Previous consultation and self reported health status as predictors of future demand for primary care

STUDY OBJECTIVE: There has been little prospective investigation of what predicts general practice consultation. The objective of this study was to investigate the extent to which previous primary care consultation and self reported health status are predictors of future primary care consultation. DESIGN: Population based cohort study in two phases. Firstly, a baseline survey (1995/96) to identify the cohort and to obtain self reported health status using the UK census limiting long term illness (LLI) question and the Short Form-36 (SF-36) health profile. Secondly, analysis of general practice medical records for two years (1994/1995) before the survey and for two years (1997/1998) after the survey. Analysis was performed on: (a) all contacts coded by the GP, (b) the subgroup of contacts given a diagnostic morbidity code by the GP. SETTING: One general practice in North Staffordshire, UK. PARTICIPANTS: 738 survey respondents who had consented to viewing of medical records including all those who reported LLI together with an age-gender matched control group of those who reported no LLI. MAIN RESULTS: High frequency consulters in 1994/95 were more likely than non-consulters or average consulters in that year to be high consulters in 1997/98 (odds ratio 5.6, 95% confidence interval 3.82 to 8.25, for all contacts; 4.4 for diagnostic coded consultations). Self reported role disability and physical limitation from the SF-36 at baseline increased the probability of being a future high consulter but the effects were weaker than for previous consultation. Previous consultation within a diagnostic group was the main predictor for future consultation within that group with weaker but significant prediction by self reported health status. CONCLUSIONS: Reliable morbidity coding in general practice provides the best available basis for predicting future demand in primary care. Self reported health status survey instruments add to this information but on their own are weaker predictors of future consultation.     

Prenatal care in the first trimester: misleading findings from HEDIS. Health Plan Employer Data and Information Set.

OBJECTIVE: To understand factors influencing Health Plan Employer Data and Information Set (HEDIS) rates for the measure 'Prenatal care in the first trimester'. DESIGN: Telephone survey of a retrospective cohort of women with a live birth. Medical record review of a sample of both responders and non-responders to the telephone survey. Detailed review of HEDIS data collection procedures. SETTING: A managed care plan in California. STUDY PARTICIPANTS: Women aged 18-49 years at date of delivery, who delivered a live birth from 1 October 1995 through 31 March 1996, and who were continuously enrolled in a California managed care plan for 12 months prior to delivery (telephone survey, n= 1,185; medical record review, n= 465). RESULTS: Of the women participating in the telephone survey, 95% indicated that their first prenatal visit occurred during the first 3 months of pregnancy. Using HEDIS 3.0 standards, a review of medical records for a sample of these women indicated that 94% of the women initiated care during the first trimester. These results contrasted sharply with 1995 and 1996 HEDIS rates of 64% and 75%, respectively. CONCLUSION: An investigation of the discrepancy between HEDIS rates and rates from both telephone survey and medical record review led to the finding that the low HEDIS rates were due not to a true low rate of early care, but to data collection problems, including difficulty obtaining medical records. Potential solutions involving health plan activities, revisions to the official HEDIS process and revised reporting of results are proposed.     

Patterns of consent in epidemiologic research: evidence from over 25,000 responders

Ethical guidelines in the United Kingdom require written consent from participants in epidemiologic studies for follow-up or review of medical records. This may cause bias in samples used for follow-up or medical record review. The authors analyzed data from seven general population surveys conducted in the United Kingdom (1996-2002), to which over 25,000 people responded. Associations of age, gender, and symptom under investigation with consent to follow-up and consent to review of medical records were examined. Consent to follow-up was approximately 75-95% among survey responders under age 50 years but fell among older people, particularly females. Consent to follow-up was also higher among responders who had the symptom under investigation (pooled odds ratio = 1.61, 95% confidence interval: 1.36, 1.92). Consent to review of medical records followed a similar pattern. Patterns of consent were relatively consistent and represented a high proportion of responders. Males, younger people, and subjects reporting the symptom under investigation were more likely to give consent, and these groups may be overrepresented in follow-up samples or reviews of medical records. Although consent is high among responders, the additive effect of nonresponse and nonconsent can substantially reduce sample size and should be taken into account in epidemiologic study planning.     

Comparing claims data and self-reported data with the medical record for Pap smear rates

The objective of this study was to assess and compare the relative accuracy of claims data and patient self-reported information with medical records for Pap smear rates. A retrospective analysis of information obtained from administrative claims files, patient medical records, and a telephone survey was performed of 400 women age 19 through 75 years who were randomly selected for participation in the study. The data were obtained from a large multispecialty group practice in Minneapolis, Minnesota for the study years 1991 through 1993. Information from administrative claims regarding Pap smear status corresponded highly with information in the medical record (sensitivity 95% or higher; specificity 95% or higher; kappa 0.896 or better). Self-reported information from the telephone survey did not correspond well with medical record information nor with results in administrative claims.     

Demographic characteristics and health behaviours of consenters to medical examination. Results from the Welsh Heart Health Survey.

STUDY OBJECTIVE--The aim was to compare the demographic characteristics and health related behaviours of people who consented to a medical examination as part of a population survey with those who did not. STUDY DESIGN--The study formed part of the (1985) Welsh Heart Health Survey, which comprised a three stage design involving household interview, self completion questionnaire, and medical examination. Subjects for medical examination were selected from responders to the questionnaire survey (67%). Sixty six per cent of this group consented to medical examination (n = 11,637). Odds ratio analysis techniques were used to compare consenters and non-consenters. MEASUREMENTS AND MAIN RESULTS--The analysis was based on self reported information available from previously completed questionnaires, and from personal interviews. The study supported the findings of previous research indicating that consenters to medical examination are more likely to be from non-manual social groups, to be aged 25-44 years, to be educated beyond school age, and to be married. Individuals with healthy lifestyle characteristics (diet, physical activity) were overrepresented among consenters. The only exception to this finding was in relation to excessive alcohol consumption. CONCLUSIONS--These findings emphasise the importance of maximising response rates in all forms of social research including surveys with a clinical component. They also have methodological and analytical implications for the Welsh Heart Health Survey.     

Frequent attenders in general practice: an attempt to reduce attendance

BACKGROUND: 'Frequent attenders' in general practice are known to include patients with a variety of problems. Most studies of frequent attenders have not assessed the impact of providing GPs with detailed summaries of the clinical records of these patients on consultation rates. Good medical records are associated with good care. If it is not relatively easy or quick for GPs to ascertain which chronic illness or psychosocial problems the patient has from the records, it will be difficult to manage the patient proactively. OBJECTIVE: The aim of this study was to investigate the impact on the consultation rate of providing a detailed and accessible summary of patients' problems including physical, social and psychological data based on information already recorded in the patients' records. METHOD: A prospective controlled study was made of frequent attenders at one UK general practice comprising four full-time GPs. A total of 104 frequent attenders were identified by examining the lists of patients attending the surgery and by including the names of patients identified by GPs from memory. The final study groups were patients who consulted a GP 11 times or more in a year. The sample was divided into two groups. In both groups, the clinical notes were summarized for data relating to physical, social and psychological problems. In the intervention group, summaries were displayed prominently in the notes which were marked with a distinctive label. GPs were asked to read and initial the available summaries in these notes. In the control group, summaries were not included in the notes and the notes were not highlighted in any way. The consultation rate of these 104 patients was recorded for 5 months after the availability of the summaries in the notes. RESULTS: Summarizing the notes in the style described in this study failed to reduce the consultation rate of the identified frequent attenders (Kruskal-Wallis H = 2.75, P = 0.1) Furthermore, in the intervention group, patients for whom there was evidence that the summaries had been consulted by their GP (24; 46%) continued to attend as frequently as those whose summaries were not endorsed as consulted (mean attendance 4.8 consultations compared with 4.2 in 5 months). CONCLUSION: Frequent attenders often have multiple problems, but prominently displayed summaries of their history for use by GPs during consultations do not reduce the frequency of consultations.     

Students conducting consultations in general practice and the acceptability to patients

OBJECTIVES: The General Medical Council has recommended that medical students should gain more experience in general practice. The study set out to determine patients' reactions to consultations conducted by a medical student alone prior to seeing their GP. DESIGN: A random sample of patients attending general practice surgeries in the Oxford area completed a questionnaire following consultation with a medical student. SETTING: Six general practice teaching surgeries. SUBJECTS: Fifth-year medical students. RESULTS: Of 130 responders 98% experienced no disadvantage in seeing the student; 35% considered that there were advantages in seeing the student; 98% said that they would be prepared to consult with a student again; 85% expressed no concerns about the gender of the student. CONCLUSIONS: The results of this study are very reassuring concerning the acceptability to patients of consulting with medical students and are more favourable than those reported for studies of students being present in consultations by GPs.     

Learning to consult with computers

OBJECTIVE: To develop and evaluate a strategy to teach skills and issues associated with computers in the consultation. INTERVENTION: An overview lecture plus a workshop before and a workshop after practice placements, during the 10-week general practice (GP) term in the 5th year of the University of Melbourne medical course. DESIGN: Pre- and post-intervention study using a mix of qualitative and quantitative methods within a strategic evaluation framework. OUTCOME MEASURES: Self-reported attitudes and skills with clinical applications before, during and after the intervention. RESULTS: Most students had significant general computer experience but little in the medical area. They found the workshops relevant, interesting and easy to follow. The role-play approach facilitated students' learning of relevant communication and consulting skills and an appreciation of issues associated with using the information technology tools in simulated clinical situations to augment and complement their consulting skills. The workshops and exposure to GP systems were associated with an increase in the use of clinical software, more realistic expectations of existing clinical and medical record software and an understanding of the barriers to the use of computers in the consultation. CONCLUSIONS: The educational intervention assisted students to develop and express an understanding of the importance of consulting and communication skills in teaching and learning about medical informatics tools, hardware and software design, workplace issues and the impact of clinical computer systems on the consultation and patient care.     

Birth defects among children born to a population occupationally exposed to pesticides in Colombia

A case-referent study of birth defects was nested in a prevalence survey of adverse reproductive outcomes carried out among 8867 floriculture workers in Bogotá, Colombia. A total of 535 children born to these workers and reported by their parents as malformed and 1070 children selected at random as referents were invited to a medical examination including consultation with a geneticist and a clinical teratologist and a review of the medical records. Seventy-six percent of both groups attended the examination. Of 403 children reported as malformed, a birth defect was confirmed for only 154 (38%). On the other hand, of the 817 children reported as normal, 735 (90%) were normal, but 68 had a birth defect and 14 had other conditions. A case-referent analysis was then carried out including 222 children with birth defects and 443 referents. An increased risk was found only for birthmarks, and specifically for hemangiomas, for children with parents exposed to pesticides in the floriculture industry.     

Response Bias in a Study of General Practice

Cockburn J, Campbell E, Gordon J J and Sanson-Fisher R W. Responsebias in a study of general practice. Family Practice 1988, 5:18–23 Response bias in quality of care research is an important, butlargely neglected concern. Differences between health care professionalswho consent to participate in research and those who do notmay distort the conclusions and prevent the results being generalizable.This is particularly likely when response rates are low, asthey often are in studies evaluating primary health care. Thepresent study outlines a method for examining this importantarea. Fifty-six general practitioners who consented to participatein an observational study of general practice were comparedwith 52 doctors who declined to participate in the research.Comparisons were made of general characteristics including age,sex, practice size and postgraduate qualifications, as wellas attitudes toward their role. This last analysis was deemedparticularly important, as the attitudes expressed may haveaffected the behaviour of the doctor in the consultation, andtherefore outcomes such as accurate diagnosis, compliance andsatisfaction. Such outcomes are often the object of study inquality of care research. The only significant difference toemerge in the present study was that non-consenters were morestrongly in favour of a medical system based on free enterpriseand fee for service (t₈₃=2.3p<0.05). No systematic differenceswere found on other general characteristics or attitudes relatingto patient care. Response bias using the stated variables wastherefore considered to be minimal. The results are discussedin terms of strategies aimed at increasing response rates inquality of care research.     

农村流入人口医疗卫生服务利用现状及影响因素分析

目的 通过分析农村流入人口医疗卫生服务利用的现状,探究影响其医疗卫生服务利用的因素,为改进农村流动人口医疗卫生服务提出建议。 方法 筛选2017年全国流动人口卫生计生动态监测调查数据中流入农村的流动人口39 578例,分析农村流入人口医疗卫生服务利用的现状,并利用多因素logistic回归分析影响农村流入人口医疗卫生服务利用的因素。 结果 18 922例最近一年有患病或身体不适的流入农村人口中,10 705例曾就诊,就诊率为56.6%;首诊机构为本地社区卫生站和本地个体诊所的分别占24.5%和18.8%;听说过国家基本公共卫生服务项目（OR = 1.127,95%CI:1.055～1.204）、已建立健康档案（OR = 1.240,95%CI:1.148～1.340）、接受过健康教育（OR = 1.224,95%CI:1.146～1.308）、有医保（OR = 1.128,95%CI:1.003～1.268）的农村流入人口医疗卫生服务利用率高;而有工作的（OR = 0.803,95%CI:0.733～0.880）、随家属迁移的（OR = 0.851,95%CI:0.729～0.994）、自评健康状况健康（OR = 0.514,95%CI:0.444～0.595）的农村流入人口卫生服务利用率较低。 结论 流入农村人口医疗卫生服务利用情况较差;患病后首诊机构多为本地社区卫生站和本地个体诊所;流动原因、就业状况、自评健康状况、健康档案建立情况、健康教育接受情况、是否听说过国家基本公共卫生服务项目以及是否有医保均会影响农村流入人口利用医疗卫生服务。     

Is frequent attendance in primary care disease-specific?

BACKGROUND: Sociodemographic characteristics of frequent attenders in general practice are known. It is not known whether frequent attendance is linked to specific diseases. OBJECTIVE: To investigate whether frequent consultation in primary care is related to specific morbidities and whether this relationship is influenced by the general practice which the patient attends. DESIGN: One-year survey of consultation data. SETTING: Nine general practices in North Staffordshire, UK. PARTICIPANTS: 1000 adults aged 18 years and over who had consulted primary care at least once during the study year were randomly selected from each practice and grouped into frequent (high and very high), medium and low frequency consulters. MAIN OUTCOME MEASURES: Type of morbidity coded at each consultation and number of repeat consultations for each morbidity (based on Read Code Chapters). RESULTS: All morbidity Chapters were associated with frequent consultation. Frequent consultation was also associated with repeated consultation within most morbidities. Stronger associations were seen with mental disorders, blood disorders, circulatory disorders, digestive disorders, endocrine diseases and with causes of injury and poisoning. Some variation between practices in the morbidities associated with frequent consultation were apparent; particularly for skin diseases and unspecified conditions. CONCLUSIONS: Frequent consulters in primary care are not restricted to particular groups of morbidities. There is some aspect of frequent consultation that is a characteristic of individuals regardless of the symptoms with which they consult. Some morbidities are more prominent than others in this group of consulters, and this may help guide practice policies and future research into frequent consulters.     

Observing decision‐making in the general practice consultation: who makes which decisions?

OBJECTIVE: To investigate opportunities for, and types of decision making in the general practice (primary care) consultation, and examine differences in skills of those doctors who are successful at meeting their patients' preferences and those who are less successful. DESIGN: Observation study of doctor-patient consultations in general practice. PARTICIPANTS: Patients attending for routine appointments in 12 general practice surgeries across Oxfordshire. METHODS: A total of 212 doctor-patient consultations were video-recorded. The patients involved completed a questionnaire to elicit their perceptions of how decisions were made. The video-taped recordings were coded with a new instrument, the Evidence Based Patient Choice Instrument (EBPCI), to classify the number and type of decision-making opportunities arising during each consultation. A total of 149 recordings were coded using the Oxbridge Rating Scale to assess the doctors' consultation styles. RESULTS: There was a range of decision-making opportunities in addition to those involving medical treatment. With the exception of 'fitness for work', decisions were generally 'doctor led'. There was only moderate agreement between patient perceptions of their level of involvement in decision making and the objective ratings using the EBPCI. There was wide variation in the ability of doctors to meet their patients' preferences for involvement. CONCLUSIONS: There are many decisions made in primary care consultations, in addition to those about medical treatments, in which patients could be involved to a greater extent than they currently are. Some doctors are significantly better than others at meeting different patients' preferences for their decision-making role. Patients' perceptions of shared decision making appears to be influenced by the doctors' general consultation skills.     

Optimal strategies for identifying patients with myocardial infarction in general practice

BACKGROUND: In order to provide evidence-based secondary prevention of coronary heart disease (CHD) in general practice, eligible patients need to be identified. The optimal strategy is one in which all appropriate patients are identified with the least effort. OBJECTIVE: The purpose of the study was to determine the optimal strategy to identify subjects with a myocardial infarction (MI) from general practice records using different search criteria. METHODS: The study was a cross-sectional survey of 10 general practices in Tayside, Scotland. A random sample of all subjects aged over 35 (n = 5061) and registered with the general practices was obtained. The main outcome measures were sensitivity, specificity, positive predictive value (PPV) and yield (the number of records that need to be examined to detect a "true case"). RESULTS: Of the sample of 5061, 207 (4.1%) were defined to have had a "gold standard" MI. A Read code for ischaemic heart disease (IHD) had the highest sensitivity (95%) but with a poor PPV (52%). All searches had high specificities. The addition of a record of hospitalization for MI to the Read code for MI gave 100% sensitivity and high yield (1 in 1.11). In situations where the Read coding is of poor quality, the alternative search strategy of a hospital record of MI or receiving aspirin or nitrates was optimum. CONCLUSIONS: Patients who had experienced an MI can be easily identified from a combination of a Read code for MI and a record of hospitalization for an MI giving 100% sensitivity and specificity with a yield of 1 in 1.11.     

Evaluation of a mobile branch surgery in a rural area.

Access to the family doctor at his or her surgery is a problem for many people living in rural Britain. The service provided by a caravan used as a general practice mobile branch surgery in a rural part of Norfolk was evaluated using a survey of residents and examination of practice records. In a village where the mobile surgery replaced a conventional branch surgery, consultation rates increased slightly during the first year of operation. In a village where the mobile surgery was a new facility, consultation rates increased substantially in the first year. Replies from residents indicated that although the limitations of the mobile surgery were recognised, the service reduced the problems of physical access in remote villages to the level of those in the village where the main surgery is situated.     

Effect of medical students' ethnicity on their attitudes towards consultation skills and final year examination performance

AIM: The study had two aims. The first aim was to examine the relationship between final year medical students' ethnicity and their attitudes towards consultation skills. The second aim was to investigate the relationship between ethnicity and final year performance. METHOD: A cross-sectional study was undertaken of all final year medical students in 1995 and 1996, both before and after their attachment through the Department of General Practice at Monash University, Australia. A questionnaire was designed to assess students' attitudes (views of importance and confidence) towards consultation skills. Also, records of final year performance were obtained from the University. RESULTS: Five clusters of consultation skills were formed through factor analysis: communication skills, difficult consultations, traditional diagnostic methods, routine management and life threatening conditions. There were no significant differences in students' attitudes towards these consultation skills based on country of birth, language, or student status preattachment. The only significant postattachment difference was that students born in non-Western countries placed a significantly higher importance on communication skills and the traditional diagnostic method than students born in Western countries. There were significant differences in final year performance between students across all three parameters of ethnic diversity. Non-Western born students performed worse than Western born students. Students who preferred using a language other than English also performed worse than those students preferring English. International students performed worse than students with Australian citizenship or permanent residency., CONCLUSIONS: The only significant difference regarding attitudes to consultation skills was that non-Western born students placed significantly greater importance on communication skills and the traditional diagnostic method postattachment than Western born students. No significant differences were found in attitudes preattachment. There were significant differences in performance, with students of ethnic background performing consistently poorer in all the final year assessment parameters analysed.     

Promoting physicians' self-assessment and quality improvement: the ABIM diabetes practice improvement module

INTRODUCTION: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self-assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice-based learning and improvement and systems-based practice. METHODS: Sixteen practicing general internists and endocrinologists with 10-year time-limited certification participated in a beta test of the ABIM's diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self-directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on-site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self-audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. RESULTS: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow-up interview, 10 stated that the quality improvement education specialist helped improve their practice. DISCUSSION: Self-assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.     

Are self-reported dates of mammograms accurate?

BACKGROUND: This paper assesses the accuracy of self-reported dates of last mammograms from a postal survey compared to dates of mammograms in medical records. METHODS: The subjects included women 50 years of age and older who were members of a local health maintenance organization, had reported ever having a mammogram, and had completed a postal questionnaire about breast cancer screening. The date of last mammogram from the postal surveys was compared to the date in medical records. RESULTS: Of 78 women who self-reported both the month and year of last mammogram in a postal survey, agreement within 1 month with the medical record data was 62.8% and agreement within 3 months was 75.6%. A total of 32.1% of the subjects underestimated the time since their last mammogram, while only 5.1% overestimated. Based on self-reported dates, 85.9% of the subjects had a mammogram within the last year compared to 76.9% based on medical records. Using medical records as the "gold standard", the sensitivity of self-reported mammogram within the last year versus more than 1 year ago was 98% and the specificity was 56%.