Deprivation and systematic stroke prevention in general practice: an audit among general practitioners in the Rotterdam region, The Netherlands

BACKGROUND: To investigate differences in quality of preventive care provided by general practitioners (GPs) to patients at risk of stroke living in deprived and non-deprived neighbourhoods in the Rotterdam region. METHODS: A 'deprivation score' was used to categorize neighbourhoods according to their deprivation status. Data on the process of patient care were collected by means of chart review and interviews with GPs. Cases of stroke (n=188) were retrospectively audited by an expert panel with guideline-based review criteria. To measure differences in quality of patient care between neighbourhoods, deprivation scores were related to scores for sub-optimal care. RESULTS: After adjustment for socio-demographic characteristics, patients in deprived neighbourhoods had an increased risk (OR 1.95 (95% CI: 0.98-3.90)) of having received sub-optimal preventive care if compared with patients in non-deprived neighbourhoods. This excess risk was limited to women (OR 3.57 (95% CI: 1.39-9.16) vs OR 1.01 (95% CI: 0.41-2.48) in men). Adjustment for socio-demographic characteristics and risk factor distribution did not change the OR for women to receive sub-optimal care significantly (OR 3.21 (95% CI: 1.24-8.31)). Sub-optimal care originated mainly from deficiencies in follow-up of treated hypertensive and diabetes patients and evaluation of patients' cardiovascular risk profile. Among treated hypertensive women in deprived neighbourhoods who received sub-optimal care, the mean number of deficiencies related to follow-up was almost double that of the corresponding group in non-deprived neighbourhoods. CONCLUSION: Quality of care to prevent stroke in general practice differs considerably between deprived and non-deprived neighbourhoods. Patients in deprived neighbourhoods, and women in particular, have almost twice the risk of receiving sub-optimal preventive care.     

Perceptions of communication between people with communication disability and general practice staff

OBJECTIVE: To explore consultation between people with communication disability and General Practice (GP) staff from the perspectives of both patients and staff. BACKGROUND: Communication disability causes a particular problem in primary care. This issue has not yet been investigated from the perspective of both patients and GP staff. DESIGN: Eight focus groups were held - four with GP practices, two with people with intellectual disability and two with people who had had a stroke. Picture symbols and Talking Mats, a visual communication framework, were used to assist the participants with communication disability. Discussions were audio recorded and analysed thematically. PARTICIPANTS: Twenty GP staff, 12 people with aphasia and six people with learning disability were interviewed.RESULTS: GP staff expressed frustration with not being understood and not understanding but there was a lack of awareness of the reasons behind these difficulties. They all said they mainly relied on carers. They recognized the significance of poor communication in terms of access to health services and agreed that the extent of the problem was greater than they had previously believed. People with communication disability described significant problems before, during and after the consultation. Although some acknowledged that they needed help from their carer, most objected to staff speaking to the carer and not to them. CONCLUSIONS: The main priorities for GP staff were the need for relevant training and simple resources. The main priorities for people with communication difficulty were continuity of staff, trust, better GP staff communication skills, and less reliance on carers.     

Health promotion in general practice: On meanings and aims in interaction

The enterprise of health promotion in medicine involves a responsibilityof distinguishing between the concepts of health and absenceof disease and of reflecting on the notions of illness and sickness.In this paper the importance of human dialogue is stressed bothas a means and end of the doctor-patient relationship and asthe main means of genuine health promotion. The outcome of healthwork is proposed to depend mainly on the way the patients areencountered. Their efforts to make themselves seen as beingsick should not on all occasions be diagnosed and treated. Bymeans of a reflected, dialogic practice patients may be listenedto and inspired to reconstruct their symbol-based relationshipto the world of meaning. The conception of health primarilyincludes man's relationship to himself. Illness is looked uponas the subject's experience of illhealth, whereas disease isunderstood as a functional imbalance of bodily organs. Thereis a tacit meaning in being ill (and found sick) that can berealized and attended to best in close relationship with thepatient. Physicians – preferably general practitioners– involved in health promotion should, it is concluded,both assist the patients to give up their sick role and continuallyelaborate their own professional competence to see and successfullyencounter the manifold specifically human issues underlyingtheir patients' presented symptoms.     

Communication in general practice: differences between European countries

BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.     

Patient participation groups in general practice in the National Health Service

General practice remains the organizational hub of first level health services in the United Kingdom. Patient participation groups are probably the most well known model for public participation in this setting and, although still not widespread, they have been a slowly expanding area of development for almost three decades. This paper sets out to critically asses patient participation groups in general practice by considering the context of their development and reviewing the research literature about groups. Critical issues needing more study and key methodological challenges are then discussed.
Patient participation groups have been a somewhat shifting and contested phenomenon, embracing trends and changing as policy priorities have changed over the years. There is some evidence to think that they might have potential as a local element within a public participation strategy in the National Health Service. However, the field studies are very limited and more research of a better quality is needed. The state of knowledge is not adequate to be able to say with any confidence if or how such groups should be developed. A better understanding is needed of the public's perspectives on this and other models of participation. There are many other questions to do with patient participation groups' purpose, equitable access, and effectiveness that need to be addressed. The methodological challenges include issues of how to involve all stakeholders in the research process; and how to study less tangible aspects of general practice organization, such as culture and power, that effect the public's participation.     

Rethinking the doctor-patient relationship in general practice

The doctor-patient relationship in general practice can best be characterized by its use. Perceptions of it will vary depending on the context within which it is situated, and on the perspective of the observer. The context of British general practice has changed over the past three decades, particularly with the development of large primary care teams and expansion in the content of consultations. From the perspective of general practitioners, this may be resulting in a shift of emphasis from “the relationship” to “consultation techniques”; however, they retain an essentially utilitarian view of the relationship as a means of enabling effective diagnosis and management. Patients appear to have fewer expectations of the relationship than doctors, and there may not be congruence in the aspects of the encounter that each finds satisfying. Sociologists tend to see the doctor-patient relationship as an ideological construct whereby general practitioners gain a sense of professional identity, and as a means of exercising and maintaining medical power. Health economists suggest it may prove to be an efficient means of rationing scarce health care resources.     

Acquisition of communication skills in postgraduate training for general practice

PURPOSE: The evidence suggests that a longitudinal training of communication skills embedded in a rich clinical context is most effective. In this study we evaluated the acquisition of communication skills under such conditions. METHODS: In a longitudinal design the communication skills of a randomly selected sample of 25 trainees of a three-year postgraduate training programme for general practice were assessed at the start and at the end of training. Eight videotaped real life consultations were rated per measurement and per trainee, using the MAAS-Global scoring list. The results were compared with each other and with those of a reference group of 94 experienced GPs. RESULTS: The mean score of the MAAS-Global was slightly increased at the end of training (2.4) compared with the start (2.2). No significant difference was found between the final results of the trainees and the reference group. According to the criteria of the rating scale the performance of both trainees and GPs was unsatisfactory. CONCLUSION: The results of this study indicate that communication skills do not improve in a three-year postgraduate training comprising both a rich clinical context and a longitudinal training of communication skills, and that an unsatisfactory level still exists at the end of training. Moreover, GPs do not acquire communication skills during independent practice as they perform comparably to the trainees. Further research into the measurement of communication skills, the teaching procedures, the role of the GP-trainer as a model and the influence of rotations through hospitals and the like, is required.     

Changing perceptions of general practitioner care

One of the major aims of the recent UK government inspired changesin general practice based primary care was to enhance the qualityof care provided for consumers. The aim of the study reportedhere was to see if these changes, specifically the implementationof the GP contract in 1990, has led to an improvement in thequality of general practitioner care, at least from the consumerspoint of view. Thus, a follow-up study was conducted to investigatewhether changes had occurred in the attitudes of consumers towardsprimary care between 1988 and 1991. Baseline data was collectedin 1988 from a random sample of adults in one health districtin South East England, with the second study being carried outin the same area in September 1991. The results indicate thatsome changes in consumer satisfaction have taken place. In thearea of access, for example, satisfaction increased with waitingtimes in the doctors' surgery (an important source of dissatisfactionin the 1988 study) and an improvement has also taken place withrespect to the time taken to get an appointment for the treatmentof an urgent condition. Similarly with regard to the doctor-patientrelationship, satisfaction with the time available in the consultationand the amount of information given has significantly improved.However, the proportion of respondents who felt they could notdiscuss their personal problems with their GP remains fairlyhigh (well over one-third) representing little change from 1988.Similarly, overall satisfaction with the GP remains high. Explanationsfor these changes are discussed.     

Ending the doctor-patient relationship in general practice: a proposed model

BACKGROUND: The doctor-patient relationship in general practice is often viewed by practitioner and patient alike as a long-term 'personal' relationship. Little, however, is known about how such relationships are ended in general practice. METHODS: This paper uses theoretical insights obtained from the sociology and social psychology of social relationships, together with the authors' own empirical work on the removal of patients from GPs' lists, to develop a theoretical model of ending the doctor-patient relationship in general practice. RESULTS: Ending the relationship involves 'breakdown' and 'termination'. 'Breakdown' in the relationship occurs when one party decides that the other has acted in such a way as to threaten that party's identity as a 'good' patient or doctor. 'Termination' may be patient initiated, doctor initiated or by mutual consent. CONCLUSIONS: It is proposed that further research is needed to delineate the rules and rituals governing entry into and maintenance of the doctor-patient relationship in general practice as well as those that govern its ending.     

Acute maxillary sinusitis in general practice: The relation between clinical picture and objective findings

Objective: The value of symptoms and clinical findings for the diagnosis of acute maxillary sinusitis in general practice is unclear. We investigated the relation between clinical picture and objective findings.

Methods: For 113 adult patients suspected by their general practitioner (GP) of having maxillary sinusitis, history and clinical examination data were related to roentgenograms, echograms and punctate results.

Results: History and examination data of the GPs showed a similar pattern for patients with and without positive punctate results. Even 22 patients with fluid and pathogenic bacteria in the sinus could not clearly be distinguished clinically. The probability of fluid in the sinus ranges from very low for X-ray results without demonstrable abnormalities, to about 60% in case of X-rays showing fluid levels.

Conclusion: Our findings demonstrate that the group of patients suspected of having maxillary sinusitis cannot be further subdivided on the basis of history and examination. Since acute rhinitis and acute sinusitis appear to be manifestations of the same clinical entity, for these patients the diagnosis acute rhinosinusitis is preferable. The patients can be roughly classified on the basis of the X-ray as to the presence of fluid and pathogenic bacteria in the sinus. The question is now whether such diagnostic classification is relevant with a view to treatment.     

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.     

Monitoring health inequalities through general practice: the Second Dutch National Survey of General Practice

BACKGROUND: For the second time a plan to monitor public health and health inequalities in the Netherlands through general practice was put into action: the Second National Survey of General Practice (DNSGP-2, 2001). The first aim of this paper is to describe the general design of DNSGP-2. Secondly, to describe self assessed health inequalities in the Netherlands. Thirdly, to present differences in prevalence of chronic conditions by educational attainment using both self-assessed health and medical records of GPs. Finally, inequalities in 1987 (DNSGP-1) and 2001 will be compared. METHODS: Data were collected from 96 (1987) and 104 (2001) general practices. The data include background information on patients collected via a census, approximately 12,000 health interview surveys per time point and more than one million recorded contacts of patients with their GPs in both years. The method of statistical analysis is logistic regression. RESULTS: The analyses shows that the lower educated have significantly higher odds of feeling unhealthy and having chronic conditions in 2001. Diabetes and myocardial infarction (GP data) showed the largest difference in prevalence between educational groups (OR 2.5 and 2.4, self-reported data). The way the data is collected (self-assessment versus GP registration) hardly affects the magnitude of the educational differences in the prevalence of chronic conditions. The pattern of health inequalities across chronic conditions in 1987 and 2001 hardly differs. Diabetes doubled in prevalence and health inequalities were not significant in 1987, but compared to the other conditions were largest in 2001 (OR 1.1 versus 2.5). CONCLUSION: Health inequalities were shown to be substantial in 2001 and persistent over time. Socio-economic differences were shown to be similar using self-assessed health data and GP data. Hence, a person's educational attainment did not appear to play a part in presenting health problems to the GP.     

Upper abdominal ultrasound in general practice: indications, diagnostic yield and consequences for patient management

BACKGROUND: Abdominal ultrasound (US) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care. OBJECTIVE: To assess the influence of upper abdominal US on patient management in general practice. METHODS: A prospective cohort study with 76 GPs and three general hospitals in The Netherlands. A total of 395 patients aged >or=18 years referred by their GPs for upper abdominal US were included. The main outcome was change in anticipated patient management assessed by means of questionnaires filled in by GPs before and after abdominal US. RESULTS: Mean age of the patients was 54.0 +/- 15.8 years, 35% were male. Clinically relevant abnormalities were found in 29% of the abdominal US, mainly cholelithiasis. Anticipated patient management changed in 64% of the patients following abdominal US. Main changes included fewer referrals to a medical specialist (from 45 to 30%); and more frequent reassurance of the patient (from 15 to 43%). However, this reassurance was not perceived as such in almost 40% of these patients. A change in anticipated patient management occurred significantly more frequently in patients with a prior cholecystectomy (82%). CONCLUSION: Anticipated patient management by the GP changed in 64% of patients following upper abdominal US. Abdominal US substantially reduced the number of intended referrals to a medical specialist, and more patients could be reassured by their GP.     

Data quality improvement in general practice

BACKGROUND: The importance of routine data generated by GPs has grown extensively in the last decade. These data have found many applications other than patient care. More attention has therefore been given to the issue of data quality. Several systematic reviews have detected ample space for improvement of data quality. A new review was conducted in order to find out which methods of improvement are effective. METHOD: The Medline database was searched using an iteratively composed set of terms and MeSH (Medical Subject Headings) headings. Only papers that focused on explicit attempts at improving data quality of medical records in general practice were included. RESULTS: Twelve studies met the inclusion criteria. No study used patient-based comparison of records with external sources as the method to assess data quality improvement. Ten studies used internal indicators or markers of data quality instead. Attempts at data quality improvement often involve some sort of individualized feedback, and nearly all attempts seem to have some positive effect. Only one of the included studies fulfilled the basic methodological requirements of an intervention study. The most recent studies used a simple before-after design. CONCLUSION: No intervention to improve data quality has been put to a rigorous enough test. We still lack empirical knowledge as to how improvement can be brought about.     

Patient evaluations of accessibility and co‐ordination in general practice in Europe

Objective  To determine whether patient evaluations of the accessibility to general practice and co‐ordination with other care providers were associated with characteristics of general practice organizations. Background  In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co‐ordination of care. Design, setting and participants  The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. Main outcome measures  Patient evaluations of general practice were measured with the 23‐item Europep instrument, from which seven items on accessibility and co‐ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. Results  Practices with a higher numbers of care providers received less positive patient evaluations (b = −0.112, P = 0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co‐ordination (1.8%) was explained by characteristics of the general practice organizations. Conclusions  General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals.     

A standardised instrument for patient evaluations of general practice care in Europe

Objective: International comparisons of health care systems may provide important insights, but they require internationally standardised and validated instruments. This paper describes the validity and reliability of the EUROPEP instrument for patient evaluation of general practice care. Methods: Surveys were performed in 16 countries among patients who visited the general practice (n=23892), using the 23-item EUROPEP questionnaire. Data were analysed with respect to content validity, reliability, criterion validity, construct validity and sensitivity of the instrument. Results: The item response among responders was good or acceptable for most items. Two internally consistent dimensions were identified, 'clinical behaviour' (17 items) and 'organisation of care' (6 items). The answers to the 23 questions predicted the overall attitudes regarding the general practitioner. Higher age, more visits to the GP and better health status predicted more positive evaluations of care, as was expected beforehand. Differences between countries were significant but moderate for most of the questions. In specific countries problems with respect to validity and reliability were found. Conclusions: An internationally standardised and validated instrument for patients' evaluations of general practice care is now available for international comparisons. Future research should improve its validity to solve the problems that were found in some countries. Eur J Gen Pract 2000;6:82–7.     

Patient empowerment,an additional characteristic of the European definitions of general practice/family medicine

Abstract

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals’ satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: ‘promote patient empowerment’. The aim of this paper is to clarify the meaning of 'patient empowerment’ and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.     

GP and patient predictors of PSA screening in Australian general practice

OBJECTIVE: We determined GP and patient variables associated first with men's prior uptake of prostate-specific antigen (PSA) screening and, subsequently, its initiation during an 'index consultation' in Australian general practice. METHODS: From the practices of 60 GPs, we recruited a sample of 423 male patients aged 40-70 years. In a waiting room questionnaire completed before their 'index consultation' (retrospective component), men reported their previous PSA screening status. We obtained demographic and clinical data, including the presence of lower urinary tract symptoms (LUTS). Men also were mailed a questionnaire 2 days after their 'index consultation' to ascertain whether the GP had discussed PSA screening (prospective component) for prostate cancer and other behaviours. GPs themselves completed questionnaires eliciting demographic and practice characteristics as well as their propensity to screen and understanding of the evidence about PSA testing. GP and patient study variables were modelled simultaneously in analyses. RESULTS: Of those 348 men consulting with their regular GP, 80 (23.0%) reported previously having had a PSA screening test. Men were significantly and independently more likely ever to have had PSA screening if their regular GP reported a propensity to initiate screening [adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) 1.23-4.20; P = 0.009]. GP age also was independently associated with men's PSA screening status [chi-squared (3) P < 0.0001] as was men's age and severity of LUTS (AOR = 2.38, 95% CI 1.58-3.57, P < 0.0001 and AOR = 1.79, 95% CI 1.00-3.19, P = 0.004, respectively). Current smokers were less likely ever to have had a PSA screening test (AOR = 0.34, 95% CI 0.16-0.69; P = 0.003). Discussion of PSA screening in their 'index consultation' was recalled independently more often by older men (AOR = 1.46, 95% CI 1.00-2.13; P = 0.04), those with moderate/severe LUTS (AOR = 1.94, 1.07-3.49; P = 0.04), those whose GP had performed or discussed a cholesterol test (AOR = 2.26, 95% CI 1.03-4.92; P = 0.04) and those whose GP had postgraduate training in family medicine (AOR = 3.13, 95% CI 1.23-8.00; P = 0.02). CONCLUSION: In the absence as yet of compelling evidence that PSA screening will prolong life or enhance its quality, our findings identify GP and patient factors that could be targeted to modify PSA screening.     

Evaluating general practice fundholding in the United Kingdom

GP fundholding was the most radical element in the package ofreforms introduced into the British National Health Servicein April 1991. Despite initial hostility from the British MedicalAssociation, this scheme has become increasingly popular withGPs, such that it now covers one-third of the UK population.GP fundholding has generated considerable interest internationallyand the British Government has hailed It as a great success.When the organizational changes were first implemented formalevaluation was not encouraged by the government. Nevertheless,some hearth services researchers have carried out evaluativestudies on the impact of GP fundholding. This paper discussesthe problems faced by those attempting to evaluate hearth carereforms, using the studies on fundholding to illustrate thedifficulties. A summary of the main findings from these studiesreveals extensive gaps in current knowledge about the impactof the scheme. Claims that the introduction of GP fundholdinghas resulted in improvements in efficiency, responsiveness andquality of care are in general not supported by the evidence.