General practitioner consultations at residential aged-care facilities

OBJECTIVES: To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities (RACFs), and to ascertain how these differ from all GP encounters in Australia as a whole. DESIGN AND PARTICIPANTS: A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health (BEACH) study, April 2004 to March 2006, comparing RACF consultations (identified by Medicare item numbers) with all BEACH study encounters in Australia. Participants were a random sample of GPs who had claimed at least 375 general practice Medicare items in the 3 months prior to the study. MAIN OUTCOME MEASURES: Differences in the characteristics of GPs and patients at RACF consultations, morbidities managed, and treatments provided to patients. RESULTS: Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters; 360/1970 GPs (18.4%) recorded at least one RACF consultation. GPs aged > or = 45 years were more likely to record at least one RACF consultation than those aged < 45 years. Patients were predominantly women (70.7%), and 83.4% were aged > or = 75 years. At RACF consultations, problems managed significantly more often included chronic problems, as well as psychological, neurological, urological, circulatory, eye and musculoskeletal problems. Dementia was the most common problem managed, at 33 times the usual management rate in everyday practice. Significantly fewer medications, non-pharmacological treatments, referrals, pathology and imaging tests were recorded at RACF consultations. CONCLUSION: GP encounters at RACFs involve the management of chronic and complex conditions, including some not frequently seen in everyday general practice. The provision of additional education and resources where required may assist with workforce shortages in this setting.     

Determinants of consultation length in Australian general practice

OBJECTIVE: To measure the independent effect on length of general-practice consultations of a range of characteristics of the general practitioner (GP), practice, patient and consultation, as a basis for considering future GP workforce needs. DESIGN: Secondary analysis of data from the BEACH (Bettering the Evaluation and Care of Health) study. SETTING AND PARTICIPANTS: Data were obtained from 1904 GPs Australia-wide on 70,758 consultations between 1 January 2001 and 31 December 2002; all consultations that were claimable from the Australian Government's Medicare system as General Practice Attendances and had recorded start and finish times were included. MAIN OUTCOME VARIABLES: Characteristics of the GP, practice, patient and consultation that were significantly related to consultation length, determined by multiple regression analysis. RESULTS: The following variables had an independent positive effect on consultation length: GP female, older, graduated in Australia, FRACGP-qualified, and in rural practice; patient female, older, new to practice, with higher socioeconomic status, no health concession card, more reasons for encounter, and more problems managed; and management of specific problem types (social, psychological and female genital problems), management of chronic disease, and provision of clinical treatments. CONCLUSION: The independent relationship of some GP, practice, patient and consultation characteristics with length of consultation may affect future GP supply. These factors should be considered in modelling future general practice workforce needs.     

基层门诊问诊临床预防服务提供水平的直接观察性研究

背景　全科医生是提供临床预防服务的最佳人选,门诊问诊是其提供临床预防服务最适合的时机,但目前我国全科医生在门诊问诊过程中提供临床预防服务的实际水平如何是未知的。目的　测量我国基层全科医生门诊问诊过程中临床预防服务项目的提供水平。方法　2018年7月-2019年1月,采用三阶段抽样策略,选取广东省8家社区卫生服务中心的18名全科医生的649名患者的门诊问诊进行门诊直接观察和录音分析,采用国际通用的全科医生门诊内容编码工具（DOC编码）,对我国基层全科医生门诊问诊的临床预防服务项目进行结构化和定量化描述。结果　在649名门诊患者问诊中,医生为186名（28.7%）患者的门诊问诊提供了至少一种临床预防服务项目;仅有3名医生为≥50%的门诊问诊提供了至少一种临床预防服务项目。营养咨询与建议、疾病筛查和疫苗接种建议和睡眠咨询与建议三类服务项目的患者覆盖率分别为13.4%、9.4%、5.6%,在提供了上述各项服务的患者中,该项服务平均问诊时长分别为（17.61±18.37）、（15.77±15.62）、（13.53±18.59）s。结论　我国基层全科医生在门诊问诊过程中提供临床预防服务的水平较低,与国外存在较大差距。     

Comparison of the accuracy of patients' recall of the content of telephone and face-to-face consultations: an exploratory study

BACKGROUND To comply with an action plan patients need to recall information accurately. Little is known about how well patients recall consultations, particularly telephone consultations increasingly used to triage acute problems. PURPOSE OF STUDY This was an exploratory study to measure how accurately patients recall the content of face-to-face and telephone consultations and what factors may be associated with accurate recall. STUDY DESIGN In Scotland in 2008, the advice (diagnoses; management plan(s); and safety-netting arrangements) given in audio recorded face-to-face and telephone consultations was compared with the advice recalled by patients at interview approximately 13 days later. Patients also performed a memory test. Interactions were sought between accurate recall, consultation type, and factors postulated to influence recall. RESULTS Ten general practitioners (GPs) and 175 patients participated; 144 (82%) patients were interviewed. Patients recalled most important components of telephone and face-to-face consultations equally accurately or with only minor errors. Overall, patients presenting multiple problems (p<0.001), with brain injury (p<0.01) or low memory score (p<0.01) had reduced recall. GPs rarely used strategies to improve recall; however, these were not associated with improved recall. CONCLUSIONS Contrary to previous hospital based research, patients tended to remember important components of both face-to-face and telephone consultations-perhaps reflecting the familiar, less anxiety provoking environment of primary care. The unsuccessful use of strategies to improve recall may reflect selective use in cognitively impaired patients. Clinicians should compensate for situations where recall is poorer such as patients presenting multiple problems or with brain injury. Patients might be advised to restrict the number of problems they present in any one consultation.     

The independent effect of age of general practitioner on clinical practice

OBJECTIVE: To establish the extent to which general practitioner age alone explains variations in patient morbidity and treatment patterns. SETTING: An on-going, national survey of general practice activity in Australia. PARTICIPANTS: A random sample of 5013 GPs with a minimum of 375 general practice Medicare items claimed in the previous 3 months. Each GP contributed details of 100 consecutive encounters, with about 1000 GPs sampled each year between 1998 and 2003. MAIN OUTCOME MEASURES: Effect of practitioner age on GP activity after removing the influence of measured confounding factors: doctor, patient and practice characteristics; number of problems; and morbidity managed at encounters. RESULTS: GP age played a significant role in practice style. In comparison with young GPs (< 35 years), older GPs provided more home visits (P < 0.001) and attendances at residential aged-care facilities (P = 0.044); were more likely to manage chronic problems (P < 0.001); had higher prescribing rates (P < 0.001), and lower rates of pathology ordering (P < 0.001) and non-pharmacological treatments (P < 0.001). Individual body system management rates also differed significantly between younger and older GPs. CONCLUSION: A GP's age plays a significant role in determining practice style. Our results have implications in terms of the ageing GP population and in the wider context of the ageing medical labour force.     

Co-morbidity in general practice

Background: Co-morbidity, or the presence of more than one clinical condition, is gaining increased attention in epidemiological and health services research. However, the clinical relevance of co-morbidity has yet to be defined. In general practice, few studies have been conducted into co-morbidity, either at a single health care encounter, an episode of care, or for a defined time period. Aims: To describe the major co-morbidity cluster profiles recorded by general practitioners. Another aim of this study is to describe the common clusters of co-prescribing. Methods and results: Twelve month data from patients attending 156 GPs from 95 practices around a six month period of January to June 2003 were analysed. This represented 840 961 encounters from about 200 000 individual patients at these participating practices. Co-morbidity and co-prescribing cluster profiles are represented by problems managed and reasons for prescribing for the top 10 presentations and top 10 prescribed drugs in the study period. Conclusions: By analysing the 10 most prevalent problems and 10 most prevalent drugs prescribed in consultations in a community sample, other co-morbidities that are particular to general practice, for example hypertension and lipid disorders, can be uncovered. Whether these clusters are causally related or occur by chance requires further analysis.     

Where there is no surgeon: the effect of specialist proximity on general practitioners' referral rates

OBJECTIVE: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). DESIGN: A cross-sectional survey of GP-patient encounters. SETTING: The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. PARTICIPANTS: A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. MAIN OUTCOME MEASURES: Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). RESULTS: Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter. CONCLUSIONS: Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.     

A comparison of general practice encounters with patients from English-speaking and non-English-speaking backgrounds

OBJECTIVE: To determine whether doctor-patient encounters in general practice with patients from a non-English-speaking background (NESB) differ from encounters with patients of English-speaking background (ESB) in terms of the type of practice where the encounters occur and the type of problems managed. DESIGN AND SETTING: A national cross-sectional survey of GP-patient encounters from a sample of all active registered GPs in Australia. PARTICIPANTS: A random sample of 1047 GPs recruited in the 12 months from April 1999 to March 2000, each providing details of 100 consecutive patient encounters. MAIN OUTCOME MEASURES: GP demographics, practice characteristics, patient demographics (including whether the patient mainly spoke a language other than English at home), and problems managed at the encounter. RESULTS: After adjusting for significant predictors, encounters with NESB patients were significantly more likely to occur at solo practices than practices of five or more GPs (odds ratio [OR], 2.15; 95% CI, 1.49-3.09), in metropolitan practices (OR, 6.34; 95% CI, 4.04-9.96), and with GPs who mostly consulted in a language other than English (OR, 5.44; 95% CI, 3.78-7.83). NESB encounters were relatively more likely to involve a respiratory problem (OR, 1.14; 95% CI, 1.04-1.26), endocrine/metabolic problem (OR, 1.41; 95% CI, 1.22-1.63) or digestive problem (OR, 1.14; 95% CI, 1.02-1.27), and relatively less likely to involve a psychological problem (OR, 0.73; 95% CI, 0.61-0.88) or social problem (OR, 0.67; 95% CI, 0.49-0.92). CONCLUSION: Differences in morbidity management rates between encounters with NESB patients and ESB patients may reflect both differences in underlying prevalences of some disorders in the population of general practice patients, as well as different reasons among the two groups for attending general practice.     

Who goes where? A prospective study of referral patterns within a newly established primary care team

Background

Since the introduction of primary care teams, referral patterns of General Practitioners (GPs) in Ireland have not been studied.

Aims

To study the referral patterns of GPs within a primary care team (PCT) to allied health care professionals in a PCT and to secondary care. To identify indirect referral pathways. To study variation in individual GP referral patterns.

Method

Questionnaire based survey. Statistical analysis was carried out using Epi Info version 3.5.1.

Results

Of 3,166 consultations, 2,841 (89.7%) were dealt with by the GP and required no referral, 107 (3.4%) were referred within the PCT, and 218 (6.9%) were referred elsewhere. Therefore, 93.1% of consultations were managed in primary care alone. Ninety percent of GPs refer patients to the PCT. Indirect referrals constituted 17% of all outpatient referrals. Females have significantly higher referral rates than males. Referral rates of GPs in single-handed practices are higher than GPs in group practices.

Conclusions

GPs alone can manage the vast majority of presentations in general practice. Greater GP access to diagnostic and therapeutic interventions may reduce outpatient referrals. GPs in group practices may collectively have greater experience and expertise and therefore can manage more patients in primary care. There is a significant variation in referral rates between both genders.     

社区卫生服务中心全科实训中心建设标准

背景　全科实训中心是全科医生培养和考核的重要平台,在要求提高全科医生临床能力的背景下,全科实训中心得到快速发展,因此亟须建立一套全科实训中心建设的标准,以为全科实训中心的功能配置提供参考标准。目的　构建一套科学性、实用性、合理性的社区卫生服务中心的全科实训中心建设标准。方法　采用文献分析法并结合实际经验,拟定目录框架,然后小组讨论,编制调查问卷。于2019-05-28至2019-07-10,邀请25名专家,采用Delphi法进行两轮专家咨询,评价专家积极系数、权威程度和专家意见协调程度,确定最终的社区全科实训中心建设标准目录。结果　填写有效问卷的25名专家专业领域平均工作年限（14.42±6.90）年,两轮咨询专家积极系数分别是96.2%和100.0%,对于硬件、软件、人员配备专家权威系数两轮咨询分别是0.83、0.83、0.85和0.90、0.89、0.89,专家意见的协调程度必要性分别是0.133、0.498（P<0.001）,可得性分别是0.280、0.390（P<0.001）。最终构建了3个一级指标（硬件配备、软件配备、人员配备）、13个二级指标、17个三级指标的社区全科实训中心建设标准。结论　本研究专家的积极程度和权威程度较高,两轮咨询后专家意见协调性良好,结果可靠,制定的社区全科实训中心建设标准可推广应用。     

Drug and alcohol related health problems in primary care--what do GPs think?

OBJECTIVE: To examine knowledge, attitudes and beliefs of general practitioners (GPs) in the field of drug and alcohol related health problems. DESIGN: A cross-sectional survey in which self-completion postal questionnaires were sent to all identifiable GPs in the Adelaide metropolitan area. Non-responders received a reminder letter and second questionnaire. SETTING, PARTICIPANTS: The target population was doctors whose principal activity was general practice, or who were in training for general practice. MAIN OUTCOME MEASURES: Demographic and "practice characteristic" information on participants. Measures of knowledge, attitudes and beliefs regarding alcohol consumption, smoking and over the counter medication. RESULTS: The response rate was 59.8%. More responders than non-responders were affiliated with the Royal Australian College of General Practitioners. Alcohol consumption was perceived to be a more difficult issue than smoking to raise during consultations. GPs indicated that significant proportions of their patients were participating in hazardous drinking (mean estimate was 13.8% of patients), but only a third of respondents believed their effort in changing alcohol related behaviour would be effective. Sixty-one per cent of respondents identified hazardous daily levels of alcohol consumption for men consistent with National Health and Medical Research Council guidelines. In the case of women this figure was 42%. Longer reported appointment times were associated with greater reported levels of enquiry about alcohol consumption. CONCLUSIONS: New developments in medical training and systems of payment in general practice need to address both the pessimistic attitude of GPs in dealing with drug and alcohol related health problems, and apparent inconsistencies in defining hazardous alcohol consumption.     

The patient and the computer in the primary care consultation

Objective

Studies of the doctor–patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman''s dramaturgy to explore patients'' approaches to the doctor''s computer in the consultation, and its influence on the patient–doctor relationship.

Design

Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.

Results

Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor''s desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor''s statements.

Conclusion

This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor–patient relationship, and is altering the distribution of power and authority between doctor and patient.     

Timer: a new objective measure of consultation content and its application to computer assisted consultations

As part of the research into the effect in the consultation of the use of a computer to prompt opportunistic preventive care a valid, objective, and practical measure of the consultation process was required. After a review of the alternative methods the Time Interval Medical Event Recorder (Timer) was developed, its reliability tested, and applied to 93 control consultations and 49 computer assisted consultations. Timer records, every five seconds, four consultation events: the problems being dealt with, the physical activity, the verbal activity, and the secondary tasks being attempted. Timer showed that control consultations lasted an average of 6 minutes 58 seconds. The doctors spent 35% of their time on administration, and patients and doctors were both conversational for just 33% of the consultation. Giving information was the most common verbal activity (48% of the duration of the consultation) with silence accounting for 21% of the time. When the computer was used the average consultation was longer, at 7 minutes and 46 seconds. The doctor's contribution to the consultation appeared to have increased. Patient centred speech fell from 36% in controls to 28% of the duration of the consultation when the computer was used, while doctor centred speech rose from 30% to 34.5%. Secondary tasks (exploring patient concepts, education, management sharing, and prevention) were attempted during 28% of the control consultations and 40% of the computer consultations. This was accounted for by the increase in prevention (p less than 0.001). Timer is a reliable and practical tool for researching the consultation, and though it has shown validity in detecting differences between consultations that use a computer and those that do not, further applications are required to establish its full value.     

Prevalence of fatigue in general practice

Background

Fatigue is an important symptom in general practice due to its association with physical, psychological and social problems.

Aim

To determine the prevalence of fatigue as an unsolicited symptom during general practice consultations.

Methods

A random sample of GPs practising in Ireland was invited to provide data on consultations held over one day. Data were recorded on the presence of fatigue as a main or supporting symptom, social and demographic characteristics.

Results

Data were recorded by 89 GPs on 1,428 consultations. The prevalence of fatigue was 25%. It was the main reason for attending the dcctor in 6.5% and a secondary reason in 19%. Sixty-two per cent of patients were female and 48% were eligible for free GP services. The mean age was 47.1 years. The presence of fatigue was associated with: attending a female GP, being female, attending a GP who had been qualified for fewer years and attending the GP frequently.

Conclusion

The prevalence of fatigue reported in this study is over three times higher than that reported in earlier work. Doctor characteristics appear to be as important as patient characteristics in determining fatigue.     

Concordance between real-time telemedicine assessments and face-to-face consultations in paediatric otolaryngology

OBJECTIVE: To determine agreement between diagnoses and management plans made during an initial videoconference appointment and subsequent face-to-face consultations in paediatric ear, nose and throat (ENT) surgery. DESIGN AND SETTING AND PARTICIPANTS: A paediatric ENT clinic servicing patients from Bundaberg, Queensland, was conducted through the Centre for Online Health at the Royal Children's Hospital (RCH) in Brisbane. Between January 2004 and February 2006, 152 consultations with 97 patients were carried out. We retrospectively audited patients' charts to compare the diagnosis and management plan formulated at the initial videoconference and the eventual diagnosis and surgical management after face-to-face consultation. The clinical outcomes for children who were not recommended for surgery at the RCH were ascertained by telephone survey. MAIN OUTCOME MEASURES: Agreement between videoconference and face-to-face consultation findings. RESULTS: Of the 97 patients, 75 were recommended for surgical management at the RCH. The remaining patients were either referred back to their general practitioner (9), followed up by the regional paediatrician (10) or lost to follow-up (3). At the conclusion of the study, seven patients were still awaiting surgery and were excluded. Among the 68 patients seen via videoconference and in person, the recorded diagnosis was the same in 99% of cases (67). Surgical management decisions were the same in 93% of cases (63). Telephone follow-up with paediatricians and GPs confirmed that there were no missed diagnoses or ongoing ENT-related problems in the 19 patients referred back to their care. CONCLUSIONS: Decisions about ENT surgical interventions for children assessed during videoconference clinics are in close agreement with decisions made by the same surgeon at face-to-face consultation. The way is open to employ telemedicine more widely for pre-admission ENT assessment. However, as in any telemedicine work, widespread application requires care.     

贵阳市社区全科医生应诊能力研究

背景　应诊能力是全科医生必备的基本能力之一,现阶段我国社区全科医生的应诊能力不容乐观。目的　了解贵阳市社区全科医生应诊能力现状,发现存在的问题,为进一步提高全科医生的应诊能力提供科学的参考依据。方法　于2018年4—7月,采用分层随机抽样的方法从贵阳市六城区64家社区卫生服务中心中抽取36家,将36家社区卫生服务中心的所有从事全科门诊的医生112名作为调查对象。运用观察法,依据自制评分表对全科医生接诊患者时的行为表现进行评分,评分表从确认和处理现患问题、连续性问题的管理、预防性照顾、改善就医遵医行为4个方面对全科医生的应诊能力进行评价,4个方面得分范围分别为0~67、0~23、0~28、0~9分,总分0~127分。结果　112名全科医生确认和处理现患问题、连续性问题的管理、预防性照顾、改善就医遵医行为平均得分分别为（23.69±3.22）、（7.64±2.39）、（3.49±3.21）、（1.86±1.41）分,平均总得分为（35.65±7.29）分;4个方面能力水平处于好的人数占比分别为15.2%（17/112）、16.1%（18/112）、18.8%（21/112）、11.6%（13/112）,总体评价为好的人数占比为19.6%（22/112）。结论　当前贵阳市社区全科医生的应诊能力需要提升。应加强全科医生全科思维的培养,在实际工作中充分应用健康档案、《接诊记录表》及各种生活压力量表,将门诊医疗与公共卫生服务进行有机整合,以提高全科医生的应诊能力。     

2016例电子会诊申请分析

目的探索院内会诊管理的方法。方法抽查会诊系统某月所有电子会诊申请,共2016例。运用Excel进行分类统计。结果 2016例会诊申请中,急会诊393例,普通会诊1623例,分别占19.5%和80.5%;医疗会诊1863例,护理会诊10例,特殊用药会诊143例,分别占92.4%、0.5%和7.1%。急会诊10分钟内到达率43.5%,普通会诊48小时内到达率91.7%。结论环节管理是保证会诊及时性的重要措施,系统建设是规范会诊行为的基础,规范操作是发挥会诊系统作用的关键。     

The influence of geographical location on the complexity of rural general practice activities

OBJECTIVES: To examine the complexity of activities undertaken in general practice in relation to degree of rurality of the practice. DESIGN AND SETTING: National mail questionnaire survey across non-metropolitan Australia in July 2002. PARTICIPANTS: 1498 respondents out of 4406 GPs providing at least 375 Medicare-rebatable consultations in rural and remote locations during January-March 2002 (response rate, 35%). MAIN OUTCOME MEASURES: Responses to five sentinel measures of practice complexity. RESULTS: In general, the proportion of GPs providing complex services increases with increasing rurality or remoteness. Isolated rural and remote GPs manage myocardial infarctions to a higher level than GPs in larger rural and regional centres, are more likely to administer cytotoxic drugs, perform forensic examinations, stabilise injured patients pending retrieval, and coordinate discharge planning more often. CONCLUSIONS: The more rural or remote the area, the more likely a GP is to be regularly engaged in complex care. These findings have implications for the workload, responsibility, vocational satisfaction, need for professional education and support, and costs and remuneration of practice.