全科医疗核心特征功能研究——基础保健的综合性

综合性是基础保健的重要特征功能,与首诊、可及性、连续性和协调性之间相互关联,共同形成基础保健高绩效的作用机制。面临人口老龄化、慢性病流行、医疗费用快速上涨的挑战,综合性服务的重要性日益凸显。明确基础保健综合性的概念内涵,是研究者、政策制定者和实践管理者亟待解决的一个根本性问题,是管理综合性服务的基础。针对我国基础保健综合性服务的概念及其内涵要素尚未清晰的现状,本文将系统梳理目前关于综合性定义与概念内涵的研究,把握综合性内涵、要素及其内涵;在此基础上,遵循可控性、穷尽性和互斥性原则,理清基础保健综合性与其他特征功能的内涵边界,给出全科医疗/基础保健综合性这一特征功能的定义与内涵,为后续建立全科医疗特征功能的可操作性定义奠定基础。     

全科医疗核心特征功能定义与内涵界定研究——可及性

可及性是基础保健五大核心特征功能之一,与首诊功能紧密联系,与综合性互相促进,影响连续性、协调性功能的实现。本文首先回顾普适的可及性概念,并在此基础上梳理基础保健可及性的概念内涵和主要特点,进而辨析基础保健可及性与其他基础保健核心特征功能的联系与区别,最后依据可控性、穷尽性和互斥性三大原则,得出基础保健可及性定义与核心要素,为全科医疗特征功能测量评价工具的研制提供理论依据。     

全科医疗核心特征功能定义与内涵界定研究——连续性

连续性是基础保健的一个十分重要而独特的特征,与首诊、可及性、综合性和协调性之间以一种互为基础、相互支撑、彼此强化的方式共同作用,形成基础保健的作用机制。本文首先系统梳理目前关于连续性定义与概念内涵的研究,把握连续性内涵要素,明晰服务连续性的显性要素与隐性要素之间的关系;在此基础上,遵循可控性、穷尽性和互斥性原则,厘清基础保健下连续性与其他四个特征功能的内涵边界,给出全科医疗/基础保健连续性这一特征功能的定义与内涵,为后续建立全科医疗特征功能可操作性定义奠定基础。     

Cumulative incidence of pertussis in an unvaccinated preschool cohort based on notifications,interview and serology

The cumulative incidence of pertussis at six years of age in the first unvaccinated cohort after cessation of immunisation in Sweden was investigated by serological methods and by a validation of the national epidemiological surveillance system by reports from the Child Health Centres (CHCs). In 312/385 (81%) eligible children, both an interview with the parents and a blood sample from the child could be obtained. The CHC reports yielded a cumulative incidence of 31%, whereas the serological assays found 54%. Of the cases reported by the parents to the CHCs, 89% were seropositives. In the additional cases of pertussis reported at the study interview, only 61% could be confirmed (p < 0.001). Among children with reported severe cough not suspected to be pertussis, 46% were seropositive, distributed as 33% seropositives in cases with cough duration of less than 4 weeks and 69% for longer coughs (p < 0.01). In the CHC reports, the parental diagnosis was found to have been confirmed in three-quarters of cases by medical personnel. The CHC reporting system was thus found to be reliable with an observed specificity of 93%, but sensitivity of only 52%. Thus, even this surveillance system, which yields the highest incidence rates, underestimates the incidence of the disease.Corresponding author.     

The incidence of pneumonia using data from a computerized general practice database

SUMMARYDespite being widely recognized as a significant public health problem there are surprisingly few contemporary data available on the incidence of pneumonia in the UK. We conducted a general population-based cohort study to determine the incidence of pneumonia in general practice in the United Kingdom. Data were obtained from The Health Improvement Network (THIN) - a computerized, longitudinal, general practice database. Recorded diagnoses of pneumonia between 1991 and 2003 were used to calculate the incidence of pneumonia stratified by year, sex, age group and deprivation score. The overall incidence of pneumonia was 233/100 000 person-years [95% confidence interval (CI) 231-235] and this rate was stable between 1991 and 2003. The incidence of pneumonia was slightly lower in females compared to males [age-adjusted incidence rate ratio (IRR) 0.88, 95% CI 0.86-0.89]. Pneumonia was most common in children aged <4 years and adults aged >65 years. There was an increased incidence of pneumonia with higher levels of socioeconomic disadvantage such that people living in the most deprived areas of the United Kingdom were 28% more likely to get pneumonia than those in the least deprived areas (age- and gender-adjusted IRR 1.28, 95% CI 1.24-1.32). In conclusion, pneumonia is an important public health problem and the incidence of pneumonia is higher in people at the extremes of age, men and people living in socially deprived areas.     

Accessibility and spatial distribution of general practice services in an Australian city by levels of social disadvantage

The accessibility and spatial distribution of health services provided by the main source of primary medical care in Australia--the general practice surgery--was investigated by level of social disadvantage of local catchment areas. All 459 general practice surgeries in Perth, an Australian city of 1.2 million residents, were surveyed with a 94% response. Amount of service provision was measured using weekly doctor-hours, available from consulting rooms during opening hours, and associated nurse-hours of service. Access factors were defined as the distance to the nearest surgery, provision of Sunday and evening services, ease of making a same day appointment, bulk-billing, and whether the surgery offered a choice of gender of doctor. There were relatively more surgeries in disadvantaged areas and doctor-hours of service provision were also greater (41.0 h/1,000 most disadvantaged vs. 37.9 h/1000 least disadvantaged). Bulk-billing care, at no direct cost to the patient, was more likely to be provided in most disadvantaged areas compared with least disadvantaged areas (61 vs. 38%). However, populations living in the most disadvantaged areas were less likely to be able to see the local GP at short notice (91 vs. 95%), to have access to a local female GP (56 vs. 62%) or a local service in the evenings (42 vs. 51%). While the overall picture of accessibility was favourable, there was considerable variation in the type of services provided to different socioeconomic groups. Health care planners should investigate the reasons for these differences and advise Government to ensure that access factors affecting publicly funded services are equitably distributed.     

The incidence of childhood and adolescent seizures in the UK from 1999 to 2011: A retrospective cohort study using the Clinical Practice Research Datalink

BackgroundIn postmarketing vaccine surveillance, adverse events observed in a vaccinated population are compared to the number expected based on a background incidence rate. The background rate should be accurate and obtained from a population comparable to the one vaccinated. Such rates are often not available.MethodsThe incidence rate of generalised convulsive, febrile and afebrile seizures was estimated in individuals born after 01-January-1998 and aged between 2 months and 15 years of age using the UK Clinical Practice Research Datalink (1999–2011).ResultsThe study population consisted of 1532,992 individuals (4917,369 person years (PY) of follow up). A total of 28,917 generalised convulsive seizure events were identified during follow-up, the overall incidence rate was 5.88 per 1000PY. Age specific rates increased sharply from 4/1000PY at 2 months of age, peaked at 19/1000PY at 16 months and decreased until approximately 6 years of age at which point they became relatively stable at 2/1000PY. 67% of GCSs were categorised as febrile: 56% using Read codes, 11% using free text. Febrile seizures accounted for the age trend in GCS, with rates peaking at 16.1/1000PY at 16 months of age while afebrile seizure rates remained relatively stable across all ages (24 seizures per 1000PY). Analysis by first occurrence of febrile seizure showed a similar pattern, comparable to published studies on the incidence of seizures in childhood.DiscussionThe rates reported in this study could be used in the postmarketing surveillance of infant vaccines. However, given the variation across strata, and the potential underascertainment of seizure events presenting to A&E, care must be taken when interpreting and using these rates.     

Academic careers in general practice and primary care

In the past 10 years, significant developments in general practice teaching and research have led to the considerable growth of academic general practice as a discipline. This paper reviews issues relating to these developments, particularly career pathways and training aspects. The need to extend these advances to the broadening arena of primary health care has given further impetus for the development of academic careers. General practice will need to work closely with secondary care, community health, and social services to develop primary health care in its broadest sense, and an evidence base, generated by relevant research and evaluation, must underpin all of this. Structural and funding changes to undergraduate education, postgraduate training and primary care research have created a range of opportunities for general practice clinicians to define career pathways, not formerly available, within multiprofessional and multidisciplinary departments and groups. Education for future general practice and primary care must underpin developments as much as a research base. Relevant masters' degrees and diplomas are now widely available, and extended vocational training and higher professional education will enable general practitioners in their formative years to consider academic opportunities.     

Pre-registration posts in general practice

Though the UK Medical Act of 1978 made the creation of pre-registration house officer posts in general practice in the UK a serious proposition there have been few attempts to explore the possibility. The absence of agreed educational objectives for the year makes it impossible to conduct the properly evaluated experiments that might assuage existing doubts about the appropriateness of introducing general practice as a setting in an objective way. Experience so far shows that carefully designed schemes are both feasible and worthwhile in the opinion of those involved. The implications for general practice are explored, the need for new educational thinking is discussed and suggestions about criteria for the approval of practices are put forward.     

Mortality in general practice: problems concerning deaths in institutions

Following the provision of all general practitioners in Grampian with data on their practice death rates, the experience of death rates at institutions in the region was examined. Nursing homes are more likely to be situated in less deprived areas and their age-specific death rates are generally higher than those experienced by residents from non-institutional settings. For residents in non-institutional settings in Grampian, higher death rates generally parallel increasing deprivation. This expected trend is reversed when describing the mortality experience of nursing home residents. One reason for this is the movement of elderly people to the locations of nursing homes in less deprived areas. Methodological issues are discussed and proposals are made to improve the analysis of mortality in this article.     

Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database

BACKGROUND: Postherpetic neuralgia (PHN) is a frequent complication of herpes zoster (HZ). Treatment results of this severe and long-lasting pain syndrome are often disappointing. From the point of view of possible prevention and early treatment, it is important to identify HZ patients who have an increased risk of developing PHN. OBJECTIVES: Our goals were to determine the incidence of HZ and PHN in a primary care population and to identify risk indicators for the occurrence of PHN. METHODS: A search for HZ and PHN was conducted in a general practice research database, comprising 22 general practices and representing 49 000 people, over a 5-year period. Potential risk indicators were analysed using multivariate logistic regression. RESULTS: A total of 837 patients had been diagnosed with HZ [incidence 3.4/1000 patients/year, 95% confidence interval (CI) 2.9-3.9]. The risk of developing PHN 1 month after the start of the zoster rash was 6.5% (95% CI 4.9-8.3). This risk was 11.7% (95% CI 8.5-14.9) for patients aged > or =55 years. Independent risk indicators for the occurrence of PHN were age [55-74 years, adjusted odds ratio (OR) 4.2, 95% CI 1.8-9.7; >75 years, OR 10.7, 95% CI 4.6-25.1] and ophthalmic localization (OR 2.3, 95% CI 1.0-4.6). CONCLUSIONS: The risk of developing PHN increases with age. Preventive strategies should focus on patients with herpes zoster aged >55 years and with ophthalmic localization.     

Influenza immunisation coverage from 2015 to 2017: A national study of adult patients from Australian general practice

ObjectivesTo assess influenza immunisation rates and coverage in adult patients from Australian general practice and identify whether practice or patients’ characteristics are associated with vaccination uptake.DesignOpen cohort study.Setting550 Australian general practices included in the MedicineInsight database.ParticipantsPatients aged 18+ years who had at least one consultation during influenza season between 2015 and 2017. Two samples were considered: (1) ‘active’ patients (at least three consultations in any two consecutive years) and (2) ‘every year’ patients (at least one consultation per year).Main outcome measuresInfluenza vaccination rates per 1,000 consultations and coverage (% vaccinated among those who consulted) from 2015 to 2017.ResultsBetween 2015 and 2017 the influenza vaccine rate changed from 57.4 to 51.7 and 67.0 per 1,000 consultations, while correspondent values for coverage were 29.3%, 25.2% and 27.6% (in ‘active’ patients). Vaccine coverage was at least 30% higher in inner regional areas, among patients aged 65+ years or those with comorbidities. Similar associations were found among ‘every year’ patients, but average coverage across the three years was higher (41% vs 27%). Aboriginal and Torres Strait Islander people, either with or without comorbidity, showed a vaccine coverage 10–30% higher than non-Indigenous people for those aged less than 65 years (p-value for interaction < 0.001).ConclusionMedicineInsight data is a useful and low-cost method to monitor influenza immunisation coverage. Independent of the sample used, vaccination coverage among Indigenous people or patients with comorbidities could be improved. Targeted strategies for high-risk groups need to be developed.     

Feasibility of training in problem-solving treatment for general practice registrars

Abstract

At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agenda's research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this first article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.