Barriers to delivering asthma care: a qualitative study of general practitioners

OBJECTIVES: To ascertain what general practitioners' priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care. DESIGN: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked "What do you think is needed to achieve best outcomes for asthma care?" To augment analysis of the discussion, sessions were taped and transcribed. PARTICIPANTS: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas. RESULTS: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority. CONCLUSIONS: Remarkable consistency was found between GPs' priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.     

Intentional collaboration: addressing transitions in care for people with severe and persistent mental illnesses

This commentary explores transitions in care for people who have severe and persistent mental illnesses and reside in long-term care communities. Challenges and historical approaches as well as barriers to successful transitions are examined. Recent policy changes in North Carolina are discussed and contextualized in emerging evidence-based practices that emphasize intentional collaborative efforts.     

全科医务人员和社区卫生人员对身体虚弱的老年人提供营养支持的看法:一项定性研究

背景营养不良可导致发病率和死亡率增加。营养不良在身体虚弱的老年人群中很常见,但是很少有研究涉及如何在基层医疗机构中管理体质量减少的身体虚弱的老年人群。目的调查全科医务人员和社区卫生人员对如何管理身体虚弱营养不良的老年人的看法和做法,以探索对此群体可能的有效干预以及提供这些干预前需要对相关人员进行哪些培训和支持。设计与场所本项定性研究在全科医疗机构和社区医疗机构中开展。方法分别对来自英国伦敦和赫特福德郡的全科医务人员、社区多学科虚弱诊疗人员和社区营养师(共60例)进行7个焦点小组访谈和1个附加访谈。对访谈结果进行主题分析。结果访谈对象认为管理虚弱老年人群的营养不良干预需要从多方面着手,并一致同意目前社区营养不良干预服务还不能满足患者的需求。然而对于职业责任制的看法却有分歧。全科医务人员提出,如果由其负责的话,通常的困难为工作量太大以及缺乏营养干预培训。社区多学科虚弱诊疗人员和社区营养师认为,最好是在基层医疗机构中向虚弱老年人群提供干预以解决营养不良问题,而且建议提供机会性筛查干预。对于虚弱或者被社会孤立的老年人来说,不管提供任何干预,健康教育都是必要的组成部分,同时辅以社会、情感和/或实际支持。结论未来对身体虚弱营养不良的老年人提供的营养支持方案应涉及多方面,比如应包含针对性的健康教育,同时,照护者和医疗卫生人员的支持服务也是必不可少的组成部分。     

Clinical psychology in general practice: a cohort study

OBJECTIVE: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care. DESIGN AND PARTICIPANTS: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries. SETTING: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002. INTERVENTION: Full assessment, case formulation and "focussed psychological interventions" relevant to the patient's condition. MAIN OUTCOME MEASURES: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales. RESULTS: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures. CONCLUSION: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients' mental health.     

Wish-fulfilling medicine in practice: a qualitative study of physician arguments

There has been a move in medicine towards patient-centred care, leading to more demands from patients for particular therapies and treatments, and for wish-fulfilling medicine: the use of medical services according to the patient's wishes to enhance their subjective functioning, appearance or health. In contrast to conventional medicine, this use of medical services is not needed from a medical point of view. Boundaries in wish-fulfilling medicine are partly set by a physician's decision to fulfil or decline a patient's wish in practice. In order to develop a better understanding of how wish-fulfilling medicine occurs in practice in The Netherlands, a qualitative study (15 semistructured interviews and 1 focus group) was undertaken. The aim was to investigate the range and kind of arguments used by general practitioners and plastic surgeons in wish-fulfilling medicine. These groups represent the public funded realm of medicine as well as privately paid for services. Moreover, GPs and plastic surgeons can both be approached directly by patients in The Netherlands. The physicians studied raised many arguments that were expected: they used patient autonomy, risks and benefits, normality and justice to limit wish-fulfilling medicine. In addition, arguments new to this debate were uncovered, which were frequently used to justify compliance with a patient's request. Such arguments seem familiar from conventional medicine, including empathy, the patient-doctor relationship and reassurance. Moreover, certain arguments that play a significant role in the literature on wish-fulfilling medicine and enhancement were not mentioned, such as concepts of disease and the enhancement-treatment dichotomy and 'suspect norms'.     

Preventive care in general practice.

Preventive care is an integral component of general practice teaching in all Australian medical schools. While curriculum time and teaching methods vary, the overriding emphasis remains on integrating both epidemiological and behavioural science approaches into the primary care setting. Preventive aspects are stressed during attachments with general practitioners. Use of appropriate theoretical frameworks and models allows the role of the general practitioner in disease prevention to be formalized. Undergraduate teaching is further reinforced by programs within the Family Medicine Programme at a vocational training level, and the Royal Australian College of General Practitioners at a continuing medical education level.     

Prescription information leaflets: a pilot study in general practice

Leaflets containing information about medicines were issued to 56 patients prescribed penicillins and 43 patients prescribed non-steroidal anti-inflammatory drugs. The patients were interviewed between four and 10 days later and their responses compared with those of 65 patients prescribed penicillin and 33 prescribed nonsteroidal anti-inflammatory drugs who did not receive a leaflet. Patients who received a leaflet were more likely to be completely satisfied with their treatment and with the information they had been given. They were also more likely to know the name of their medicine and much more aware of potential unwanted effects. Although there was no evidence that knowledge increased the incidence of adverse effects, when these did occur they were more likely to be recognised as being due to the medicine. Further studies of other leaflets are warranted, including leaflets for drugs that are taken long term.