Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Should general practitioners call patients by their first names?

OBJECTIVE--To assess the acceptability to patients of the use of patients'' first names by doctors and doctors'' first names by patients in general practice. DESIGN--An administered questionnaire survey. SETTING--5 General practices in Lothian. PATIENTS--475 Patients consulting 30 general practitioners. MAIN OUTCOME MEASURE--Response by patients to questionnaire on attitude to use of first names. RESULTS--Most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65. Most patients (324) did not, however, want to call the doctor by his or her first name. CONCLUSIONS--General practitioners should consider using patients'' first names more often, particularly with younger patients.     

Postal survey of patients' satisfaction with a general practice out of hours cooperative.

OBJECTIVE: To assess patients'' satisfaction with out of hours care by a general practice cooperative compared with that by a deputising service. DESIGN: Postal questionnaire survey. SETTING: A general practice cooperative in London and a deputising service operating in an overlapping area. SUBJECTS: Weighted samples of patients receiving telephone advice, a home visit, or attending a primary care centre after contacting either service in an eight week period. MAIN OUTCOME MEASURES: Patients'' overall satisfaction and scores for specific aspects of satisfaction. Satisfaction with telephone advice or attendance at centre compared with home visit. Relation between satisfaction and patient''s age, sex, ethnic group, car ownership, preference for consulting own doctor, and expectation of a visit. RESULTS: The overall response rate was 67% (1555/2312). There was little difference in overall satisfaction between patients contacting the cooperative or the deputising service, but patients contacting the latter were less satisfied with the explanation and advice received and the wait for a visit. There were significant differences between patients in different age and ethnic groups, with white patients and those aged over 60 years being more satisfied. Lower scores for overall satisfaction were reported by patients who received telephone advice, those who would have preferred to see their own doctor or who originally wanted a home visit, and those who waited longer for their consultation. Overall levels of patients'' satisfaction seemed to be lower than previously reported. CONCLUSIONS: There were larger differences in satisfaction between different groups of patients than between different models of organisation for out of hours care. A shift to a service based predominantly on telephone advice may lead to increased patient dissatisfaction.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey

ObjectivesTo examine patients'' views on access and continuity in general practice to derive quality standards.DesignSecondary analysis of data from general practice research studies and routine quality assessment activities undertaken by practices and primary care trusts.SettingGeneral practice.ParticipantsGeneral practice patients.ResultsSatisfactory standards of access were next day appointments with general practitioners and a 6-10 minute wait for consultations to begin. A satisfactory level of continuity was seeing the same general practitioner “a lot of the time.” Standards varied with the analytic method used and by sociodemographic group.ConclusionsStandards expected by patients in primary care can be derived from linked report-assessment pairs. Patients may have expectations of access that are in excess of government targets. Patients also have high expectations of continuity of care. It is unclear the degree to which such standards are reliable or valid, how conflicts between access and continuity should be resolved, or how these standards relate to other priorities of patients such as high quality interpersonal care.

What is already known on this topic

Standards are increasingly being set for the provision of health servicesSurveys and consultation exercises before the NHS plan helped set the standard for a maximum waiting time of 48 hours for appointments to see general practitionersThe optimal methods by which patients should be involved in setting standards and the utility of such standards are unclear

What this study adds

Satisfactory standards of access were next day appointments, a 6-10 minute wait for consultations to begin, and seeing the same general practitioner a lot of the timePatients may have expectations for access to primary care in excess of current government targets     

Screening Primary-Care Patients Forgoing Health Care for Economic Reasons

Background

Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients'' health-care needs and financial resources.

Objectives

Identify a screening question to, indirectly, rule out patients'' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians'' attitudes toward deprivation.

Design

Multicenter cross-sectional survey.

Participants

Forty-seven general practitioners working in the French–speaking part of Switzerland enrolled a random sample of patients attending their private practices.

Main Measures

Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels.

Key Results

Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4–12.1) reported a member of their household to have forgone health care during the 12 previous months. The question “Did you have difficulties paying your household bills during the last 12 months” performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R² = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times.

Conclusion

General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.     

Predicting compliance with a regimen of digoxin therapy in family practice.

The ability of family physicians to predict patients'' compliance with a regimen of digoxin therapy was studied by an analytic survey. Compliance was assessed by a pill count at a home visit and measurement of the serum digoxin level in a blood sample obtained at that visit. Of 74 patients 70% were found to be taking more than 80% of their pills and 86% had a therapeutic serum digoxin level. The 10 physicians were unable to predict compliance better than chance, even for the 58 patients they had known for 5 or more years. Physicians should be cautious in predicting compliance, and when they prescribe oral digoxin therapy they should monitor the patient''s compliance by means of the serum digoxin levels.     

Measuring outcomes in primary care: a patient generated measure,MYMOP, compared with the SF-36 health survey.

OBJECTIVE--To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness. DESIGN--Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with'' practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed. SETTING--Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre. SUBJECTS--Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days. OUTCOME MEASURES--Standardised response mean and index of responsiveness; view of practitioners. RESULTS--The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.4 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with < 0.45 for SF-36. MYMOP''s validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients'' priorities. CONCLUSION--MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.     

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.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.     

Patients' assessment of out of hours care in general practice

A sample of 177 patients drawn from 13 north London practices were interviewed shortly after they had sought help from their practice outside normal surgery hours. Patients were asked to describe the process and outcome of their out of hours call, to comment on specific aspects of the consultation, and to access their overall satisfaction with the encounter.Parents seeking consultations for children were least satisfied with the consultation; those aged over 60 responded most positively. Visits from general practitioners were more acceptable than visits from deputising doctors for patients aged under 60, but for patients aged over 60 visits from general practitioners and deputising doctors were equally acceptable.Monitoring of patients'' views of out of hours consultations is feasible, and the findings of this study suggest that practices should regularly review the organisation of their out of hours care and discuss strategies for minimising conflict in out of hours calls—particularly those concerning children.     

Telematics: a new tool for epidemiological surveillance of diarrhoeal diseases in the Aquitaine sentinel network.

A sentinel health information system using telematics and a network of general practitioners was set up in Aquitaine in south western France in 1986. Among the health problems under surveillance was acute diarrhoea. Data for each patient who fulfilled the usual case definition for acute diarrhoea were reported by general practitioners using home terminals (Minitels) connected to a central computer by telephone. Over one year 2234 cases of diarrhoea were reported, the incidence varying from 0.8 to 1.5 cases per doctor per week. Seasonal variations in incidence were observed, with peaks in the winter and in the summer. Only 379 (17%) episodes of diarrhoea were classified as severe, and these patients consulted their general practitioners earlier than patients whose diarrhoea was less severe. Foreign travel was rarely found in the patients'' histories, but clusters of cases were found in communities (4.6%) and in families (22.3%). The advantages of this system were easy reporting and immediate feedback, but it was difficult to extrapolate the data, and the system was inadequate for intervening in outbreaks of diarrhoeal disease. Our knowledge of diarrhoeal diseases in south west France improved.     

Narrowing the health gap between a deprived and an endowed community

A 15 month campaign by a primary health care team in Stockton on Tees raised the uptake of preventive care of its patients in a severely deprived area to a level generally exceeding that of a more endowed neighbouring community. This was achieved by opportunistic attention after unrelated consultations, writing twice to each household with a list of its outstanding items necessary for preventive care, using health visitors to encourage attendance, and occasionally undertaking preventive care in patients'' homes. Extra clerical staff were needed to implement the new recording and monitoring procedures introduced.With rigorous monitoring and organisation general practitioners may improve the uptake of preventive health care by their more deprived patients.     

Patient and general practitioner delays in acute myocardial infarction

The longest component of the total delay in coming under coronary care is patient delay, and it has been suggested that public education might be used to make it shorter. The patterns of patient delay were studied in 450 patients with acute myocardial infarction uncomplicated by cardiac arrest out of hospital, of whom 243 had a previous history of ischaemic heart disease. Patient delays had a skewed distribution with a modal delay of up to one hour, a median delay of two hours, and a mean delay of 10 hours. Two thirds of patients had sought help from their general practitioners within four hours of the onset of symptoms. During the first four hours the longer that patients delayed the lower was the subsequent mortality (27%, 18%, and 9% for delays of one hour or less, up to two hours, and up to four hours, respectively), but patients who delayed four to eight hours had the highest mortality of all (38%). Neither the median value nor the pattern of patient delays was altered by a previous history of ischaemic heart disease.There were pronounced differences in doctor delays, depending on the patient''s age, delay time, and ultimate place of treatment, showing that the doctors'' behaviour was influenced before they had seen their patients. Nevertheless, the median total delay for patients aged up to 70 was one hour 35 minutes, and a higher proportion of patients were seen early after infarction than in recent hospital trials of thrombolytic treatment.These findings suggest that the patients'' call for help and the doctors'' response may be at an instinctive level according to the patients'' distress; these patterns of behaviour may be difficult to modify by public education.     

Comparative Study of District and Community Hospitals

Opinions conflict on whether there is a place in the Health Service for general practitioner (community) hospitals in which the patients'' treatment is mainly the responsibility of their family doctors. The authors therefore analysed a sample of the patients admitted in the course of a year to a group of two general district hospitals with a comparable sample of the patients admitted to a general practitioner hospital. The aim was to analyse the type of care provided in the general practitioner hospital, to assess whether it was appropriate for the type of cases treated, and to decide whether the patients would have been better off in the district general hospital (and vice versa). The main conclusions are that a district hospital is best for serious illnesses needing skilled decisions and assessments but that most of the work of these hospitals is not of this kind and a community hospital staffed by general practitioners offers many advantages to patients—provided the work being done is constantly under critical assessment. The authors plead for special refresher courses under the N.H.S. for general practitioners working in community hospitals.     

How can good general practitioner care be achieved?

It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government''s recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.     

Qualitative study of views of health professionals and patients on guided self management plans for asthma

ObjectivesTo explore the views held by general practitioners, practice nurses, and patients about the role of guided self management plans in asthma care.DesignQualitative study using nine focus groups that each met on two occasions.SettingSouth Wales.Subjects13 asthma nurses, 11 general practitioners (six with an interest in asthma), and 32 patients (13 adults compliant with treatment, 12 non-compliant adults, and seven teenagers).ResultsNeither health professionals nor patients were enthusiastic about guided self management plans, and, although for different reasons, almost all participants were ambivalent about their usefulness or relevance. Most professionals opposed their use. Few patients reported sustained use, and most felt that plans were largely irrelevant to them. The attitudes associated with these views reflect the gulf between the professionals'' concept of the “responsible asthma patient” and the patients'' view.ConclusionsAttempts to introduce self guided management plans in primary care are unlikely to be successful. A more patient centred, patient negotiated plan is needed for asthma care in the community.     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.