Decreasing the number of consultations for minor illnesses of Turkish and Dutch inhabitants of a deprived area in The Netherlands: an intervention study

OBJECTIVE: The purpose of this study was to assess the effectiveness of GPs personally handing out to their patients booklets about minor ailments and self-limiting health problems (minor illnesses). METHODS: The study was a pre-test-post-test, control group design and took place in seven general practices. The participants were 162 patients (72 Turkish, 70 Dutch and 20 of other nationality) who frequently visit their GP (>5 times a year), living in deprived areas of The Hague. They were recruited in the waiting rooms of participating general practices. GPs personally handed out booklets to their patients about 12 of the most common minor illnesses and explained how to use them. The main outcome measures were consultations for the 12 minor illnesses listed in the booklet, reported by the patients themselves as well as registered in the general practice medical records, and the number of self-reported illnesses the patients suffered from. RESULTS: The results of both the self-report and the medical records show a significant decrease in number of consultations for minor illnesses in the entire research population, Turkish as well as Dutch. The number of self-reported self-limiting health problems of the Dutch increased. CONCLUSION: Due to the non-randomization procedure, some caution with regard to generalization must be taken. The results indicate that distribution by the GP of booklets with tailored information when a patient is ill leads to a reduction in consultations for minor illnesses.     

The value of reasons for encounter in early detection of colorectal cancer

Background: Symptoms with a high predictive power for colorectal cancer (CRC) do not exist.

Objective: To explore the predictive value of patients’ reason for encounter (RFE) in the two years prior to the diagnosis of CRC.

Methods: A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date.

Results: We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR?+?and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3–6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3–6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53).

Conclusion: Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.     

Do longer consultations improve the management of psychological problems in general practice? A systematic literature review

Background  

Psychological problems present a huge burden of illness in our community and GPs are the main providers of care. There is evidence that longer consultations in general practice are associated with improved quality of care; but this needs to be balanced against the fact that doctor time is a limited resource and longer consultations may lead to reduced access to health care.     

GPs' attitudes to minor ailments.

BACKGROUND: It is generally considered that a significant proportion of 'inappropriate' demand for GP services is generated by consultations for minor ailments. How GPs manage minor ailments is likely to affect how patients perceive and handle similar illnesses in the future. Whilst this potentially has significant implications for general practice workload, research investigating GP' attitudes towards minor ailments and their management is sparse. OBJECTIVE: Our aim was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management. METHODS: A questionnaire survey was conducted in 1999, derived from a series of 20 qualitative interviews with practising GPs. The survey was sent to one GP randomly selected from each practice (n = 759) in eight English health authorities. Attitudinal statements were analysed using factor analysis. RESULTS: Four hundred and fourteen GPs (54.5%) completed and returned the questionnaire. Respondents were consulted regularly about minor illness or symptoms, with almost all (95.6%) having experienced a minor ailment consultation in the previous week. Factor analysis suggested four issues to be of importance in determining GP' attitudes to minor ailment management. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk. CONCLUSION: Although GPs are clearly frustrated by the level of minor ailment consultations, this study suggests that there may be complex factors which influence their attitudes. For the optimal management of minor ailments, inter-professional relationships potentially are of great importance. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.     

Trends in morbidity and general practitioners' workload for middle-aged and elderly people from 1956 to 1982

This paper presents analysis of the National Morbidity Surveys carried out in 1956, 1972 and 1982. Over this period an increasing proportion of middle-aged and elderly patients consulted their general practitioners (GPs) and the average patient consulted for more illnesses. This rise in reported morbidity, particularly for circulatory and musculo-skeletal illnesses, occurred during a period of decline in the mortality rate, which suggests that the latter is a poor indicator of population health. The sharp reduction in the consultation rate between 1956 and 1972 suggests that GPs were limiting their role to primary assessment. However, despite a resurgence in the total number of consultations by 1982, the rapid increase in morbidity between 1972 and 1982 further eroded the levels of consultation per episode of illness. Given that the age-structure of the elderly population is gradually shifting upwards and that each generation reports more illness than its predecessor, GPs can expect to face increasing levels of demand for services from elderly patients.     

Relationship between the use of postgraduate educational material on human immunodeficiency virus and the number of HIV consultations in family practice]

An enquiry using a structured questionnaire was conducted among all 6300 GPs in the Netherlands in order to assess the distribution of HIV-related problems over general practices in the Netherlands and the influence on it of the use of the 'HIV-wijzer voor de huisarts', a loose-leaf handbook on HIV, distributed since 1988 among all Dutch general practitioners. The enquiry was conducted one year after its publication. The 2156 respondents (34%) appeared to be reasonably representative of all GPs. The results show minor imperfections because a small proportion of the questionnaires was filled out incompletely. Almost 90% of respondents mentioned HIV-related consultations, 24% had HIV-seropositive patients and 18% had AIDS patients. These numbers were correlated mainly with municipality size, less with region. The use of the 'HIV-wijzer' was related to occurrence of HIV-related consultations and AIDS patients in a practice. GPs who do not encounter these problems are little motivated to read the 'HIV-wijzer'. For them, other means of education have to be developed or HIV has to be included in existing education programmes on other subjects.     

Impacts of chronic non-communicable diseases on households’ out-of-pocket healthcare expenditures in Sri Lanka

This article examines the effects of chronic non-communicable diseases (NCDs) on households’ out-of-pocket health expenditures in Sri Lanka. We explore the disease specific impacts on out-of-pocket health care expenses from chronic NCDs such as heart diseases, hypertension, cancer, diabetics and asthma. We use nationwide cross-sectional household income and expenditure survey 2012/2013 data compiled by the department of census and statistics of Sri Lanka. Employing propensity score matching method to account for selectivity bias, we find that chronic NCD affected households appear to spend significantly higher out-of-pocket health care expenditures and encounter grater economic burden than matched control group despite having universal public health care policy in Sri Lanka. The results also suggest that out-of-pocket expenses on medicines and other pharmaceutical products as well as expenses on medical laboratory tests and other ancillary services are particularly higher for households with chronic NCD patients. The findings underline the importance of protecting households against the financial burden due to NCDs.     

Teamwork in Sri Lankan general practice

This paper reports part of a study to investigate the organizationof general practice in Sri Lanka with particular reference toteamwork. Questionnaires were sent to 347 members of the twobodies representing general practitioners and to a further 43doctors who were identified as providing either traditionalor Western primary medical care in a defined population. A responserate of 74.2% was obtained. All practitioners of traditional(Ayurvedic) medicine were single-handed and 54.4% of membersof the College of General Practitioners in Sri Lanka also workedon their own. All ancillary staff were employed by the practitionerand the mean number of staff was 3.1. Multifactor comparisonwas undertaken. More staff were employed by practitioners whowere under 45 years old, who lived within five miles of a hospital,and who had in-patient facilities. Questions are posed concerningthe development of team care in Sri Lanka.     

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND: Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs. OBJECTIVES: Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice. METHOD: A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices. RESULTS: The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice. CONCLUSION: The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.     

Changing morbidity patterns in children in Dutch general practice: 1987–2001

Objectives: To examine the presentation and pattern of childhood morbidity in general practice compared with 14 years ago.

Methods: We used data of all children aged 0–17 years from two cross-sectional surveys performed in 1987 and 2001 in general practice in the Netherlands. The total number of children in the practices participating in these surveys were 86,577 children in 1987 and 82,053 children in 2001. First of all, we compared consultation rates of children in general practice. Secondly, childhood morbidity was assessed by episodes of disease, coded according to the International Classification of Primary Care (ICPC). We compared childhood morbidity in 1987 and 2001 by assessing the distribution of episodes among ICPC chapters stratified by ethnicity, and by comparing incidence rates of most frequently presented diseases.

Results: Childhood consultation rates have decreased from 2.7 visits a year per child in 1987 to 2.1 in 2001. The distribution of episodes among ICPC chapters has also changed. Respiratory problems are still the most frequently presented health problem in children but the proportion has decreased from 25.5% in 1987 to 23.3% in 2001. Skin problems were presented more often (23.0% in 2001 versus 17.8% in 1987), and Western children more often presented with skin problems than with respiratory problems in 2001. Incidence rates of most respiratory diseases have decreased and specific skin diseases (dermatomycosis, impetigo and eczema) were diagnosed more often.

Conclusion: In the Netherlands, childhood morbidity has changed. Skin diseases have become more important in general practice and respiratory problems are declining.     

The work by the developing primary care team in China: a survey in two cities

BACKGROUND: China is in the process of converting its existing primary care resources into general practice. The infrastructure is different from that of many other countries. OBJECTIVES: We surveyed patients' reasons for encounter (RFE) and the health providers' diagnoses in the general practice clinics of two large northern cities in order to assess the nature of the work of these practices. METHOD: Practices whose staff had a short course of training in the theory and practice of the International Classification of Primary Care (ICPC) were recruited to document the RFE and diagnoses of patient encounters in two separate winter weeks. RESULTS: The practices dealt mainly with chronic illness in older patients. Hypertension-related problems were the most frequent diagnoses, followed by upper respiratory tract infection. Patients also consulted very frequently for dizziness. Overall, there was good agreement between RFE and diagnosis in some organ systems. CONCLUSION: In their present form, the Chinese practices surveyed were delivering the full range of general practice care to a self-selected age group of patients. The ICPC was very useful for monitoring the work of general practice from the perspective of both the patients and the providers.     

Comparison of the smoking behaviour and attitudes of smokers who believe they have smoking-related problems with those who do not

BACKGROUND: Motivation to stop smoking is associated with smokers' possessing substantial smoking-related morbidity or believing that they have symptoms caused by smoking, but it is not clear if this holds for smokers attending general practice consultations. OBJECTIVE: Our aim was to compare the attitudes and behaviour of smokers attending their GP with symptoms that they believe are smoking related with those who do not. METHOD: A cross-sectional, pre-consultation survey of patients attending GPs in Leicester, UK was carried out. RESULTS: A total of 83.8% (2955/3525) of people attending GPs completed the questionnaire and 34.7% were smokers. Multiple logistic regression showed that where smokers perceived that their problems were smoking related they were more likely to have tried stopping in the past [odds ratio (OR) 1.78, 95% confidence interval (CI) 1.26-2.67], to want to stop smoking (OR 1.83, CI 1.15-2.9) or to intend to stop in the near future (OR 1.58, CI 1.03-2.43). CONCLUSION: Smokers who attend GPs' routine consultations and believe that they have smoking-related problems are more motivated to stop than others. This suggests that it is important for GPs to ascertain patients' views about the aetiology of their symptoms before discussing smoking with them.     

The presentation and management of female breast symptoms in general practice in Sheffield.

BACKGROUND: Relatively little is known about the incidence of breast symptoms in primary care consultations and GPs' patterns of referral to secondary care. OBJECTIVE: We aimed to identify the consultation rate for breast symptoms in general practice and to describe the management of those symptoms, including patterns of referral to secondary care. METHOD: Prospective data were collected by 248 GPs concerning 508 women consulting for breast symptoms. A verification study was carried out in nine practices to compare the data collected prospectively with information recorded contemporaneously in the same patients' notes. Main outcome measures were number of patients with lump, pain, nipple discharge, skin or nipple problems, family history or other symptoms at first or subsequent consultation, management action, age of patient and number of patients meeting study criteria for whom GPs did not record information in the prospective study. RESULTS: The mean number of consultations per GP over the 4-week recording period was 2.05. However, examination of a patient's notes from a sample of nine practices participating in the verification study suggested that GPs recorded only slightly over half of the consultations for breast symptoms on the study pro forma. At their first consultation, 40% of women presented with a breast lump and 40% with breast pain. Fifty-eight per cent of women with lumps were referred for specialist evaluation after a first or subsequent consultation, whereas the comparable percentage for women referred for pain was 17%. CONCLUSIONS: At an initial consultation for breast symptoms, GPs refer approximately one-third of women to secondary care. Women are most likely to be referred for a lump or for a family history of breast cancer and least likely to be referred for breast pain. The verification study suggests that relying on GPs to collect data on a specific group of patients may produce an underestimate of the consultation rates for a specified condition.     

Referrals and relationships in Sri Lankan general practice

A detailed questionnaire was sent to the 347 members of the two professional bodies of general practitioners in Sri Lanka. A second questionnaire was sent to 123 of the responders two months later. The number of referrals to and from general practitioners are reported. No form of contact occurred for any of the referrals to general practitioners or for 20% of the referrals to secondary care services. The frequency and perceived value of contacts between general practitioners and others are reported. Factors which might lead to improving the referral pattern and relationships of general practitioners with their colleagues in Sri Lanka are discussed.     

The value of case studies

Background: Studies describing GP consultation have identified duration of consultation as an important marker of patient satisfaction. Duration of consultation differs between countries. Objective: The aim of this study was to measure the duration of consultations and the different segments of the consultation in a representative sample of GPs in the Nantes district (France).

Material and methods: 150 GPs in the Nantes district were randomly selected from the telephone directory. A letter of explanation was sent, followed up by a telephone call asking the GPs to receive an observer into their surgery. The observer timed consultations and the different segments of the consultation. Results: 30 out of 150 GPs contacted agreed to participate. 329 consultations were observed. Average duration of consultation was 14 min and 24 s; it was 15 min in non-computerised practices and 12 min and 50 s in computerised practices. Consultations for psychological problems or with many reasons for consulting took longer. Doctors usually talked more than patients, except during long consultations. Patients were not examined in only 2% of consultations. Trainers in general practice had longer consultations. Discussion: Many GPs refused to receive the observer; the ratio of trainers within the group of respondents (40%) was higher than in the general GP population (7–10%). As in other studies, female GPs were overre-presented as active participants. In our sample, the average duration of consultation was longer than in other studies. The finding regarding the duration of consultation in computerised practices may need validation in other studies. EurJ Gen Pract 2000;6:88–92.     

Comparison of patients' and general practitioners' evaluations of general practice care

Objectives: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care.

Design: Written surveys among patients and GPs.

Setting: General practice in the Netherlands.

Subjects: 1772 patients (from 45 GPs) and a random sample of 315 GPs.

Main outcome measures: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale.

Results: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone").

Conclusions: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

     

Familiarity with a GP and patients' evaluations of care. A cross-sectional study

BACKGROUND: Personal continuity is considered a core feature of general practice care. Nowadays, another important concept for general practice may be patients' familiarity with a GP. OBJECTIVES: We studied the extent to which patients see a familiar GP, and how this matches their preferences. Furthermore we studied the impact of knowing the GP on patients' evaluations of consultations. METHODS: A cross-sectional design was used and 2400 patients visiting 17 general practices (30 GPs) in The Netherlands for a consultation were approached; 2152 patients completed the questionnaire. The main outcome measures were: i) the extent to which patients saw a familiar GP in relation to the reason for encounter, perceived seriousness of symptoms, and concern about symptoms; and ii) the impact of 'knowing the GP' on patients' overall satisfaction with the consultation, feeling of being helped to move forwards, trust in the GP, and perceived clearness of treatment plans. RESULTS: Patients saw a familiar GP to a high extent, regardless of the reason for encounter, perceived seriousness of symptoms and worries. Higher levels of familiarity with a GP were associated with higher levels of satisfaction, with increased feelings of being helped forward, with more trust in the GP, and with the perception of clearer treatment plans made. A multivariate model including the variable 'knowing the GP' explained 11% of the observed variance in patients' evaluations of consultations. CONCLUSION: Familiarity with a GP improves patients' assessment of general practice care. Also in the future, personal continuity should be promoted.     

Where have all the back pains gone? Changes in the reasons for requiring out-of-hours medical care from a centralized primary care centre after changing to a list system

OBJECTIVE.: We aimed to study changes in reasons for seeking assistanceduring out-of-hours work in a single health centre before andafter introduction of the list system. METHOD.: A questionnaire concerning all out-of-hours general practiceconsultations for 1 week each month in two separate years (in1990 and 1993) was completed in one health centre in centralFinland (Palokka health centre) in a region with 39 465 inhabitants(37 960 inhabitants in 1990). All patients contacting the healthcentre to request medical help during out-of-hours work wereasked to complete the questionnaire. Outcome measures were consultationrates by ICPC main codes. RESULTS.: The annual out-of-hours consulting rate per 1000 inhabitantsdecreased from 823 to 533 (35%) (P < 0.001). The clearestdecrease (57%) from 172 to 74 consultations per 1000 inhabitantsoccurred in patients with musculoskeletal problems. A markedreduction (75%; from 52 to 13 consultations per 1000 inhabitants)was found in male patients with back symptoms. For female patientswith neck problems the reduction of out-of-hours consultationswas also marked (67% reduction; from 12 to 4 consuttations per1000 inhabitants). CONCLUSIONS.: Improvement of continuity of care for patients having musculoskeletalproblems is partly a question of organization, and it is alsoeconomically justifiable. Keywords. Out-of-hours work, consultation rates, primary health care utilization, list system, musculoskeletal disease.