Avian Influenza: a global threat needing a global solution

Aim

To investigate whether participation in a clinical audit and education session would improve GP management of patients who smoke.

Methods

GPs who participated in an associated smoking cessation research program were invited to complete a three-stage clinical audit. This process included a retrospective self-audit of smoking cessation management practices over the 6 months prior to commencing the study, attending a 2.5 hour education session about GP management of smoking cessation, and completion of a second retrospective self-audit 6 months later. Twenty-eight GPs completed the full audit and education process, providing information about their smoking cessation management with 1114 patients. The main outcome measure was changes in GP management of smoking cessation with patients across the audit period, as measured by the clinical audit tool.

Results

The majority of GPs (57%) indicated that as a result of the audit process they had altered their approach to the management of patients who smoke. Quantitative analyses confirmed significant increases in various forms of evidence-based smoking cessation management practices to assist patients to quit, or maintain quitting across the audit period. However comparative analyses of patient data challenged these findings, suggesting that the clinical audit process had less impact on GP practice than suggested in GP's self-reported audit data.

Conclusion

This study provides some support for the combined use of self-auditing, feedback and education to improve GP management of smoking cessation. However further research is warranted to examine GP- and patient-based reports of outcomes from clinical audit and other educational interventions.     

Use of a clinical audit to promote the quality use of medicines to rural and remote general practitioners

Very few methods have been shown to change prescribing behaviour. Queensland Rural Medical Support Agency's Quality Use of Medicines (QUM) Program aims to engage rural general practitioners (GPs) in the development of strategies to improve health outcomes in relation to the quality use of medicines. The present paper describes the development of a tool to audit the management of heart failure in rural general practice and to encourage rural GPs to undertake such an audit as a method of continuing medical education. A self-administered retrospective clinical audit of heart failure patients was undertaken by rural and remote GPs. Fourteen doctors undertook the audit, providing data on 270 patient cases. Patient data collected include 30% not receiving adequate angiotensin-converting enzyme inhibitor doses, 45% of patients who may benefit from a beta-blocker and 14% of patients taking a drug known to aggravate heart failure. The majority of participants would review a patient following the audit and 93% confirmed that the audit assisted them in identifying patients whose heart failure management could be enhanced. The clinical audit provided results and a commentary to allow GPs reflective educational opportunities through the dissemination of results and engagement with appropriate educational organisations (e.g. Australian College of Rural and Remote Medicine) to inform the development of educational standards for personal development programs in QUM. Audits must be relevant and practical to meet the learning needs of GPs.     

Retinal photography for diabetic retinopathy screening in Indigenous primary health care: the Inala experience

Objective: We aimed to determine the impact of clinic based retinal photography on access to appropriate screening for diabetic retinopathy (DR). Design, setting and participants: We opportunistically recruited patients undergoing their annual diabetic cycle of care over a two year period in the urban Indigenous primary health care clinic. Data were collected on retinal outcomes, health variables and referral patterns. Main outcome measures: Access to appropriate screening and ophthalmic follow up, prevalence of DR, acceptability and feasibility of clinic‐based retinal photography were the main outcome measures of this study. Results: One hundred and thirty‐two of a possible 147 patients consented to participate. 30% of participants had DR. Appropriate screening and ophthalmic follow up increased six fold, from 20 to 124 participants, following the introduction of the retinal camera. Most participants felt very positive about DR screening. Conclusions: Primary care DR screening using retinal photography can improve access to DR screening for indigenous patients, reduce the burden on busy outpatient departments and should reduce visual loss. Policy‐makers could contribute to screening sustainability by funding a medicare item‐number for primary care based DR screening associated with the annual diabetic cycle of care. An upfront Practice Incentive Program (PIP) payment could offset set up costs.     

Screening for diabetic retinopathy in remote Australia: a program description and evaluation of a devolved model

Objectives: To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure. Method: Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database. Results: The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley‐wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics’ home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting. Conclusions: Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area. What is already known: Screening and early treatment of diabetic retinopathy can prevent visual loss associated with diabetes. However, there is little published literature about the operational aspects of diabetic retinopathy screening programs in remote area settings. What this study adds: Diabetic retinopathy screening in remote areas can be successfully implemented using non‐mydriatic retinal photography performed by credentialed local health professionals, such as Aboriginal health workers and nurses.     

Screening for diabetic retinopathy: developing a standardized photographic protocol for St. John's Hospital

The management of people with diabetes involves input from many healthcare professionals including doctors, nurses, podiatrists and dieticians. In February 1999 at the request of the Consultant Diabetologist a diabetic screening service was established at St. John's Hospital using digital retinal photography. A preliminary photographic protocol was put into place immediately. In order to establish if the protocol was suitable, or at the level of a national standard, the author carried out an extensive literature search. There proved to be a paucity of published information specifically related to guidelines for diabetic retinopathy screening, using a photographic method. The author therefore issued questionnaires to randomly selected medical photography and diabetic screening units throughout the United Kingdom. The research and results of this study has enabled the provision of an effective and efficient retinopathy screening service. Medical photographers are now recognized as part of the diabetic clinic 'team' that care for patients at St. John's Hospital.     

Digital image compression should be limited in diabetic retinopathy screening

Digital colour retinal photography is a useful modality for diabetic retinopathy screening. Unlike film photography, the size of the image depends on the resolution of the acquired image. With the availability of high-resolution digital cameras, larger images requiring greater storage-memory will inevitably be generated. Image compression may then be necessary so that these images can be viewed conveniently, archived and transmitted across computer networks. Unfortunately with the paucity of clinical studies on retinal image compression, more research is necessary to develop evaluation tools to identify optimum image compression ratios for diabetic retinopathy screening.     

Diabetic retinopathy screening in New Zealand requires improvement: results from a multi-centre audit

Objective: To determine whether diabetic retinal screening services and retinopathy referral centres in New Zealand meet the national guidelines for referral and assessment of screen detected moderate retinal and mild macular diabetic eye disease. Methods: Diabetic retinal screening pathways and the data collected at four main centre retinal screening services were described and compared with recommendations in the national diabetes retinal screening guidelines. A retrospective audit of photoscreen detected moderate retinopathy (grade R3), and mild maculopathy (grades M2B and M3) during May to August 2008 was undertaken. Data collected by retinopathy referral centres were used to examine the follow‐up of screen detected cases and to make comparisons with the national recommendations. Results : All four screening services used the guidelines for grading, but the recommended dataset was incomplete. Not all recorded data were readily accessible. The retinal photos of 157 (2.4%) patients were graded as R3, M2B, M3 or a combination. The proportion of those screened with these grades varied across the four centres from 1.2% to 3.4%. Follow‐up of the 157 screen positive patients did not always comply with guideline recommendations. Seventy five (48%) were referred for review by an ophthalmologist as recommended, 45 (60% of referred) were seen within the recommended six months. Nine patients (15% of the 60 with a documented assessment) were referred for or received laser treatment at 12‐months follow‐up. Conclusion: Quality diabetic retinal screening data systems and quality assurance programs are required to improve the monitoring and quality of retinal screening in New Zealand.     

Quality of care of patients with diabetes: collation of data from multi-practice audits of diabetes in primary care.

BACKGROUND: GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991. OBJECTIVES: We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care. METHODS: A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures. RESULTS: Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%). CONCLUSION: This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.     

AGE/RAGE调控轴在铅砷联合暴露糖尿病模型中的作用

目的 研究环境重金属铅砷联合暴露对糖尿病视网膜血管的影响及作用机制。方法 建立铅砷联合暴露低高剂量及链脲佐菌素(streptozocin，STZ )诱导的糖尿病+铅砷暴露低高剂量C57/B6小鼠模型，通过视网膜血管染色、渗漏实验观察视网膜血管的形态功能变化，并经外周血晚期糖基化终末产物(Advanced Glycation End products, AGEs)检测及视网膜组织的蛋白免疫 印迹实验（Western Blot, WB）检测确定AGEs/晚期糖基化终末产物受体（the receptor for advanced glycation end products, RAGE)调控轴的影响。结果 与对照组相比，铅砷短期暴露使血糖升高（对照组5.475mmol/l、模型组16.200mmol/l、模型低染组22.925mmol/l、模型高染组27.700mmol/l，F=36.784，P＜0.05），并引发调节视网膜血管的AGEs/RAGE调控轴的早期变化。而当患有糖尿病小鼠再暴露于铅砷后，会明显加重糖尿病的视网膜病变，并且AGEs/RAGE调控轴在此过程中具有重要作用，该调控轴可经CCM3及下游因子VEGFR2发挥对视网膜血管变化的影响，并降低铁死亡相关蛋白GPX4低表达。结论 铅砷联合暴露对糖尿病视网膜病变中血管新生和异构增加具有重要影响。     

Power and influence in clinical effectiveness and evidence-based medicine

BACKGROUND: The need to base clinical interventions on valid findings of research has been a dominant theme in clinical practice during the last quarter of a century. However, there is much evidence showing that research evidence reaches everyday practice slowly. Solutions to this problem include evidence-based practice and implementation by guidelines and audit. Studies of these methods have included surveys of clinicians' views, implementation projects and evaluations of educational interventions, but they have not examined their implications for the power structure of clinical organizations. This is surprising, given the emphasis placed on medical power in sociological studies of health care. METHODS: A framework derived from management theory defines and summarizes theories of power and influence under the headings: sources of power, overt methods of influence, unseen or covert methods of influence and individual response to influence. This framework is then used to analyse the power and influence possessed and exerted by general practitioners (GPs) and hospital consultants and how these are affected by evidence-based practice and guidelines and audit programmes. OUTCOMES: GPs are seen as having less expert power than consultants and to be more compliant with externally managed guidelines and audit programmes. It is pointed out that compliance with guidelines and audit programmes helps GPs to meet their contractual requirement to be involved in clinical audit activities. Evidence-based practice, which directly challenges the authority of expert opinion is seen as a threat to the power of consultants, but a potential opportunity for GPs and other clinicians whose status is traditionally lower.     

Diabetes and its Long-term Complications in General Practice: a Survey in a Well-defined Population

The aim of this study was to assess the prevalence of long-termcomplications in all patients with non-insulin-dependent diabetesmellitus, who were known to their general practitioners (GPs).During one year 19 GPs in the area of Hoogeveen in the Netherlandsexamined their non-insulin-dependent (NIDDM) patients, includingthose under specialist's care. A detailed protocol was used;the GPs were trained in the diagnostic procedures. Complicationswere either already known from the records or newly discoveredduring screening. In a population of 41940 14.5/1000 patientswith diabetes were identified: 12/1000 NIDDM and 2.5/1000 insulin-dependent-diabetesmellitus (IDDM). Of the 509 NIDDM patients, 387 (76%) couldbe screened for late complications. Signs and symptoms of latecomplications were found in many patients: retinopathy (14%),nephropathy (57%), neuropathy (68%) and macroangiopathy (53%).The prevalence of serious complications was: proliferative retino-and maculopathy (3.3%); diabetic foot (2.6%); renal failure(2.5%). The systemic screening revealed a high number of previouslyunknown cases. It is concluded that many patients with NIDDMdevelop signs and symptoms of late complications. Most casesare identified by systemic screening only. More long-term studiesof the prognosis of late com plications in NIDDM are needed.     

Referrals to physiotherapy: the relation between the number of referrals, the indication for referral and the inclination to refer

This article studies the relation between the referral rate and the type of patients general practitioners refer for physiotherapy. The study population consists of GPs participating in the Netherlands' Sentinel Stations Network, who recorded data on all referrals to physiotherapy during one year and filled in a questionnaire. Results show that the pattern of referral indications of high referring GPs does not differ systematically from that of low referring GPs. High referring GPs evaluate their patients complaints more as purely or mainly somatic. High referring GPs were no more inclined to give in to their patients demands, had busier practices, closer relations with physiotherapists and viewed their knowledge of physiotherapy as more satisfactory than low referring GPs. Some policy implications are discussed in respect to these results.     

Training interventions for general practitioners providing an occupational health service in the British Army

BACKGROUND: General practitioners (GPs) working in the British Army, whether civilian or military, are responsible for providing a first line occupational health (OH) service in addition to their primary health care role. Despite the medical classification system being well established, previous publications have shown considerable inconsistency in the knowledge among GPs. AIM: The aim of this audit cycle was to test effectiveness of training interventions designed for GPs, providing the first line OH service. METHOD: The audit cycle was divided into three stages. The Stages I and III were audits examining the standard of OH records initiated by GPs during a 4-month period (pre- and post-training). The Stage II was a training intervention. Statistical significance was assessed with the chi-square test. RESULTS: The stage one audit showed a statistically significant standard difference between the medical boards initiated by civilian and military GPs. This gap was bridged and the overall standard of the OH records improved significantly after the training. CONCLUSIONS: Appropriate training can enhance a first line OH service provided by GPs. The training must be reinforced at regular intervals. Both OH specialists and GPs can complement each other so as to identify, intervene and prevent work-related ill-health.     

某院2007～2011年糖尿病视网膜病变患者的生存质量调查

目的 探讨糖尿病视网膜病变的发病率、危险因素及视网膜激光光凝和手术治疗的有效率.方法 回顾性分析了2007年3月～2011年11月在某院诊治的糖尿病视网膜病人,进行了体格检查,实验室检查,裂隙灯眼底检查,眼底照相,眼底FFA造影检查,有适应症的患者进行了视网膜激光光凝或行玻璃体切割手术治疗.统计了DR的患病率及相关危险因素,治疗的有效率.结果 糖尿病视网膜病变的患病率约为40.1％,其中以轻、中度较多见;BMI、病程、血糖、血脂、血压均是其发生的危险因素,适时的采取治疗措施能取得良好的治疗效果.结论 糖尿病视网膜病变发病率较高,定期进行眼底检查能做到早发现,早诊断,早治疗,及时挽救患者的有用视力,提高生存质量.     

The role of GP's compensation schemes in diabetes care: Evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.     

Quality incentives for GPs in a regulated market

This paper analyses whether GPs in a capitation system have incentives to provide quality even though health is a credence good. A model is developed where the quality of the service varies due to inherent differences between the GPs and rational patients make choices based on the outcome of treatment. We find that it is difficult to provide appropriate incentives since the search activity of patients offsets direct effects of a change in reimbursement. Variation in the inherent ability of the GPs is good since it increases the search activity of the patients and the optimal reimbursement scheme is inversely proportional to the dispersion in types. Finally, we find that offering a menu of contracts can potentially increase social welfare above the level of a simple capitation regime, but it tends to lead to a higher variation in quality levels.     

Do clinical practice education groups result in sustained change in GP prescribing?

BACKGROUND: Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. OBJECTIVE: Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. METHODS: A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. RESULTS: An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. CONCLUSION: The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.     

Psychosocial explanations of complaints in Dutch general practice.

BACKGROUND: Dutch GPs are frequently consulted by patients presenting physical complaints which have a psychosocial cause. Until now, this type of complaint has often been the subject of study, but the way in which psychosocial explanations for complaints are broached and discussed has not yet been studied. OBJECTIVE: We aimed to analyse the way in which GPs and patients relate physical complaints to psychosocial causes and whether this affects the advice or treatment given in the course of the consultation. We hoped to provide insight into the actual behaviour of GPs and patients concerning these issues. METHODS: From a corpus of 279 videotaped consultations, 24 consultations of eight GPs, four female and four male in different practices, were selected for analysis. The verbal behaviour of GPs and patients in the selected consultations was transcribed in detail and subsequently analysed, according to the qualitative methodology of conversation analysis. RESULTS: Patients present explicit, as well as implicit, psychosocial explanations. GPs respond confirmatively to the first kind and almost ignore the latter. GPs present two types of psychosocial cause-seeking questions. Verifying questions suggesting a psychosocial cause lead to an explicit response from patients; conversely, exploratory queries investigating potential psychosocial causes lead always to a denial. Subsequently, GPs initiate a checklist strategy to investigate potential psychosocial causes. This strategy hardly ever leads to establishing a psychosocial explanation. GPs nearly always focus on the somatic aspects of the complaint, notwithstanding the establishment of a psychosocial explanation. They will hardly ever give any psychosocial advice in the course of that same consultation. CONCLUSION: GPs and patients are cautious in relating physical complaints with psychosocial causes. Psychosocial explanations are formulated and treated as delicate activities in the context of the consultation. GPs and patients both contribute to psychosocial explanations, but GPs contribute more to this delicate topic than their patients do.     

Is the National Service Framework standard for thrombolytic therapy achievable in a rural area?

The National Service Framework (NSF) for coronary heart disease requires that patients with acute myocardial infarction should start thrombolytic therapy within 60 min of the patient making contact with the National Health Service. In an audit of 700 patients with suspected acute myocardial infarction, patients' first contact was most commonly with a general practitioner (GP) (505/700; 72 per cent), who attended on 88 per cent (446/505) of occasions when they were called. In 93 per cent (255/284) of cases where both GP and an ambulance attended, the GP arrived first, by 25 min (median). In the final audit period, median call-to-thrombolysis time was 90 min (26 per cent < or = 60). We conclude that with existing physical and personnel resources in this semi-rural area of Northern Ireland, the NSF standard for thrombolytic treatment is unlikely to be met in a majority of cases unless GPs adopt prehospital thrombolysis.