Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

Background

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.

Aim

The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.

Design and setting

Retrospective cross-sectional study in general practices in England.

Method

Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.

Results

GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.

Conclusion

Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’.     

Why do patients with cancer access out-of-hours primary care? A retrospective study

Background

Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care.

Aim

To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department.

Design and setting

A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011.

Method

Subjects were identified by filtering the OOH computer database using the Read Codes ‘neoplasm’, ‘terminal care’, and ‘terminal illness’. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s).

Results

Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication.

Conclusion

Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning.     

Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

Verbal and non-verbal behaviour and patient perception of communication in primary care: an observational study

Background

Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours.

Aim

To explore the relationship of observer ratings of behaviours of videotaped consultations with patients’ perceptions.

Design and setting

Observational study in general practices close to Southampton, Southern England.

Method

Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains.

Results

In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), ‘back-channelling’ (for example, saying ‘mmm’) (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness (‘aloof’) was helpful and optimism unhelpful. Finishing with non-verbal ‘cut-offs’ (for example, looking away), being professionally cool (‘aloof’), or patronising, (‘infantilising’) resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication.

Conclusion

These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional ‘coolness’ at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end.     

Patients’ assessments of the continuity of primary care in Finland: a 15-year follow-up questionnaire survey

Background

Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.

Aim

To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.

Design and setting

A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.

Method

The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.

Results

Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96).

Conclusion

Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland.     

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care

Background

Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area.

Aim

To ascertain the key learning points from GPs’ experiences of diagnostic errors and approaches to clinical decision making associated with these.

Design and setting

Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK.

Method

Two datasets of semi-structured interviews were combined. Questions focused on GPs’ experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically.

Results

Learning points include GPs’ reliance on ‘pattern recognition’ and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a ‘restricted rule out’ approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed.

Conclusion

Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors.     

Factors influencing professional decision making on unplanned hospital admission: a qualitative study

Background

Unplanned admissions to hospital are a challenge for healthcare systems internationally. In the UK variation in unplanned admission rates across geographical areas, general practices and GPs remains largely unexplained.

Aim

To identify factors influencing professional decision making around unplanned hospital admission.

Design and setting

Qualitative study with a purposive sample of health and social care professionals from three primary care trusts, two acute hospitals, social services and an ambulance service in the South West of England.

Method

Semi-structured interviews were conducted with 19 professionals. Interviews were audio-recorded and transcribed. Data were analysed thematically drawing on the constant comparative method.

Results

The main factors influencing professional decision making around unplanned admissions were: lack of availability of seamless care on a 24/7 basis; ‘professional tribalism’ and poor information flow; service targets and performance management; commissioning culture and the impact of a ‘market approach’; and clinical governance structures, tolerance of risk and the role of peer support. A tension was perceived between the need to reduce unplanned admissions by tolerating more risk in primary care and a risk averse culture in secondary and emergency care.

Conclusion

Professional decision making that leads to unplanned admission to hospital is influenced by a range of organisational and individual health or social care professional factors. Finding ways to modify and ameliorate the effects of these systems and individual influences should be considered an important goal in the design of new interventions.     

Use of alarm features in referral of febrile children to the emergency department: an observational study

Background

The diagnostic value of alarm features of serious infections in low prevalence settings is unclear.

Aim

To explore to what extent alarm features play a role in referral to the emergency department (ED) by GPs who face a febrile child during out-of-hours care.

Design and setting

Observational study using semi-structured, routine clinical practice data of febrile children (<16 years) presenting to GP out-of-hours care.

Method

Logistic regression analyses were performed to assess the association between alarm features of serious infections (selected from two guidelines and one systematic review) and referral to the ED. Adherence to the guideline was explored by a 2×2 contingency table.

Results

In total 794 (8.1%) of 9794 eligible patients were referred to the ED. Alarm signs most strongly associated with referral were ‘age <1 month’, ‘decreased consciousness’, ‘meningeal irritation’, and ‘signs of dehydration’. Nineteen percent of 3424 children with a positive referral indication according to the guideline were referred to the ED. The majority of those not referred had only one or two alarm features present. A negative referral indication was adhered to for the majority of children. Still, in 20% of referred children, alarm features were absent.

Conclusion

In contrast to guidance, GPs working in primary out-of-hours care seem more conservative in referring febrile children to the ED, especially if only one or two alarm features of serious infection are present. In addition, in 20% of referred children, alarm features were absent, which suggests that other factors may be important in decisions about referral of febrile children to the hospital ED.     

Quality care provision for older people: an interview study with patients and primary healthcare professionals

Background

In recent years, primary health care for the ageing population has become increasingly complex.

Aim

This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people.

Design and setting

This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands.

Method

All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached.

Results

Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals.

Conclusion

Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.     

Predicting prolonged duration of fever in children: a cohort study in primary care

Background

Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care.

Aim

To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.

Design and setting

A prospective cohort study at a GPs’ cooperative (GPC) out-of-hours service.

Method

Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact.

Results

Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that ‘sore throat’ (OR 2.8; 95% CI = 1.30 to 6.01) and ‘lymph nodes palpable’ (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01).

Conclusion

The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.     

Continuity in different care modes and its relationship to quality of life: a randomised controlled trial in patients with COPD

Background

New care modes in primary care may affect patients’ experienced continuity of care.

Aim

To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease (COPD) changes after different care modes are introduced, and to analyse the relationship between continuity of care and patients’ quality of life.

Design and setting

Randomised controlled trial with 2-year follow-up in general practice in the Netherlands.

Method

A total of 180 patients with COPD were randomly assigned to three different care modes: self-management, regular monitoring by a practice nurse, and care provided by the GP at the patient''s own initiative (usual care). Experienced continuity of care as personal continuity (proportion of visits with patient''s own GP) and team continuity (continuity by the primary healthcare team) was measured using a self-administered patient questionnaire. Quality of life was measured using the Chronic Respiratory Questionnaire.

Results

Of the final sample (n = 148), those patients receiving usual care experienced the highest personal continuity, although the chance of not contacting any care provider was also highest in this group (29% versus 2% receiving self-management, and 5% receiving regular monitoring). There were no differences in experienced team continuity in the three care modes. No relationship was found between continuity and changes in quality of life.

Conclusion

Although personal continuity decreases when new care modes are introduced, no evidence that this affects patients’ experienced team continuity or patients’ quality of life was found. Patients still experienced smooth, ongoing care, and considered care to be connected. Overall, no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged.     

What happens when doctors are patients? Qualitative study of GPs

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 analysis

Results

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.     

Developing a preliminary ‘never event’ list for general practice using consensus-building methods

Background

The ‘never event’ concept has been implemented in many acute hospital settings to help prevent serious patient safety incidents. Benefits include increasing awareness of highly important patient safety risks among the healthcare workforce, promoting proactive implementation of preventive measures, and facilitating incident reporting.

Aim

To develop a preliminary list of never events for general practice.

Design and setting

Application of a range of consensus-building methods in Scottish and UK general practices.

Method

A total of 345 general practice team members suggested potential never events. Next, ‘informed’ staff (n =15) developed criteria for defining never events and applied the criteria to create a list of candidate never events. Finally, UK primary care patient safety ‘experts’ (n = 17) reviewed, refined, and validated a preliminary list via a modified Delphi group and by completing a content validity index exercise.

Results

There were 721 written suggestions received as potential never events. Thematic categorisation reduced this to 38. Five criteria specific to general practice were developed and applied to produce 11 candidate never events. The expert group endorsed a preliminary list of 10 items with a content validity index (CVI) score of >80%.

Conclusion

A preliminary list of never events was developed for general practice through practitioner experience and consensus-building methods. This is an important first step to determine the potential value of the never event concept in this setting. It is now intended to undertake further testing of this preliminary list to assess its acceptability, feasibility, and potential usefulness as a safety improvement intervention.     

Users' reports and evaluations of out-of-hours health care and the UK national quality requirements: a cross sectional study

Background

National standards for delivery of out-of-hours services have been refined. Health service users'' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs.

Aim

To investigate NHS service users'' reports and evaluations of out-of-hours care in the light of UK national service quality requirements.

Design

Cross sectional survey.

Setting

Three areas (Devon, Cornwall, Sheffield) of England, UK.

Method

Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users'' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment (‘call back time’); the time waiting for a home visit; and the waiting time at a treatment centre.

Results

UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of ‘up to an hour’), only one-third of users reported this as ‘excellent’. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as ‘excellent’, this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes.

Conclusion

Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of ‘good’ quality by service users. Attaining ‘excellent’ levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users'' expectations as well as their experience of care.     

Effect of stepped care on health outcomes in patients with osteoarthritis: an observational study in Dutch general practice

Background

A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.

Aim

To assess the association between care that is in line with the SCS recommendations and health outcomes.

Design and setting

Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.

Method

Care was considered ‘SCS-consistent’ if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0–100); active pain coping with the Pain Coping Inventory (range 10–40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12–48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.

Results

No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, −4.3 (95% confidence interval [CI] = −10.3 to 1.7) and −1.9 (95% CI = −7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.

Conclusion

The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.