Practice and patient characteristics related to blood pressure in patients with type 2 diabetes in primary care: a cross-sectional study

BACKGROUND: Good blood pressure control reduces the risk of long-term complications of diabetes; however, most people with diabetes do not achieve recommended blood pressure targets. OBJECTIVE: To quantify the relationships between patient and practice factors and blood pressure in patients with type 2 diabetes. METHODS: A cross-sectional study was carried out in 42 general practices in Nottingham. Participants were 1534 people with type 2 diabetes. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by questionnaire. The outcome measures were systolic and diastolic blood pressure. RESULTS: In all, 46% of participants had well-controlled blood pressure (or= 25 kg/m(2), and increased with alcohol consumption. Systolic blood pressure increased whereas diastolic blood pressure decreased with increasing age and duration of diabetes. Current smokers and ex-smokers had a significantly lower diastolic blood pressure than those who had never smoked. Patients from practices where blood pressure targets were negotiated with most patients had significantly lower mean systolic and diastolic blood pressure than those where targets were negotiated with few patients. CONCLUSIONS: A number of patient characteristics are associated with blood pressure. Negotiating individual goals for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore the process of negotiating targets.     

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.     

Continuity of care and intermediate outcomes of type 2 diabetes mellitus

BACKGROUND: The relevance of continuity of care in chronic illness is uncertain. OBJECTIVE: We evaluated whether experienced continuity of care for type 2 diabetes is associated with HbA1c, blood pressure or body weight. METHODS: Cohort study in 19 family practices in London, UK. Participants were 209 type 2 diabetic patients with 156 (75%) followed-up at 10 months. Main measures were experienced continuity of care (ECC) by patient questionnaire (mean score 62.1, SD 16.0), satisfaction with care, health-related quality of life [short-form 12 (SF-12)], HbA1c, blood pressure and body weight. Analyses were adjusted for baseline values, age, sex, ethnicity, duration of diabetes, diabetes treatment, education, housing tenure and whether living alone. RESULTS: Experienced continuity scores were obtained for 193 (92%) of participants at baseline and 156 (75%) at follow-up with no difference in outcome measures between those followed-up and those not. Subjects with the highest satisfaction ratings, compared with the lowest, had higher experienced continuity (difference in experienced continuity 7.87, 95% confidence interval 3.22-12.5, P = 0.001). ECC was not associated with HbA1c (adjusted difference per 10-unit increase in ECC score, -0.09%, -0.29 to 0.12%, P = 0.402), systolic blood pressure (-0.41, -2.88 to 2.06 mm Hg, P = 0.746), body mass index (-0.08, -0.34 to 0.18 kg/m(2), P = 0.562) or SF-12 physical component score (0.73, -0.88 to 2.35, P = 0.375). CONCLUSION: Experienced continuity of diabetes care is associated with greater patient satisfaction but not with improved intermediate outcomes during 10 months follow-up in this setting. Studies with more subjects will be required to determine whether continuity of care is associated with the frequency of adverse events.     

Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK

OBJECTIVES: We aimed to explore the experience and attitudes of primary care patients with diabetes living in a UK community with a high proportion of South Asian patients of Indian origin, with particular reference to patient empowerment. METHODS: Semi-structured interviews were conducted with patients with diabetes attending two general practices in Leicester, UK. Patients were interviewed in English, Gujarati or Punjabi and interviews were transcribed with translation into English where necessary. Broad themes were identified and Framework charting was used to organise data for analysis. RESULTS: Interviews were conducted with 15 South Asian and 5 white patients. We identified both similar and culturally specific elements within the experience, attitudes and barriers in the two ethnic groups. High regard for education, particularly in South Asians, was associated with a positive attitude to empowerment through knowledge, but also sometimes led to low motivation to become partners in diabetes management. High prevalence of diabetes and strong family networks meant that families were an important source of knowledge for South Asians and that these patients generally had good emotional support. Practical considerations such as the need for a convenient venue for educational initiatives were common to both ethnic groups, but some cultural preferences were also identified, for example for appropriate language provision and separate gender sessions. CONCLUSIONS: Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.     

The relationship between primary health care organization and quality of diabetes care

Abstract

Background: Despite many quality improvement trials, diabetes care often remains suboptimal. Few studies in a primary care setting have investigated the ‘real life’ association between organizational differences and quality of diabetes care. Methods: Observational study among ten health care centres with a total of 45 general practitioners (GP). We investigated health care organization and related this to quality of care in a total of 1849 electronic patient records. Results: There were large differences among health care centres in the percentage of patients receiving optimal care (range: 8–67%). The odds to receive good quality of care was higher if the health care centre had a diabetes education program (OR: 4.3; CI: 3.4–5.4), when yearly medical check-ups were done by both the GP and nurse practitioner (NP) (OR: 5.5; CI: 4.2–7.3), planned that after the patient visited the NP the patient is discussed with the GP (OR: 1.8; CI: 1.6–2.0), and had structured follow-up measures for compliance to check-ups (OR: 0.7; CI: 0.5–0.9 and OR: 0.59; CI: 0.5–0.7 for respectively one and two active measures compared to three active measures).

Conclusion: Also in real life, quality of care for type 2 diabetic patients is related to health care organization.     

Physical health care of patients with schizophrenia in primary care: a comparative study

BACKGROUND: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care. OBJECTIVE: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia. METHODS: Design: Case-matched retrospective case note review. Setting: Twenty-two general practices in the Birmingham area (UK). Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients. Main outcome measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups. RESULTS: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 1.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05). CONCLUSIONS: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.     

Chronic pain in type 2 diabetic patients: A cross-sectional study in primary care setting

Background: Although diabetes mellitus (DM) is often associated with painful neuropathic syndromes, a significant number of DM patients suffer from non-neuropathic (nociceptive) pain. Unfortunately, there is insufficient data on the epidemiology of nociceptive pain in DM patients and its effect on their quality of life.

Objective: To characterize pain in type 2 DM patients, and assess its effect on their quality of life.

Methods: The study population included 342 type 2 DM patients, 18 years of age and above (mean age 70.7 ± 9.7), who reported having pain. The study questionnaires included the Brief Pain Inventory (BPI), the S-LANSS scale to assess pain with neuropathic features, life impact, and socio-demographic data.

Results: One hundred and fifty-five DM patients (46.5%) reported having pain of predominantly neuropathic origin. Almost 75% of patients with neuropathic pain were females, compared to 57.8% of patients with nociceptive pain (P = 0.002). More patients with neuropathic pain reported constant daily pain (57.6% vs. 42.4%, P < 0.0001), and worse pain during the night (53.3% vs. 46.7%, P = 0.045). The pain affected daily activities, walking capacity, and mood. Patients with neuropathic pain reported a greater negative effect of pain on their quality of life than those with nociceptive pain (41.0% vs. 15.3%, P < 0.0001).

Conclusion: The impact of neuropathic pain in DM patients is much more significant than nociceptive pain and affects their quality of life and daily function to a greater degree.     

Anticoagulant treatment of patients with chronic atrial fibrillation in primary health care in Sweden--a retrospective study of incidence and quality in a registered population

BACKGROUND: The number of patients receiving anticoagulant treatment is increasing. Chronic atrial fibrillation is the most common treatment diagnosis. The literature indicates a variable level of treatment control. Estimates of time within the therapeutic range have been recommended as a measurement of quality. Electronic patient records are providing clinical data that are useful for audits concerning anticoagulant treatment in real-life practice. OBJECTIVE: Our aim was to assess warfarin treatment for chronic atrial fibrillation in primary health care with regard to prevalence, incidence and quality. METHODS: A 2 year retrospective study was carried out of electronic patient records up to April 2002 in primary health care in Stockholm, including 12 primary health care centres with a registered population of 203 407. Main outcome measures were the number of new patients on wafarin treatment for chronic atrial fibrillation, and time within the therapeutic prothrombin range in the first 90 days of treatment using a linear interpolation method. RESULTS: In total, 827 patients were on warfarin treatment for chronic atrial fibrillation, giving a prevalence of 0.41%. Of these, 144 patients (study group) started treatment with warfarin for chronic atrial fibrillation during the study period, giving a yearly incidence of 0.07%. Their mean age was 73.1 years and 61.1% were men. There were 1721 prothrombin monitoring episodes registered in the first 90 days of treatment, on average once a week per patient. The average proportion of time within the therapeutic range was 54.1% (95% confidence interval (CI) 50.1-58.1), and the proportion of therapeutic tests was 50.2% (95% CI 47.8-52.6). CONCLUSIONS: During the first, second and third months of warfarin treatment for chronic atrial fibrillation, patients were outside the therapeutic range time nearly half the time. There was a gender difference favouring men regarding initiation of treatment.     

UK GPs' and practice nurses' views of continuity of care for patients with type 2 diabetes

BACKGROUND: Continuity of care is widely regarded as a core value of primary care. Type 2 diabetes is a common chronic disease with major health, social and economic impacts. Primary health care professionals in many countries are involved in the management of patients with type 2 diabetes, but their perspectives on continuity remain neglected in research. OBJECTIVE: To explore UK GPs' and nurses' experiences of continuity of care for patients with type 2 diabetes in primary care settings. METHODS: Semi-structured individual interviews were conducted with 16 GPs and 18 practice nurses who manage patients with type 2 diabetes recruited from 20 practices with various organizational structures in Leeds, UK. RESULTS: Three types of continuities were identified: relational continuity from the same health care professional, team continuity from a group of health care professionals and cross-boundary continuity across primary-secondary care settings. Relational continuity was influenced by the quality of the patient-health care professional relationship, policy of the National Health Service (NHS) in the UK (new General Medical Services contract), walk-in centres, the behaviour of receptionists and the structure and systems of the practice. Team and cross-boundary continuities were influenced by the relationship between team members and by effective communication. Relational continuity contributed to more 'personal care', but the usual health care professional might know less about diabetes. Team continuity was important in providing 'physical care', but patients could be confused by conflicting advice from different professionals. Cross-boundary continuity helps to provide 'expert advice', but is dependent upon effective communication. CONCLUSION: GPs and practice nurses dealing with patients with type 2 diabetes identified three types of continuities, each influenced by several factors. Relational continuity deals better with psychosocial care while team continuity promotes better physical care; therefore, imposing one type of continuity may inhibit good diabetic care. Cross-boundary continuity between primary and secondary care is fundamental to contemporary diabetic services and ways should be found to achieve more effective communication.     

A comparison of two methods of collecting economic data in primary care

BACKGROUND: There have been few attempts to assess alternative methods of collecting resource use data for economic evaluations. OBJECTIVE: This study aimed to compare two methods of collecting resource use data in primary care: GPs' case records and a self-complete postal questionnaire. METHODS: 303 primary care attenders were sent a postal survey, incorporating a questionnaire designed to collect service utilisation information for the previous six months. Data were also collected from GP case records. The reporting of GP visits between the two methods, and estimates of costs associated with those visits, were compared. RESULTS: There was good agreement between the number of GP visits recorded on GP case records (mean 3.03) and on the CSRI (mean 2.99) (concordance correlation coefficient = 0.756). In contrast, estimates of average costs of visits from CSRI data were higher and had greater variance compared to case record-based costs (54.63 pound sterling versus 42.37 pound sterling; P = 0.003). This may be explained by differences in average visit length (11.66 versus 9.36 minutes). CONCLUSIONS: This study shows good agreement between GP case records and a self-complete questionnaire for the reporting of GP visits. However, differences in costs associated with those visits arose due to differences in the method used for calculating length of visit.     

Association between perceived health status and satisfaction with quality of care: evidence from users of primary health care in Oman

OBJECTIVE: Our aim was to assess the influence of perceived health status, as measured by SF-12, on the client's views of service quality. METHODS: A structured interview of patients was carried out in six primary health care centres in Adh Dhahira region health authority in the Sultanate of Oman. A total of 1226 patients aged 15 and over attending the different health care services within the health centres took part in the study. The main outcome measures were patients' satisfaction with the different aspects of health care and their perceived physical and mental health status. RESULTS: When adjusted for the relevant background factors such as age and gender, poor perceived health status has been found to predict less positive judgements of various aspects of health care quality. Poor mental health status, for example, predicts less positive judgements of aspects that are linked to the accessibility of the service and interpersonal aspects of care such as the working hours of the centre, GP's attitude and time spent with the GP (P < 0.05, <0.05 and <0.01, respectively). Poor physical health status, on the other hand, predicts less positive judgements of aspects such as cleanliness of the building, confidentiality of consultation with the GP, explanation about the visit to the antenatal clinic and standard of antenatal clinic in general (P < 0.05, <0.05, <0.05 and <0.05, respectively). CONCLUSION: Users' perceived health status has to be evaluated concurrently with assessing satisfaction with the quality of health care services. This would provide more valid results with regard to the patients' views on their level of satisfaction with health care quality.     

A simple pragmatic system for detecting new cases of type 2 diabetes and impaired fasting glycaemia in primary care

BACKGROUND: Although whole population screening for type 2 diabetes is not currently considered to be justified, targeted screening within higher risk groups may be more cost-effective, and more pragmatic. OBJECTIVES: Our aim was to investigate the feasibility and performance of a pragmatic system for identifying patients with type 2 diabetes and impaired fasting glycaemia (IFG). METHODS: A clustered observational survey of the prevalence of diabetes and IFG was carried out in randomly selected patients from four at-risk groups. Patients were identified by computerized searching of practice databases for age and body mass index (BMI) risk criteria. Sixteen practices in South West England screened 1287 Caucasian patients from four groups with progressive levels of theoretical risk (age >70 and BMI >or=33, age >65 and BMI >or=31, age >60 and BMI >or=29, and age >50 and BMI >or=27). Fasting plasma glucose was measured and repeated if abnormal to determine the prevalence of new cases in each group. BMI and age data were validated against measures taken at the clinic. RESULTS: The response rate was 60.6% and the prevalence of new cases of type 2 diabetes in each group was 4.7% [95% confidence interval (CI) 2.8-7.7], 5.7% (95% CI 4.0-8.2), 3.8% (95% CI 2.4-6.0) and 2.6% (95%CI 1.4-4.7), respectively. An additional 5.2-8.4% had IFG. CONCLUSIONS: Targeted screening by searching existing GP records for age and BMI criteria is feasible for use in general practice in the UK. Screening of patients with a BMI of >or=27 and aged >50 by fasting glucose identified a substantial prevalence of undetected type 2 diabetes and IFG. The relative costs and benefits as well as the pragmatic advantages of different systems need further evaluation.     

Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs

OBJECTIVES: The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs. METHODS: A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs. RESULTS: The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15-2.82] and waiting time (OR = 1.96, 95% CI 1.20-3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29-0.83). Satisfaction with doctor-patient interaction was not associated with CAM use. Being 'very satisfied' on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14-0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the 'chronic disease triad' (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45-6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14-0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07-3.31). CONCLUSION: CAM use in Asian patients is prevalent and associated with the 'chronic disease triad' (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor-patient interaction.     

Pilot study of potential barriers to blood pressure control in patients with inadequately controlled hypertension

BACKGROUND: Most people with high blood pressure (BP) are managed in primary care, but BP control is often inadequate. OBJECTIVES: To examine potential barriers to adequate BP control in patients with poorly controlled hypertension. DESIGN: Cross-sectional survey. SETTING: Computerized inner city general practice. PARTICIPANTS: A total of 155 hypertensive patients aged 50-80 years with last recorded BP > or =150/90 mm Hg (or > or =140/85 mm Hg if diabetic). METHODS: Patients were invited to attend a nurse-led clinic where BP was measured according to a standardized protocol and patients were asked to complete a semi-structured questionnaire including lifestyle, compliance with treatment and knowledge about hypertension. Details of BP reviews were obtained from medical records. RESULTS: A total of 110 patients (71%) with a mean age of 65 years attended the nurse-led clinic of whom 27% were of African origin. Of those who attended, 52 (47%) had adequately controlled BP when measured according to protocol. The remaining 58 (53%) had inadequately controlled BP. Of patients on treatment, 94% (83/88) reported taking it at least 6 days a week. Only 9% of patients knew their target BP and only 39% that treatment aims to prevent stroke or heart attack. Patients with diabetes were more likely than those without to have BP > or = audit standard (79% 26/33 versus 42% 32/77, P < 0.001). CONCLUSION: About half of apparently uncontrolled hypertensive patients had BP below target when measured according to standard methods. Reported compliance was good, but patient knowledge of target BP was poor. Patients with diabetes were more likely than those without to have inadequately controlled BP.     

How patients with depressive symptoms view their condition: a qualitative study

BACKGROUND: Depressive symptoms are common in primary care, yet considerable professional controversy exists about appropriate management including the effectiveness of treatments. In addition, avoiding prescribing antidepressants at least initially is recommended. Views of patients themselves should therefore be particularly important in agreeing management strategies. OBJECTIVE: To examine lay beliefs about depressive symptoms in primary care. METHOD: A total of 23 semi-structured interviews were conducted with patients scoring positively for depression on the Hospital Anxiety and Depression Score in a primary care setting. RESULTS: Differentiating 'depression' from understandable reactions to adversity was difficult for patients. The wide range of consequences discussed included adverse effects on others, difficulties coping with feeling out of control and loss of self-identity. Negative images of depression, such as depression being a 20th century phenomenon, were pervasive. Views about medication varied. Various management strategies described included strategies of detachment, engagement in activities and 'blotting out' symptoms. CONCLUSIONS: Patients' views about depressive symptoms are significantly different from conventional medical views. A 'disease management approach' fits uncomfortably with patients' experiences. Acknowledging feelings of loss of control and loss of self-identity in consultations may be useful. The wide employment of techniques patients use to control their disorders, such as support from others, engagement in activities and working at relationships, may be useful to encourage in consultations as alternatives to the use of antidepressant medication.     

The North Dublin randomized controlled trial of structured diabetes shared care

BACKGROUND: A new diabetes shared care service was introduced in North Dublin. It was designed as a randomized controlled trial with a complex intervention comprising education of participating practitioners, the introduction of a community-based diabetes nurse specialist, local agreement on clinical protocols and structured communication across the primary-secondary care interface. OBJECTIVES: Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care. METHODS: A Cluster randomized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practices in North Dublin. Biophysical outcomes (HbA1c, blood pressure, body mass index), psychosocial measures (smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores) and process outcomes were collected. RESULTS: There were significant improvements in diabetes care delivery and in psychosocial outcomes, but no significant improvements in biomedical outcomes. Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual reviews and fewer patients defaulting from care. There were also significant improvements in information exchange between primary and secondary care. CONCLUSION: Structured diabetes shared care, in a mixed health care system, can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients, with improved information exchange across the primary-secondary care interface.     

Developing research management and governance capacity in primary care organizations: transferable learning from a qualitative evaluation of UK pilot sites

BACKGROUND: The capacity and capabilities for undertaking primary care research have increased both within and outside of the UK in recent years. The UK Department of Health aims to facilitate this further by establishing a national network of primary care organizations (PCOs) ready to act as hosts for shared research governance systems. However, it is unclear which models offer the most effective option. In addition, there is confusion over new processes and concern that researchers may be deterred from addressing important questions. OBJECTIVES: The research ascertains how PCOs selected as pilot sites have organized research management and governance (RM&G). METHODS: We adopted a case study approach involving interviews with key informants in a purposive sample of eight pilot PCO (RM&G) sites. RESULTS: Motivating factors for PCOs to host RM&G included the possibility of additional resources and more effective use of research to improve service delivery. A range of organizational models were adopted, often reflecting existing strategic alliances. It is envisaged that it will not be effective or cost-effective for many PCOs to make individual arrangements for RM&G, and so models are already developing among groups of PCOs and partner organizations. The extent of partnerships between PCOs varied with concern over critical mass and dilution of expertise in larger groupings. The development and implementation of systems in pilot sites was facilitated by the support of the wider PCO in recognizing research as a valued and integral part of the organization; the effective management of relationships and the establishment of equal partnership arrangements for RM&G, and the effective use of existing R&D infrastructure and expertise. CONCLUSIONS: RM&G partnerships vary according to local circumstances. It is likely that groupings will develop in the future with increasing co-terminosity and across wider health organization boundaries, such as Strategic Heath Authorities (in the UK) or primary care research networks. Critical mass of RM&G arrangements is likely to be linked to levels of research activity. There are real concerns over the levels of bureaucracy associated with the implementation of research governance; however, those PCOs that develop as RM&G sites have the opportunity to enrich their organizations and expand clinically relevant R&D. Partnership working within PCOs and with primary care research networks, academic departments or acute trusts, may be the key to success. Those undertaking research within primary care settings outside of the UK can learn important lessons from the UK experience and ensure development of high quality research that informs improvements in patient care.     

Outcomes of diabetes care: a population-based study.

AIMS: To describe prevalence, metabolic control, and complications of diabetes mellitus in a county in Northern Sweden, in order to improve diabetes care and guide decision makers. METHODS: A population-based, cross-sectional, retrospective study of medical records of all registered persons with diabetes mellitus (n = 5251) in the area. Assessments and examinations concerning metabolic control and complications were studied over a period of 15 months. RESULTS: Of the 5143 patients included, 13% had Type 1, 86% Type 2, and 1% other types of diabetes. An annual check-up was performed in 84% of patients. Glycosylated haemoglobin (HbA1c) was assessed in 88%, and had a mean value of 7.3% (sd 1.3%). Metabolic control was good in 33% and acceptable in another 26%. Risk factors for complications were found in 64%; in 35% body mass index was > 30; 50% had hypertension; 22% were smokers; 51% had macro- and/or microvascular complications; ischaemic heart disease 26%; a cerebrovascular lesion 13%; amputation 1.8%; proteinuria 7.9%; microalbuminuria 2.6%; peripheral neuropathy 30%; impaired peripheral circulation 29%; and retinopathy 37%. CONCLUSIONS: The majority of patients with diabetes in the study area attended an annual check-up, had acceptable metabolic control and severe complications were uncommon. Nevertheless, the number of undocumented examinations was high, 40% of the patients had unacceptable metabolic control and more than 50% had macrovascular risk factors. These findings emphasize the importance in diabetes care of smoking cessation and intensive treatment of high blood pressure.     

The association between culture, climate and quality of care in primary health care teams

BACKGROUND: Culture and climate represent shared beliefs and values that may influence quality of care in health care teams, and which could be manipulated for quality improvement. However, there is a lack of agreement on the theoretical and empirical relationships between climate and culture, and their relative power as predictors of quality of care. This study sought to examine the association between self-report measures of climate and culture in primary care teams and comprehensive measures of quality of care. METHODS: The data were derived from a cross-sectional survey of 492 professionals in 42 general practices in England. Self-report measures of culture (the Competing Values Framework) and climate (the Team Climate Inventory) were used, together with validated measures of quality of care from medical records and self-report. RESULTS: The majority of practices could be characterized as 'clan' culture type. Practices with a dominant clan culture scored higher on climate for participation and teamwork. There were no associations between culture and quality of care, and only limited evidence of associations between climate and quality. CONCLUSIONS: The current analysis would not support the hypothesis that culture and climate are important predictors of quality of care in primary care. Although larger studies are required to provide a definitive test, the results may suggest the need for a more complex model of the associations between culture, climate and outcomes, and further research may be required into the interaction between culture and climate with other determinants of behaviour such as internal and external incentives.