may improve both care and patients'' and physicians'' satisfaction.This feature appears regularly in THE WESTERN JOURNAL OF MEDICINE. It is intended to cover recent developments in a broad range of issues that will have an impact—either directly or indirectly—on clinical practice. Occasionally the seminars may include informed speculation about likely future developments.     

Information needs of cancer patients in west Scotland: cross sectional survey of patients' views.

OBJECTIVE: To assess the needs of patients with cancer for information about their condition. DESIGN: Cross sectional survey of patients'' views by means of semistructured interview with questionnaire. SETTING: A regional cancer centre and two university hospitals in west Scotland. SUBJECTS: 250 (93%) of 269 cancer patients invited to participate in study who were selected by age, sex, socioeconomic status, and tumour site to be representative of cancer patients in west Scotland. MAIN OUTCOME MEASURES: Patients'' need to know whether they had cancer, the medical name of their illness, progress through treatment, how treatment works, side effects, chances of cure, and treatment options. RESULTS: 79% (95% confidence interval 73% to 84%) of patients wanted as much information as possible, and 96% (93% to 98%) had a need or an absolute need to know if they had cancer. Most patients also wanted to know the chance of cure (91% (87% to 94%)) and about side effects of treatment (94% (90% to 97%)). When the replies were cross tabulated with patients'' age, sex, deprivation score, and type of treatment there was a linear trend for patients from more affluent areas to want more information and those from deprived areas to want less. There was a strong preference for diagnosis of cancer to be given by a hospital doctor (60% (53% to 66%). CONCLUSION: Almost all patients wanted to know their diagnosis, and most wanted to know about prognosis, treatment options, and side effects.     

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.