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.     

General practice postal surveys: a questionnaire too far?

A primary care led NHS, driven by evidence based practice, needs to build on a firm foundation of research in primary care. As researchers are making increasing use of questionnaire surveys to assess general practitioners'' views and attitudes, so response rates to questionnaire surveys among general practitioners are dropping. The reasons include lack of perceived relevance of the research and lack of information and feedback about it, and researchers need to be more aware of the realities of everyday practice. Approaches that might reverse this trend include monitoring all research activities going on in an area to ensure that practices are not overused, giving general practitioners incentives to participate, and improving the relevance of research and the quality of questionnaires.     

Use of traditional health practices by Southeast Asian refugees in a primary care clinic.

To determine the prevalence of use of traditional health practices among different ethnic groups of Southeast Asian refugees after their arrival in the United States, we conducted a convenience sample of 80 Cambodian, Lao, Mien, and ethnic Chinese patients (20 each) attending the University of Washington Refugee Clinic for a new or follow-up visit. Interpreters administered a questionnaire that dealt with demographics, medical complaints, traditional health practices, health beliefs, and attitudes toward Western practitioners. In all, 46 (58%) patients had used one or more traditional health practices, but the prevalence varied by ethnic group. Coining and massage were used by all groups except the Mien, whereas moxibustion and healing ceremonies were performed almost exclusively by the Mien. Traditional health practices were used for a variety of symptoms and, in 78% of reported uses, patients reported alleviation of symptoms. The use of traditional health practices is common among Southeast Asian refugees. Clinicians who care for this population should be aware of these practices because they may supersede treatments prescribed by physicians or leave cutaneous stigmata that may be confused with disease or physical abuse. Good patient care may necessitate the use or tolerance of both Western and traditional modalities in many Southeast Asian refugees.     

A total audit of preventive procedures in 45 practices caring for 430,000 patients.

OBJECTIVE--To develop and report the results of a system of audit of computer records in general practice. DESIGN--A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING--Forty five general practices, widely distributed in England and Wales. SUBJECTS--All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES--Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS--Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor''s desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors'' list sizes were associated with better performance. CONCLUSIONS--Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.     

Collecting morbidity data in general practice: the Somerset morbidity project.

OBJECTIVE--To collect a valid, complete, continuous, and representative database of morbidity presenting to primary care and to use the data to help commission services on the basis of local need and effectiveness. SETTING--Computerised general practices in Somerset. METHODS--Participating general practices were selected to be representative of the district health authority population for general practice and population characteristics. All conditions presented at face to face consultations were assigned a Read code and episode type and the data were regularly validated. Data were sent by modem from the practices via a third party to the health authority each week. MAIN OUTCOME MEASURES--Proportion of consultations coded and accuracy of coding. RESULTS--11 practices agreed to participate. Validations for completeness during April 1994 to March 1995 revealed that 96.4% of the records were coded; 94% of the 1090 records validated had appropriate episode types and 87% appropriate Read codes. The results have been used to help formulate the health authority''s purchasing plans and have enabled a change in the local contracts for surgery for glue ear. CONCLUSIONS--The project has shown the feasibility of establishing a network of practices recording and reporting the morbidity seen in primary care. Early indications are that the data can be useful in evidence based purchasing.     

Cervical smear abnormalities in the United Arab Emirates: a pilot study in the Arabian Gulf

OBJECTIVE: To gather epidemiologic data on cervical abnormalities and make recommendations pertaining to a national cervical screening policy in the United Arab Emirates (UAE). STUDY DESIGN: A cross-sectional survey of patients and physicians in the UAE with regard to cervical cytology was carried out. Knowledge, attitudes and practices (KAP) of a group of female primary care physicians on cervical cytology were assessed by a self-administered questionnaire. Pap smears and Chlamydia testing were offered to women attending selected primary care centers and secondary health care facilities. RESULTS: Results of Chlamydia prevalence and KAP were published elsewhere; this report addresses the cytologic aspects of this study. There were 2,013 smears collected from primary health centers and 2,042 from secondary care. The overall rate of cervical screening among women in this survey was 85.5% in primary care and 77% in secondary care. The proportion of unsatisfactory smears was < 5%. The prevalence of cervical abnormalities according to the Bethesda System 2001 was 3.6%. There were 9 (primary care) and 21 (secondary care) cases of low grade squamous intraepithelial lesion (LSILs), for a prevalence of 0.77%. There were 4 primary care and 17 secondary care cases of high grade squamous intraepithelial lesion (HSIL), for a prevalence of 0.54%. The combined prevalence for LSIL and HSIL is 1.32%. There were 3 cases of glandular abnormalities. The atypical squamous cells of undetermined significance/SIL ratio was 1.71. No cases of squamous cell carcinoma were detected. No tissue follow-up information is available. The prevalence of cervical abnormalities is low in the UAE. We first recommend the institution of a more organized approach to opportunistic screening in the UAE with appropriate clinical follow-up rather than the immediate launch of a cervical mass screening program.     

Prevention in practice: what Wessex general practitioners are doing.

A random sample of 214 general practitioners in the Wessex region was invited to complete a postal questionnaire about the practice of preventive medicine and 90% replied. This inquired into their attitude and behaviour towards smoking and accident prevention, promoting exercise, and controlling obesity and hypertension. The results were generally encouraging. Most recognised their key role in health promotion and health education and their shared responsibility with other professionals. Many had made progress in smoking prevention and control of obesity and hypertension. Promoting exercise and accident prevention left room for improvement. The availability of information in patients'' records to identify and monitor problem areas was particularly lacking. We conclude that further progress might be achieved by better training of general practitioners, and developing information systems orientated towards promoting health. The team approach in primary care needs to be strengthened. In particular extending the role of the health visitor and practice nurse may provide the support so vital for the successful outcome of preventive initiatives. Community unit management teams need to consider carefully how they may encourage advances in health promotion in primary care.     

Environmental issues in relation to agricultural practices and attitudes of farmers: A case study from Saudi Arabia

PurposeThe Kingdom of Saudi Arabia is continuously in search of environment-friendly farming practices since mass-scale agriculture was initiated. It is imperative to gauge to the level of awareness of the farmers on the agricultural practices causing environmental issue in order to devise new agricultural extension programs. This research aims to identify the attitudes of farmers towards agriculture and environment in Al-Ghat area of Saudi Arabia.MethodologyA simple random sample of 110 farms truly representing the farming community was drawn to meet the objectives of the study. Data were collected by using the pre-tested questionnaire during the face-to-face interviews. In order to understand the message of study, data were analyzed for percentages, arithmetic average and standard deviation in addition to the simple Pearson correlation coefficient.ResultsThe results showed that the high proportion (87.3%) of farmers was interested in continuing to work farm and 77.3% of farmers did not consider adopting agriculture their main occupation. The findings of the survey reveal that some 55.5% of the respondent farmers were aware of the agricultural practices and their relation to the environment. Some 57.3% of the surveyed farmers are aware of potential benefits of enhanced utilization of agricultural organic wastes. However, main profession, farm employment (as the independent variables) showed a significant positive correlation with the attitudes of farmers towards their working in agriculture (as a dependent variable). Also a significant negative relationship between the educational levels and the attitudes of the farmers towards working in agriculture was noticed. The study also indicated a significant correlation between education and the degree of awareness of agricultural practices related to the environment and maximizing the optimum utilization of agricultural waste i.e. organic residues.ConclusionsThe study suggested the need for new awareness and orientation programs to educate farmers and extension workers, highlighting the environment- friendly agricultural practices.Recommendation: There is need to offer incentives and facilities to keep the farmers stay in the farming business. Extension staff must keep educating them on beneficial features of organic farm waste and crop residues as organic fertilizers.     

Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders.

OBJECTIVES: To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally. DESIGN: Controlled trial, randomised by general practice. SETTING: Inner London borough of Newham. SUBJECTS: 2064 women aged 50-64 years who had failed to attend for breast screening. Women came from 26 of 37 eligible practices, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported. MAIN OUTCOME MEASURES: Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation. RESULTS: Attendance in the intervention group was significantly better than in the control group (9% v 4%). The response was best in Indian women--it was 19% in the intervention group and 5% in the control group. CONCLUSIONS: This simple, low cost intervention improved breast screening rates modestly. Improvement was greatest in Indian women--probably because many practice staff shared their cultural and linguistic background. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates.     

Proactieve en gestructureerde zorg voor kwetsbare oudere patiënten in de eerstelijn: Achtergrond, opzet en uitvoering van een screenings- en zorgprogramma

Background

Currently, primary care for the older, vulnerable patient is reactive, fragmented and does not meet patients needs. Given the expected increase of home-dwelling frail elderly people a transition is needed to proactive and integrated care.

Methods

In the described study, we explore two innovative interventions in primary care. First we describe a newly developed screening and monitoring program for frail elderly patients based on routine care information in general practice. Second, we describe a multidisciplinary intervention program by trained nurses for frail elderly patients in general practice. The effectiveness of the interventions is examined in a three-armed, cluster randomized trial, taking place in 58 primary care practices in Utrecht, the Bilt and Maarsenbroek.

Results

Three thousand eight patients are included. Primary outcome measure is the impact of the interventions on the daily activities, measured with the Katz questionnaire. Secondary outcomes measures are the quality of life, mortality, recording in a care or nursing home, visit to an emergency room or outpatient unit, recording in the hospital and volunteer caregivers tax.     

Behind the screens: care staff observations on delivery of oral health care in nursing homes

Objective: To identify qualitatively carer staff attitudes, practices and clinical comments related to oral health care of functionally dependent nursing home clients. Design: Open-ended questions included in a longer quantitative questionnaire. Setting: 22 randomly selected nursing homes in the Bristol area. Subjects: 416 carers employed in these homes. Results: The majority of carers thought that clients had a right to good oral health, accepted the carers' role in helping clients with oral and denture hygiene, but recognised that oral health care provision was deficient. However, some carers believed oral health care to be solely the clients' responsibility despite high disability levels. Main barriers to providing oral health care were low prioritisation of oral health by nursing management, lack of co-operation from cognitively impaired clients, and lack of training. Carers were critical of homes' lack of arrangements for routine professional dental cheeks, lack of commitment to staff training, low standards of oral health care by colleagues, and lack of provision of oral hygiene aids and cleansing materials for clients. Many responses indicated ways in which nursing home oral health care could be improved. Carers reported contrasting experiences of dental treatment, and deplored recent decreased availability of subsidised dental care. Conclusions: Carers' generally positive attitudes towards clients' oral health care should encourage health educators. Insights gained from qualitative data can help to identify the less obvious causes for poor oral care delivery, which can then be addressed in education and training initiatives in nursing home settings.     

Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score.

OBJECTIVES: To establish whether a questionnaire incorporating MacKie''s risk factor flow chart can identify patients at high risk for melanoma so that they can be targeted for primary and secondary prevention. To validate the risk score derived from the questionnaire and test the feasibility of self completion by comparing patients'' self reported skin characteristics with a skin examination performed by an experienced general practitioner. DESIGN: Prospective questionnaire survey followed by a comparative study. SETTING: 16 randomly selected group practices in a health district in Cheshire, United Kingdom. SUBJECTS: Questionnaire survey--3105 consecutive patients aged 16 years and over attending for a primary care consultation; comparative study--a self selected subsample of 388 of the 3,105 patients. MAIN OUTCOME MEASURES: MacKie risk group for melanoma. Comparison of high risk skin characteristics reported by patients and those noted during a skin examination by a doctor (kappa statistic). RESULTS: 4.3% of patients (87% women) were in the highest risk group and 4.4% (79% men) were in the second highest risk group, as defined by the MacKie score. Agreement between patients'' self appraisal of skin characteristics and clinical skin examinations was reflected in kappa values of 0.67 for freckles, 0.60 for moles, and 0.43 for atypical naevi. CONCLUSION: This questionnaire helped to identify a group at high risk for melanoma. Furthermore, good agreement was found when the patient''s risk scores were compared with results of the clinical skin examination. This risk score is potentially useful in targeting primary and secondary prevention of melanoma through general practice.     

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.     

White ethnicity in twenty-first-century America: findings from a new national survey

The 1980s and early 1990s witnessed a great deal of research on white ethnicity. Yet since this time, few systematic empirical studies of white ethnicity have emerged. This paper uses data from a recent nationally representative survey of Americans to (re)assess white ethnicity in the twenty-first century. Three primary areas are explored: (1) the pervasiveness and salience of ethnic claims among white Americans; (2) the social and demographic characteristics of self-identified white ethnics; and (3) the impact of white ethnic identity on political opinions and racial attitudes. We find that a smaller but significant number of white Americans claim ethnicity today and that distinguishing social characteristics of white ethnics still remain. Contrary to current prevailing theoretical formulations, however, these markers of distinction do not appear to be related to political or racial attitudes in any systematic way.     

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.     

Would primary health care workers give appropriate dietary advice after cholesterol screening?

The purpose of this study was to obtain information on the dietary knowledge of primary health care workers and on their ability to apply this knowledge in practice. A total of 128 primary health care workers (53 general practitioners and 61 nurses) in 12 practices and 14 primary care facilitators were surveyed by questionnaire between December 1987 and June 1988. All of the practices were participating in a project to promote prevention in primary care and offered health checks designed to identify and deal with cardiovascular risk factors. The questionnaire focused on issues related to managing patients with moderate hypercholesterolaemia. The results of the study showed some important gaps in the health workers'' knowledge--for example, only 91 understood that dietary intake of polyunsaturated fatty acids as a proportion of total fat intake should be increased in a diet designed to reduce serum lipid concentrations. Appreciable gaps in their ability to give practical and appropriate dietary advice were also identified: 35 gave advice that would have led to the patient losing weight (although his history indicated that he was not overweight), and 27 gave only negative advice, offering no suggestions about substituting healthy foods for unhealthy ones. The demand for primary health care workers to give dietary advice is increasing and is likely to increase further if a national screening programme for hypercholesterolaemia is recommended. The results of this survey point to a need for improved nutritional education and training in dietary counselling for general practitioners, nurses, and primary care facilitators.     

General practitioners in partnership with management: an organisational model for debate.

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community.     

Do attitudes expressed in surveys predict ethnic discrimination?

Survey data on people’s reported attitudes towards ethnic minorities are sometimes used as a proxy for ethnic discrimination. However, there is weak empirical evidence of a link between reported attitudes and discrimination. In this article, we use survey data on people’s attitudes towards ethnic minorities combined with a direct measure of ethnic discrimination from a field experiment in the Swedish housing market to re-examine this policy-relevant issue. We find clear evidence of a link between reported attitudes towards ethnic minorities and the extent of ethnic discrimination: in regions where attitudes are more negative, there is more discrimination, and vice versa. Thus, in contrast to most prior studies, our results suggest that reported attitudes may be a useful predictor of ethnic discrimination.