The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

Chronically ill Australians' satisfaction with accessibility and patient-centredness

Objective. To evaluate the association of characteristics of patients andgeneral practices with patient assessment of quality of care. Design. Cross-sectional multi-practice study using the general practiceassessment survey. Settings. General practices in Australia. Participants. Ninety-six general practices and 7505 chronic illness patientsaged 18 years. Main outcome measures. Access of care and patient-centredness. Results. Two factors were identified in factor analysis: ‘Accessof care’ and ‘Patient-centredness’. Multilevelregression analysis showed significant associations betweenpatients' assessments and patient and practice characteristics.Patients from smaller practices (one to three general practitioners)reported better access to care compared with larger practices.Patients from urban areas were more satisfied with patient-centrednessthan those from rural areas. Self-reported health status andage had a positive and home ownership, employment and education,and patients from non-English-speaking countries a negativerelationship with both scores. Females were more satisfied withpatient-centredness. Conclusions. Patient assessments of quality of care and patient-centrednesswere strongly associated with practice and patient characteristics.This has important implications for interpreting assessmentsof the quality of primary care, and for policy and practicemeasures designed to improve this.     

A quality management model for integrated care: results of a Delphi and Concept Mapping study

Objective. The objective of this study is to identify the elements andclusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methodswere applied. A literature study was conducted to identify elementsof integrated care. In a Delphi study experts commented andprioritized 175 elements in three rounds. During a half-a-daysession with the expert panel, Concept Mapping was used to clusterthe elements, position them on a map and analyse their content.Multi-dimensional statistical analyses were applied to designthe model. Participants. Thirty-one experts, with an average of 8.9 years of experienceworking in research, managing improvement projects or runningintegrated care programmes. Results. The literature study resulted in 101 elements of integratedcare. Based on criteria for inclusion and exclusion, 89 uniqueelements were determined after the three Delphi rounds. By usingConcept Mapping the 89 elements were grouped into nine clusters.The clusters were labelled as: ‘Quality care’, ‘Performancemanagement’, ‘Interprofessional teamwork’,‘Delivery system’, ‘Roles and tasks’,‘Patient-centeredness’, ‘Commitment’,‘Transparent entrepreneurship’ and ‘Result-focusedlearning’. Conclusion. The identified elements and clusters provide a basis for a comprehensivequality management model for integrated care. This model differsfrom other quality management models with respect to its generalapproach to multiple patient categories, its broad definitionof integrated care and its specification into nine differentclusters. The model furthermore accentuates conditions for effectivecollaboration such as commitment, clear roles and tasks andentrepreneurship. The model could serve evaluation and improvementpurposes in integrated care practice. To improve external validity,replication of the study in other countries is recommended.     

Patients'' perspective in Chilean primary care: a questionnaire validation study

Objective. The aim of this study was to adapt and validate an instrumentfor assessing quality of care from the patients' perspectivein the context of Chilean primary care. Methods. The ‘Health Centre Assessment Questionnaire’ ismade up of six multiple-item scales and two single-item scalesaddressing eight key areas of primary care activity. A furthertwo single-item scales ask about the overall satisfaction andthe way in which the centre deals with patients' health issues.The adaptation process was developed according to methods describedin the specialized literature. The instrument was initiallypre-tested in a sample of 100 primary care patients. The validationwas carried out in 10 urban public primary healthcare centreswhere 2896 patients were invited to complete the questionnaire.The validity and reliability of the instrument was assessedusing standard psychometric techniques. Results. Ninety nine per cent (2870) of those approached completed thequestionnaire. It was acceptable to most of the patients asreflected by the high response rate, and a full range of possiblescores in most of the scales. Reliability was good as reflectedby high internal consistency and homogeneity. Validity was supportedby the confirmation of scaling assumptions, the moderate correlationsbetween multiple-item scales, and by the confirmation of our‘a priori’ hypothesis. Conclusions. The questionnaire could be a useful instrument for assessinga number of important dimensions in Chilean primary care. Itis acceptable, reliable and valid. Further work is requiredto evaluate its validity against external criteria and its test–retestreliability.     

Drug prescribing in hospital as experienced by general practitioners: East versus West Germany

BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are oftenchanged during hospitalization. This study set out to test thehypothesis that the extent of drug change and the informationprovided by the hospital determines the GPs' assessment of hospitalco-operation. The perception of drug change and hospital co-operationmay also be influenced by the degree of institutional separationof primary and secondary care. Therefore we compared GPs' respectiveattitudes in ‘East’ and ‘West’ Germany. METHOD: In 1993, a representative sample of ‘eastern’ and‘western’ German doctors received a structured questionnaire;554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPsbelieved that their medication was changed in hospital in morethan 60% of their patients. Only a minority of eastern (10%)and western (15%) doctors described the information providedby the hospitals as more or less satisfactory. More westernthan eastern doctors (56% versus 32%) expressed dissatisfactionwith hospital co-operation. Respondents in eastern Germany whofelt sufficiently informed about hospital drug change were morelikely to express satisfaction with the hospital doctors' co-operation.In the former area of West Germany the judgement of co-operationwas significantly better if the extent of drug change and thefrequency of generic drug replacement by original brand-namedrugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matterof concern, especially for GPs who are working in an area witha tradition of strictly separated primary and secondary care. Keywords. Drug prescribing, family practice, interprofessional relations, health system.     

Facing future challenges in general practice: a clinical method with computer support

This paper proposes a clinical method for general practice whichis patient-centred and which ensures that the doctor's agendais supported to secure ‘best practice’. It encompassesself-learning for GPs which is patient-focused and describesthe encouragement and support of patient self-care. The methodattempts to be pragmatic and usable within GPs' available time.The method, however, is not solely focused on the GP; it encompassesthe primary health care team and the patient. It uses clinicalinformation systems to assist in the management of the patientcare plan, to supply information to the GP and patient, in orderto aid shared decision making and to quality assure clinicalactivity. It goes further by extending the care process to handle‘virtual’ encounters in which the clinical informationsystems play a central role. Keywords. Family practice, medical informatics, models, philosophy, physician-patient relationships.     

Sore throat management in general practice

This paper discusses primary care management of sore throatin the context of recent national ‘consensus’ guidelinesfrom the Drugs and Therapeutics Bulletin. The guidelines advisetaking a throat swab, using typical clinical features whereswabs are not available, and suggest that antibiotics shortenthe duration of symptoms and prevent complications. Systematicreviews and individual studies indicate that the evidence forprescribing antibiotics for most presentations of sore throatin general practice is marginal, and the benefits are probablyoutweighed by the likely costs of antibiotics. Using clinicalscorecards or symptom clusters to identify individuals who wouldbenefit from treatment is insensitive with low predictive value,although inexpensive. Using throat swabs as a gold standardfor diagnosis is inappropriate since they are neither very specificnor sensitive, and will greatly increase costs of management.The relative lack of evidence for the efficacy of antibioticsand for the use of throat swabs from primary care research,and also an unbalanced perspective of dangers and complicationsrelated predominantly to a secondary care setting, underlinesthe problem of achieving valid consensus guidelines. Guidelinesnot firmly based on evidence appropriate to the intended settingare more likely to be received sceptically and hinder gettingresearch into practice. Keywords. Sore throat, clinical guidelines, tonsilitis, pharyngitis, throat swab.     

Anxiety and depression in general practitioners: associations with type of parctice, fundholding, gender and other personal characteristics

BACKGROUND: There is evidence both that a doctor's own well-being is closelyassociated with efficiency and positive attitude to patients,and that levels of stress, anxiety and depression in doctorsare rising. OBJECTIVES: This postal survey aimed to measure anxiety and depression levelsin general practitioners in 1994 and identify any associationswith personal and practice characteristics. METHODS: All general practitioners with patients in Staffordshire wereinvited to complete the Hospital Anxiety and Depression (HAD)scale. RESULTS: Six hundred and twenty of 896 general practitioners replied(response rate 69%). No gender differences were found in ratesof anxiety and depression; overall, 19% of respondents were‘cases’ of anxiety and 22% others had borderlineanxiety scores; 10% were ‘cases’ of depression and16% others had borderline depression scores. Anxiety ‘caseness’was associated with living alone, amount of on-call duties undertaken,and being fourth/fifth wave fundholders. Depression ‘caseness’was associated with having little free time from practice work,amount of on-call, being single handed, and working in a non-trainingpractice. CONCLUSIONS: The authors concluded that the level of mental ill-health ingeneral practitioners is a matter of concern and is associatedwith workload. Keywords. Anxiety, depression, general practitioners, personal characteristics, practice characteristics.     

The uses and abuses of meta-analysis

Meta-analysis is a quantitative process of summary and interpretationwhich involves pooling information from independent studiesconcerning a single theme in order to draw conclusions. Greatlyincreased employment of meta-analysis is currently being advocatedfor clinical and policy decision making. However, the prestigeof meta-analysis is based upon a false model of scientific practice.Interpreting empirical research is an extremely complex activityrequiring clinical and scientific knowledge of the field inquestion; and teams of professional ‘meta-analysts’with a primary skill base in information technology and biostatisticscannot take over this role. Meta-analysis is not a hypothesis-testingactivity, and cannot legitimately be used to establish the realityof a putative hazard or therapy. The proper use of meta-analysisis to increase the precision of quantitative estimates of healthstates in populations. If used to estimate an effect, the realityof that effect should have been established by previous scientificstudies. But the summary estimate from a meta-analysis can onlybe directly applied to a target population when the ‘meta-protocol’and ‘meta-population’ match the target situationin all relevant particulars. These constraints can rarely besatisfied in practice, so the results of meta-analysis typicallyrequire adjustment—which is a complex, assumption-ladenprocess that negates many of the statistical power advantagesof a meta-analysis. Lacking any understanding or acknowledgementof the need for adjustment, most meta-analyses must be regardedas abuses of the technique. Keywords. Meta-analysis, mega-trials, epidemiology, clinical science.     

Parents and nurses during the immunization of children--where is the power? A conversation analysis

Background. Best practice for health care practitioners is consideredpatient-centred approaches which empower patients. Immunizationof young children requires maintaining this approach while retainingprofessional management. Objective. The objectives were to assess situations within theimmunization event with discordance between health providerand caregiver and evaluate strategies used to empowering parentswhile obtaining the desired clinical outcome. Methods. This was a qualitative study nested within a largerstudy of immunization rates in 124 randomly selected primarycare practices. Interactions between immunizing practice nurses,caregivers and children were videotaped and transcribed andunderwent conversation analysis. Six purposively sampled primarycare practices in Auckland, New Zealand, served as the setting.The participants were eight practice nurses immunizing 10 childrenand their parents. Normative pattern of interactions and ‘deviantcases’ involving discordance between nurse and parent. Results. A total of 168 minutes of video-recorded conversationfrom 10 immunization sessions provided strong ‘typical’pattern and equally striking ‘deviant cases’. Parentsmostly treated nurses as ‘experts’ and acceptedasymmetry of knowledge over medical matters. Nurses demonstratedskilful strategies in delineating their area of medical expertisefrom areas in which patients are expert—their knowledgeof themselves and their children. Conclusion. While patient centredness and empowering patientsare contemporary goals of primary health care delivery, theseattributes are not precisely defined. Patients may wish to beinformed, but many trust their health professionals to directtheir decision making. Although health professionals may impartas much knowledge as they can, asymmetry of knowledge remains.However, patients hold expertise beyond their clinical situationin the social and economic world in which they live. Keywords. Caregivers, immunization, power, primary health care, qualitative research.     

The Psychosocial Impact of Mass Screening for Cardiovascular Risk Factors

In Leek, a small town in the north of the Netherlands, 428 menaged between 30–33 years were invited to take part ina screening test for cardiovascular risk factors. Questionnaireswere sent to the 267 men who had participated in the screeningtest as well as to the 161 non-participants, in order to gainan insight into the participatory behaviour and the experienceof those involved. The non-participants gave a diversity ofmotives for not taking part but did not admit to anxiety aboutfinding abnormal results. More than half of the participantswho replied (51%, n = 107) were found to have an ‘abnormality’—;thatis they scored on one or more of cigarette smoking, overweight,hypertension, hyperlipoproteinaemia, albuminuna or glucosuria.The supplementary information provided on nutrition and smokingcaused a large proportion of them to claim they had changedto a more healthy life-style after the screening test. Thosewho were under the impression that they had led healthy livesbut were still found to have an ‘abnormality’ wereoften very astonished and sometimes worried about the result.The men without ‘abnormalities’ did not lead significantlyhealthier lives than the rest in terms of exercise, smoking,diet and so on; for them the result might have a ‘certificateof health’ effect justifying their not always healthybehaviour.     

'Only connect': the centrality of doctor-patient relationships in primary care

EM Forster's call in A Passage to India to ‘only connect’is a shorthand for the hundreds of ways in which doctor–patientrelationships have been discussed in the literature. As Chew-Grahamstates, in the parallel editorial, this relationship, and thepatient-centred ideology which underpins it, is seen as intrinsicallytherapeutic. The evidence base for such an assumption is wellestablished, most notably in the literature on quality and continuityof care. The centrality of relationship-based primary care There is a strong association between personal continuity, enablementand patient satisfaction.¹ Since personal continuity impliesboth empathy and personal responsibility,^2,3 the studies overallshow a strong correlation between quality relationships andpatient satisfaction. Reviews of     

The Denominator for Audit in General Practice

Fleming D M (Birmingham Research Unit of the RCGP, LordswoodHouse, 54 Lordswood Road, Harborne, Birmingham B17 9DB). Thedenominator for audit in general practice. Family Practice 1985;2: 76–81. Different denominators for morbidity studies were compared fromtwo large studies in Britain. From the second national morbiditysurvey, data from 24 single-handed doctors showed a close correlationbetween the denominators ‘persons consulting’ and‘list size’ (r > 0.9) in both years of the survey,but a weaker correlation between ‘consultations’and ‘list size’ (r=0.6). However, when examiningrank order statistics for visiting and out-patient referralrates, it was immaterial for most doctors which denominatorwas chosen. Only for recorders with a consultation rate at theextremes of the range was the choice of denominator criticalto the interpretation of the data. In the practice activity analysis study, based on 47 doctorsand a mean of 284 consultations in two weeks, the correlationbetween ‘persons consulting’ and ‘total consultations’was 0.99. Thus the number consultations provided a satisfactoryproxy for persons consulting in a two-week study. These results justify the use of ‘consultations’over two weeks as a denominator in general practice audit incircumstances where rank order is appropriate for the interpretationof data.     

Unquoted, unchallenged, general practice research will be casting pearls before swine

Research is the major driving factor in further improving healthcare and should be directed at the clinical decisions that havethe greatest impact on the health status of the population.Most people receive formal medical care in general practice,^1,2and GPs are in many countries the only physicians directly accessibleto the public.³ Primary care is where research will contributemost to improve medical care for all. But the profile of primarycare research is surprisingly low. Against this background theWorld Organization of Family Doctors (Wonca) has developed apolicy to improve the status of general practice research, expandthe evidence-base for GPs, and contribute to better health careworldwide—named after the place of the policy-initiatingconference ‘the Kingston report’.⁴ Priorities inbuilding primary care research capacity are:

the establishment     

Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study

Background. There is a lack of evidence regarding the kindsof decisions made by primary care nurses and the informationsources they use in clinical decision making. Objective. To describe the decisions made by nurses workingin general practice and the sources of information they useto underpin those decisions. Methods. Qualitative methods (interviews, observation, documentaryanalysis) were used to collect data on the clinical decisionmaking and information seeking behaviour of a purposive sampleof 29 practice nurses and four nurse practitioners from generalpractices in the North of England. Data were collected November2001–September 2002. Results. A seven-fold typology captured the types of decisionsthe nurses made on a daily basis concerning assessment, diagnosis,intervention, referral, communication, service delivery andorganization (SDO) and information seeking. Faced with clinicaluncertainty, the majority of the nurses in the study reliedon personal experience, or obtained advice and information fromGP or other colleagues. These ‘human sources’ ofinformation were overwhelmingly preferred to text or on-lineresources. Despite encounters with evidence-based resourcesthrough continuing professional development, the nurses rarelyused them to seek answers to routine clinical questions. Conclusion. The decisions of the nurses in the study were mainlyconcerned with undifferentiated diagnosis and treatment, inthe context of acute conditions and chronic disease management.‘Human sources’ of information were preferred toany other; however, we do not know whether information obtainedfrom colleagues is based on research. Keywords. Decision making, information use, practice nurses.     

Clinically relevant diagnostic research in primary care: the example of B-type natriuretic peptides in the detection of heart failure

With the emergence of novel diagnostic tests, e.g. point-of-caretests, clinically relevant empirical evidence is needed to assesswhether such a test should be used in daily practice. With theexample of the value of B-type natriuretic peptides (BNP) inthe diagnostic assessment of suspected heart failure, we willdiscuss the major methodological issues crucial in diagnosticresearch; most notably the choice of the study population andthe data analysis with a multivariable approach. BNP have beenstudied extensively in the emergency care setting, and alsoseveral studies in the primary care are available. The usefulnessof this test when applied in combination with other readilyavailable tests is still not adequately addressed in the relevantpatient domain, i.e. those who are clinically suspected of heartfailure by their GP. Future diagnostic research in primary careshould be targeted much more at answering the clinically relevantquestion ‘Is it useful to add this (new) test to the othertests I usually perform, including history taking and physicalexamination, in patients I suspect of having a certain disease’. Keywords. Diagnosis, primary care, heart failure, B-type naturiuretic peptide.     

UK research staff perspectives on improving recruitment and retention to primary care research; nominal group exercise

Background. Primary care studies often encounter recruitmentdifficulties, but there is little evidence to inform solutions.As part of a National Institute for Health Research School forPrimary Care Research and UK Clinical Research Network programme,we elicited research staff perspectives on factors facilitatingor obstructing recruitment. Objective. To identify factors that experienced research staffconsider important in successful recruitment and retention andtheir confidence in achieving them. Methods. An iterative series of three workshops was held. Thethird used a modified nominal group technique to categorizewhether factors related to the ‘context’ in whichthe research took place, the ‘content’ of the studyor the recruitment ‘process’ and to prioritize themby their importance to success. Results. Eighteen research staff participated in the prioritizationworkshop. They prioritized positive attitudes of primary carestaff towards research and trust of researchers by potentialparticipants as major contextual factors affecting recruitment.Studies needed to be considered safe and relevant by staff andfit with practice systems. They proposed that researchers strengthenrelationships with staff and participants and minimize workloadfor primary care teams. Although confident in many recruitmentprocesses, respondents remained uncertain how to achieve culturalchange so that research became part of normal practice activityand how best to motivate patients to participate. Conclusions. Research workers taking part identified factorswhich might be important in recruitment, several of which theyexpressed little confidence in addressing. Understanding howto improve recruitment is crucial if current efforts to strengthenprimary care research are to bear fruit. Keywords. Attitude of health personnel, health services research, patient selection, primary health care, randomized-controlled trials.     

Occupation and Risk for the Occurrence of Low-Back Pain (LBP) in Danish Employees

Using data from a nation-wide cross-sectional survey in 1990a study examining the risk for occurrence of LBP in variousspecific occupations was made among 5,185 Danish employees aged19–59 years old. After adjusting for the confounding effectsof age and gender we found significantly increased risks ofLBP in three out of nine major occupational categories. Theywere, ‘health care and social work’ (OR=1.52, 95%CI=1.28–1.80), ‘mining, quarrying and constructionwork’ (OR=1.97, 95% CI=1.41–2.74) and ‘manufacturingand machine operation work’ (OR=1.21, 95% CI=1.05–1.40).Among 39 second-level occupational categories the highest riskswere observed among persons employed in ‘building constructionwork’ (OR=1.97, 95% CI=1.41–2.74), ‘socialwork, child day care work and psychological work’ (OR=1.64,95% CI=1.32–2.05). Skilled and unskilled manual workershad an increased risk of LBP. Received       10 March 1995 Accepted        1 November 1995     

Mawas Diri a tool to stimulate community participation

The term ‘community participation’ is popular developmentrhetoric yet it tends to remain a topic of discussion aroundconference tables rather than a reality in most communitiesof the developing world. Political will may be guaranteed butthe tools which can facilitate the process of translating communityparticipation into reality are scarce. To help fill this gapan Indonesian non-governmental organization, Yayasan IndonesiaSejahtera, developed a problem-solving tool called Mawas Diri.The tool is employed by representatives of the target groupand uses indicators directly related to their situation. Itis used by village health workers (VHWs) or others who havebeen trained in its use, to evaluate the healthiness of homesand the neighbourhood in general. With this tool, VHWs have succeeded in collecting reliable datawhich are used for village planning activities and monitoringthe progress of programmes. It has also proved to be an effectivemotivational tool for stimulating people to initiate a widevariety of activities aimed at creating a healthier environmentand life-style. More fundamentally, this problem-solving toolhas reversed the usual procedure of ‘outsiders’determining a community's problems and providing programmesfor their solution. With Mawas Diri the community members aremore aware of the nature and extent of their problems and canthen determine which of these they can solve using their ownresources, and which require government or other outside participation. Experiences with Mawas Diri in Indonesia have illustrated thatvillage communities can play a significant role in planning,implementing and monitoring programmes leading to healthierlives.     

The harmful consequences of elevating the doctor-patient relationship to be a primary goal of the general practice consultation

Introduction In the UK, it has been estimated that an ‘average’GP will undertake 8000 face to face clinical interactions annually.¹The consultation has come to be identified as the cornerstoneof general practice,² and to be seen more than an occasion forthe medical work of diagnosis and treatment.³ Beginning withthe work of Balint,⁴ it has also come to be seen as a ‘meeting’of individuals in which (often undifferentiated) symptoms areexpected to be understood and accommodated in relation to theirsocial and psychological contexts. Much effort in educationand research has been invested in giving the consultation thisdeeper meaning and wider range of potential practice.⁵ Thus,whilst the doctor–patient relationship is a given in today'sprimary care, achieving a satisfactory doctor–patientrelationship has also been elevated to be an outcome or goalof every consultation. In many ways, exploring that