共查询到20条相似文献,搜索用时 31 毫秒
1.
2.
3.
Amy Waller Mariko Carey Danielle Mazza Serene Yoong Alice Grady Rob Sanson-Fisher 《The British journal of general practice》2015,65(634):e312-e318
Background
GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.Aim
To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.Design and setting
Cross-sectional survey of patients attending Australian general practice clinics.Method
Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.Results
In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).Conclusion
Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required. 相似文献4.
Fiona Fox Michael Harris Gordon Taylor Karen Rodham Jane Sutton Brian Robinson Jenny Scott 《The British journal of general practice》2009,59(568):811-818
Background
Current evidence about the experiences of doctors who are unwell is limited to poor quality data.Aim
To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.Design of study
Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.Setting
Two primary care trusts in the West of England.Method
A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysisResults
Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.Conclusion
Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service. 相似文献5.
Jane Roberts Ann Crosland John Fulton 《The British journal of general practice》2014,64(622):e254-e261
Background
Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.Aim
To explore the relationship between the above three influences to develop an overarching conceptual model.Design and setting
Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.Method
Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.Results
In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.Conclusion
The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents. 相似文献6.
Chris Shiels Mark Gabbay Jim Hillage 《The British journal of general practice》2014,64(620):e137-e143
Background
The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.Aim
To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.Design and setting
Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.Method
Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.Results
The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.Conclusion
Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers). 相似文献7.
Jonathan Hammond Katja Gravenhorst Emma Funnell Susan Beatty Derek Hibbert Jonathan Lamb Heather Burroughs Marija Kovand?i? Mark Gabbay Christopher Dowrick Linda Gask Waquas Waheed Carolyn A Chew-Graham 《The British journal of general practice》2013,63(608):e177-e184
Background
General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful ‘gatekeepers’. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience.Aim
To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work.Design and setting
Ethnographic observation in seven urban general practices in the north-west of England.Method
Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters.Results
Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to ‘play’ the system.Conclusion
Framing the receptionist–patient encounter as one between the ‘powerful’ and the ‘vulnerable’ gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings. 相似文献8.
Helen Lester Max Birchwood Nick Freemantle Maria Michail Lynda Tait 《The British journal of general practice》2009,59(563):e183-e190
Background
Delays in accessing care for young people with a first episode of psychosis are significantly associated with poorer treatment response and higher relapse rates.Aim
To assess the effect of an educational intervention for GPs on referral rates to early-intervention services and the duration of untreated psychosis for young people with first-episode psychosis.Design of study
Stratified cluster randomised controlled trial, clustered at practice level.Setting
Birmingham, England.Method
Practices with access to the three early-intervention services in three inner-city primary care trusts in Birmingham were eligible for inclusion. Intervention practices received an educational intervention addressing GP knowledge, skills, and attitudes about first-episode psychosis. The primary outcome was the difference in the number of referrals to early-intervention services between practices. Secondary outcomes were duration of untreated psychosis, time to recovery, use of the Mental Health Act, and GP consultation rate during the developing illness.Results
A total of 110 of 135 eligible practices (81%) were recruited; 179 young people were referred, 97 from intervention and 82 from control practices. The relative risk of referral was not significant: 1.20 (95% confidence interval [CI] = 0.74 to 1.95; P = 0.48). No effect was observed on secondary outcomes except for ‘delay in reaching early-intervention services’, which was statistically significantly shorter in patients registered in intervention practices (95% CI = 83.5 to 360.5; P = 0.002).Conclusion
GP training on first-episode psychosis is insufficient to alter referral rates to early-intervention services or reduce the duration of untreated psychosis; however, there is a suggestion that training facilitates access to the new specialist teams for early psychosis. 相似文献9.
10.
Neil Perkins Anna Coleman Michael Wright Erica Gadsby Imelda McDermott Christina Petsoulas Kath Checkland 《The British journal of general practice》2014,64(628):e728-e734
Background
The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.Aim
To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.Design and setting
In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.Method
A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.Results
Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.Conclusion
GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration. 相似文献11.
Isobel M Cameron Kenneth Lawton Ian C Reid 《The British journal of general practice》2009,59(566):644-649
Background
Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.Aim
To assess whether GPs prescribe antidepressants appropriately.Design of study
Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.Setting
Four practices in Grampian, Scotland.Method
Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.Results
A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.Conclusion
There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively. 相似文献12.
Joanne E Butterworth John L Campbell 《The British journal of general practice》2014,64(628):e709-e718
Background
Older patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients.Aim
This study explored older patients’ trust in their GPs and their perceptions of shared decision making.Design and setting
Qualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK.Method
A constant comparative approach was applied to thematic analysis of transcribed interviews.Results
All participants valued feeling involved in decisions but differed regarding how they felt involved. Trust influenced preferences for shared decision making: a trusted GP ‘ally’, to competently manage participants’ increasing health-information requirements throughout the vulnerable ageing process, was important. Trust was affected by factors contributing to the facilitation of involvement. GP characteristics, communication skills, consultation duration, and continuity of care were common themes.Conclusion
Although limited geographically and subsequently by ethnic group, the present sample allows for reasonable transferability of the study to other UK populations. A range of factors are highlighted for consideration when planning primary healthcare delivery: to facilitate the optimal involvement of older patients in decisions about their health care, while enhancing their trust in the GP; to help minimise potential health inequalities for this patient group. 相似文献13.
14.
Clare McDermott Richard Coppin Paul Little Geraldine Leydon 《The British journal of general practice》2012,62(601):e538-e545
Background
Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As ‘gatekeepers’ to NHS, GPs are expected to make best use of resources and may be criticised for ‘inappropriate’ admissions. Little is understood about the influences on GPs as they make such decisionsAim
To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital.Design and setting
A purposive sample of 21 GPs from two counties in the South of England.Method
Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.Results
This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients’ and relatives’ preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable.Conclusion
Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions. 相似文献15.
16.
Stephen Campbell Kerin Hannon Helen Lester 《The British journal of general practice》2011,61(585):e183-e189
Background
Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.Aim
To explore GP and practice staff views and experiences of exception reporting in the QOF.Design of study
Qualitative semi-structured interviews.Setting
Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.Method
Semi-structured interviews, analysed using open explorative thematic coding.Results
Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.Conclusion
Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism. 相似文献17.
Shamil Haroon Peymane Adab Carl Griffin Rachel Jordan 《The British journal of general practice》2013,63(606):e55-e62
Background
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.Aim
To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.Design and setting
Pilot randomised controlled trial in two general practices in the West Midlands, UK.Method
A total of 1634 ever-smokers aged 35–79 years with no history of COPD or asthma were randomised into either a ‘targeted’ or ‘opportunistic’ case-finding arm. Respiratory questionnaires were posted to patients in the ‘targeted’ arm and provided to patients in the ‘opportunistic’ arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.Results
Twenty-six per cent (212/815) in the ‘targeted’ and 13.6% (111/819) in the ‘opportunistic’ arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the ‘targeted’ and ‘opportunistic’ arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = –0.5% to 3.08%]). Over a 12-month period, the ‘opportunistic’ case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the ‘targeted’ and £242.20 in the ‘opportunistic’ arm.Conclusion
Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this. 相似文献18.
Sabrina Grant Sheila M Greenfield Arie Nouwen Richard J McManus 《The British journal of general practice》2015,65(640):e776-e783
Background
Self-monitoring blood pressure (SMBP) is becoming an increasingly prevalent practice in UK primary care, yet there remains little conceptual understanding of why patients with hypertension engage in self-monitoring.Aim
To identify psychological factors or processes prompting the decision to self-monitor blood pressure.Design and setting
A qualitative study of patients previously participating in a survey study about SMBP from four general practices in the West Midlands.Method
Taped and transcribed in-depth interviews with 16 patients (6 currently monitoring, 2 used to self-monitor, and 8 had never self-monitored). Thematic analysis was undertaken.Results
Three main themes emerged: ‘self’ and ‘living with hypertension’ described the emotional element of living with an asymptomatic condition; ‘self-monitoring behaviour and medication’ described overall views about self-monitoring, current practice, reasons for monitoring, and the impact on medication adherence; and ‘the GP–patient transaction’ described the power relations affecting decisions to self-monitor. Self-monitoring was performed by some as a protective tool against the fears of a silent but serious condition, whereas others self-monitor simply out of curiosity. People who self-monitored tended not to discuss this with their nurse or GP, partly due to perceiving minimal or no interest from their clinician about home monitoring, and partly due to fear of being prescribed additional medication.Conclusion
The decision to self-monitor appeared often to be an individual choice with no schedule or systems to integrate it with other medical care. Better recognition by clinicians that patients are self-monitoring, perhaps utilising the results in shared decision-making, might help integrate it into daily practice. 相似文献19.
John L Campbell Mary Carter Antoinette Davey Martin J Roberts Marc N Elliott Martin Roland 《The British journal of general practice》2013,63(608):e171-e176