A quality management model for integrated care: results of a Delphi and Concept Mapping study

Objective. The objective of this study is to identify the elements andclusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methodswere applied. A literature study was conducted to identify elementsof integrated care. In a Delphi study experts commented andprioritized 175 elements in three rounds. During a half-a-daysession with the expert panel, Concept Mapping was used to clusterthe elements, position them on a map and analyse their content.Multi-dimensional statistical analyses were applied to designthe model. Participants. Thirty-one experts, with an average of 8.9 years of experienceworking in research, managing improvement projects or runningintegrated care programmes. Results. The literature study resulted in 101 elements of integratedcare. Based on criteria for inclusion and exclusion, 89 uniqueelements were determined after the three Delphi rounds. By usingConcept Mapping the 89 elements were grouped into nine clusters.The clusters were labelled as: ‘Quality care’, ‘Performancemanagement’, ‘Interprofessional teamwork’,‘Delivery system’, ‘Roles and tasks’,‘Patient-centeredness’, ‘Commitment’,‘Transparent entrepreneurship’ and ‘Result-focusedlearning’. Conclusion. The identified elements and clusters provide a basis for a comprehensivequality management model for integrated care. This model differsfrom other quality management models with respect to its generalapproach to multiple patient categories, its broad definitionof integrated care and its specification into nine differentclusters. The model furthermore accentuates conditions for effectivecollaboration such as commitment, clear roles and tasks andentrepreneurship. The model could serve evaluation and improvementpurposes in integrated care practice. To improve external validity,replication of the study in other countries is recommended.     

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

Dietary and exercise assessment in general practice

BACKGROUND: Diet and physical activity are important in many conditionsmanaged in primary care. Dietary and physical activity assessmentis complex, has inherent inaccuracies related to self-reporting,and is only a small part of a larger context of developing effectiveintervention in primary care. However, for personalized assessmentin routine clinical care, and for the assessment of differentintervention strategies in a general practice research setting,validated life-style assessment tools are needed. OBJECTIVE: We aimed to discuss the requirements for assessment tools andto identify feasible validated assessment instruments for usein primary care. METHODS: Potential tools were identified from a Medline search, UK ResearchIntelligence, and contact with groups known to be working inthe area. RESULTS: Several brief instruments assess mainly fat in the US diet butthe limited range of foods covered and the setting of studieslimits their generalizability. Only one tool developed for UKuse—‘DINE’, which scores total fat, fibreand unsaturated fat—was identified which is both feasibleand has documented reasonable validated characteristics. Evenfor this tool there are doubts about the validation ‘standard’.No diet or physical activity validation studies have used bothsubjects and health professionals from general practice settings. CONCLUSION: There are very few feasible and validated dietary or physicalactivity assessment tools for use in clinical care or researchin general practice, and doubts about the design and settingsof published validation studies. Further research is neededto validate and develop a range of feasible life-style assessmenttools with specified time and training requirements for usein primary care. Keywords. Nutrition assessment, primary health care, exercises.     

'Only connect': the centrality of doctor-patient relationships in primary care

EM Forster's call in A Passage to India to ‘only connect’is a shorthand for the hundreds of ways in which doctor–patientrelationships have been discussed in the literature. As Chew-Grahamstates, in the parallel editorial, this relationship, and thepatient-centred ideology which underpins it, is seen as intrinsicallytherapeutic. The evidence base for such an assumption is wellestablished, most notably in the literature on quality and continuityof care. The centrality of relationship-based primary care There is a strong association between personal continuity, enablementand patient satisfaction.¹ Since personal continuity impliesboth empathy and personal responsibility,^2,3 the studies overallshow a strong correlation between quality relationships andpatient satisfaction. Reviews of     

Chronically ill Australians' satisfaction with accessibility and patient-centredness

Objective. To evaluate the association of characteristics of patients andgeneral practices with patient assessment of quality of care. Design. Cross-sectional multi-practice study using the general practiceassessment survey. Settings. General practices in Australia. Participants. Ninety-six general practices and 7505 chronic illness patientsaged 18 years. Main outcome measures. Access of care and patient-centredness. Results. Two factors were identified in factor analysis: ‘Accessof care’ and ‘Patient-centredness’. Multilevelregression analysis showed significant associations betweenpatients' assessments and patient and practice characteristics.Patients from smaller practices (one to three general practitioners)reported better access to care compared with larger practices.Patients from urban areas were more satisfied with patient-centrednessthan those from rural areas. Self-reported health status andage had a positive and home ownership, employment and education,and patients from non-English-speaking countries a negativerelationship with both scores. Females were more satisfied withpatient-centredness. Conclusions. Patient assessments of quality of care and patient-centrednesswere strongly associated with practice and patient characteristics.This has important implications for interpreting assessmentsof the quality of primary care, and for policy and practicemeasures designed to improve this.     

Occupation and Risk for the Occurrence of Low-Back Pain (LBP) in Danish Employees

Using data from a nation-wide cross-sectional survey in 1990a study examining the risk for occurrence of LBP in variousspecific occupations was made among 5,185 Danish employees aged19–59 years old. After adjusting for the confounding effectsof age and gender we found significantly increased risks ofLBP in three out of nine major occupational categories. Theywere, ‘health care and social work’ (OR=1.52, 95%CI=1.28–1.80), ‘mining, quarrying and constructionwork’ (OR=1.97, 95% CI=1.41–2.74) and ‘manufacturingand machine operation work’ (OR=1.21, 95% CI=1.05–1.40).Among 39 second-level occupational categories the highest riskswere observed among persons employed in ‘building constructionwork’ (OR=1.97, 95% CI=1.41–2.74), ‘socialwork, child day care work and psychological work’ (OR=1.64,95% CI=1.32–2.05). Skilled and unskilled manual workershad an increased risk of LBP. Received       10 March 1995 Accepted        1 November 1995     

Sore throat management in general practice

This paper discusses primary care management of sore throatin the context of recent national ‘consensus’ guidelinesfrom the Drugs and Therapeutics Bulletin. The guidelines advisetaking a throat swab, using typical clinical features whereswabs are not available, and suggest that antibiotics shortenthe duration of symptoms and prevent complications. Systematicreviews and individual studies indicate that the evidence forprescribing antibiotics for most presentations of sore throatin general practice is marginal, and the benefits are probablyoutweighed by the likely costs of antibiotics. Using clinicalscorecards or symptom clusters to identify individuals who wouldbenefit from treatment is insensitive with low predictive value,although inexpensive. Using throat swabs as a gold standardfor diagnosis is inappropriate since they are neither very specificnor sensitive, and will greatly increase costs of management.The relative lack of evidence for the efficacy of antibioticsand for the use of throat swabs from primary care research,and also an unbalanced perspective of dangers and complicationsrelated predominantly to a secondary care setting, underlinesthe problem of achieving valid consensus guidelines. Guidelinesnot firmly based on evidence appropriate to the intended settingare more likely to be received sceptically and hinder gettingresearch into practice. Keywords. Sore throat, clinical guidelines, tonsilitis, pharyngitis, throat swab.     

Parents and nurses during the immunization of children--where is the power? A conversation analysis

Background. Best practice for health care practitioners is consideredpatient-centred approaches which empower patients. Immunizationof young children requires maintaining this approach while retainingprofessional management. Objective. The objectives were to assess situations within theimmunization event with discordance between health providerand caregiver and evaluate strategies used to empowering parentswhile obtaining the desired clinical outcome. Methods. This was a qualitative study nested within a largerstudy of immunization rates in 124 randomly selected primarycare practices. Interactions between immunizing practice nurses,caregivers and children were videotaped and transcribed andunderwent conversation analysis. Six purposively sampled primarycare practices in Auckland, New Zealand, served as the setting.The participants were eight practice nurses immunizing 10 childrenand their parents. Normative pattern of interactions and ‘deviantcases’ involving discordance between nurse and parent. Results. A total of 168 minutes of video-recorded conversationfrom 10 immunization sessions provided strong ‘typical’pattern and equally striking ‘deviant cases’. Parentsmostly treated nurses as ‘experts’ and acceptedasymmetry of knowledge over medical matters. Nurses demonstratedskilful strategies in delineating their area of medical expertisefrom areas in which patients are expert—their knowledgeof themselves and their children. Conclusion. While patient centredness and empowering patientsare contemporary goals of primary health care delivery, theseattributes are not precisely defined. Patients may wish to beinformed, but many trust their health professionals to directtheir decision making. Although health professionals may impartas much knowledge as they can, asymmetry of knowledge remains.However, patients hold expertise beyond their clinical situationin the social and economic world in which they live. Keywords. Caregivers, immunization, power, primary health care, qualitative research.     

Facing future challenges in general practice: a clinical method with computer support

This paper proposes a clinical method for general practice whichis patient-centred and which ensures that the doctor's agendais supported to secure ‘best practice’. It encompassesself-learning for GPs which is patient-focused and describesthe encouragement and support of patient self-care. The methodattempts to be pragmatic and usable within GPs' available time.The method, however, is not solely focused on the GP; it encompassesthe primary health care team and the patient. It uses clinicalinformation systems to assist in the management of the patientcare plan, to supply information to the GP and patient, in orderto aid shared decision making and to quality assure clinicalactivity. It goes further by extending the care process to handle‘virtual’ encounters in which the clinical informationsystems play a central role. Keywords. Family practice, medical informatics, models, philosophy, physician-patient relationships.     

UK research staff perspectives on improving recruitment and retention to primary care research; nominal group exercise

Background. Primary care studies often encounter recruitmentdifficulties, but there is little evidence to inform solutions.As part of a National Institute for Health Research School forPrimary Care Research and UK Clinical Research Network programme,we elicited research staff perspectives on factors facilitatingor obstructing recruitment. Objective. To identify factors that experienced research staffconsider important in successful recruitment and retention andtheir confidence in achieving them. Methods. An iterative series of three workshops was held. Thethird used a modified nominal group technique to categorizewhether factors related to the ‘context’ in whichthe research took place, the ‘content’ of the studyor the recruitment ‘process’ and to prioritize themby their importance to success. Results. Eighteen research staff participated in the prioritizationworkshop. They prioritized positive attitudes of primary carestaff towards research and trust of researchers by potentialparticipants as major contextual factors affecting recruitment.Studies needed to be considered safe and relevant by staff andfit with practice systems. They proposed that researchers strengthenrelationships with staff and participants and minimize workloadfor primary care teams. Although confident in many recruitmentprocesses, respondents remained uncertain how to achieve culturalchange so that research became part of normal practice activityand how best to motivate patients to participate. Conclusions. Research workers taking part identified factorswhich might be important in recruitment, several of which theyexpressed little confidence in addressing. Understanding howto improve recruitment is crucial if current efforts to strengthenprimary care research are to bear fruit. Keywords. Attitude of health personnel, health services research, patient selection, primary health care, randomized-controlled trials.     

Drug prescribing in hospital as experienced by general practitioners: East versus West Germany

BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are oftenchanged during hospitalization. This study set out to test thehypothesis that the extent of drug change and the informationprovided by the hospital determines the GPs' assessment of hospitalco-operation. The perception of drug change and hospital co-operationmay also be influenced by the degree of institutional separationof primary and secondary care. Therefore we compared GPs' respectiveattitudes in ‘East’ and ‘West’ Germany. METHOD: In 1993, a representative sample of ‘eastern’ and‘western’ German doctors received a structured questionnaire;554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPsbelieved that their medication was changed in hospital in morethan 60% of their patients. Only a minority of eastern (10%)and western (15%) doctors described the information providedby the hospitals as more or less satisfactory. More westernthan eastern doctors (56% versus 32%) expressed dissatisfactionwith hospital co-operation. Respondents in eastern Germany whofelt sufficiently informed about hospital drug change were morelikely to express satisfaction with the hospital doctors' co-operation.In the former area of West Germany the judgement of co-operationwas significantly better if the extent of drug change and thefrequency of generic drug replacement by original brand-namedrugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matterof concern, especially for GPs who are working in an area witha tradition of strictly separated primary and secondary care. Keywords. Drug prescribing, family practice, interprofessional relations, health system.     

Testing a conceptual model related to weight perceptions, physical activity and smoking in adolescents

The purpose of this study was to test a conceptual model basedon theoretical and empirically supported relationships relatedto the influences of weight perceptions, weight concerns, desiresto change weight, friends, age and location in relation to physicalactivity (PA) and smoking in adolescents. A total of 1242 malesand 1446 females (mean age = 15.6 ± 1.3) were recruitedfrom rural and urban Canadian schools. Study respondents providedself-reports of PA, ‘smoking’, ‘perceivedbody weight’, ‘desire to change weight’, ‘concernabout weight gain’ and ‘friends' smoking and PAbehaviors’. Results revealed an acceptable fitting model² (40) = 155.63, P < 0.05, root mean square error of approximation= 0.047 and comparative fit index = 0.98. Large effect sizesfor both genders were observed between friends' and adolescents'smoking behavior, and between perceived body weight and desireto change weight. Further, significant differences were identifiedbetween the male and female models [² difference (24) = 65.28,P < 0.05]. Several findings of this study point to the needto design programs to motivate adolescent females to adopt healthyweight-control practices and to target young peoples' socialnetworks to promote health behaviors, especially with regardto smoking. Received on December 22, 2005; accepted on June 15, 2006     

Who gets what: politics, evidence, and health promotion

Science journal, starting with its July 2005 issue, presentsits readers with 125 questions and problems yet to be resolvedby the scientific community. These range from the deceptivelysimple (‘what is the structure of water?’), theobvious (‘what triggers puberty?’ or ‘whatare the roots of human culture?’), to the amazingly esoteric(‘do mathematically interesting zero-value solutions ofthe Riemann zeta function all have the form of a+bi?’). More than half of these issues have     

Improving care for patients with diabetes: the role of simple reminders

It is now accepted that the correct place for routine managementof the person with diabetes is in primary care with supportingservices from specialists; various models of such care havebeen recently described.¹ The paper describing a ‘logistics support service’by Marianne Meulepas et al.² suggests that simple recall ofpatients for blood and annual review checks improves diabeticcontrol, with an HbA1c improvement of 0.7% when compared withthe control. The     

A new editor for Family Practice

Martin Luther believed that no-one should stay in a professionalrole for more than 10 years before moving on, and I am surethat you can think of many other aphorisms that would indicatethat I have been in this job too long. Well, Family Practicehas a new Editor, but before I tell you who it is, I would likethe opportunity to reflect on Family Practice, primary care,publishing and research. John Howie, one of Glasgow's most distinguished sons and certainlyEdinburgh's most distinguished primary care researcher, wasthe founding editor of Family Practice. This was a joint venturebetween Oxford University Press and the Royal College of GeneralPractitioners, to whom we must be grateful for helping to launchthe journal. For several years, ‘WONCA News’     

Health care as an instrument of Apartheid policy in South Africa

The paper focuses on five central features of health policyin South Africa. These are: (1) the differential expenditureon the health services for Whites, Coloureds, Indians and Africans;(2) the inequality between rural and urban African health services;(3) the structure and financing of rural health services forAfricans; (4) the recent restructuring of the urban health servicesfor Whites, Coloureds and Indians under the New Constitution;and (5) family planning policy. In each case the policy cannotbe adequately explained merely as a symptom of the differentialaccess to political and economic power: health services arealso instruments of the state in achieving Apartheid goals.Firstly, the health services aid in the reproduction of theBlack labour force according to White economic needs. The provisionof health care for Blacks outside the bantustans is geared towardsthe urban population as the supplier of a large and increasinglyskilled, Black workforce, rather than the Black population atlarge. Secondly, the health services support the commitmentto ‘separate development’ in various ways. Theyreproduce an ideology which legitimizes Apartheid. Within thebantustans, they are an important factor in inducing ‘surplus’Africans from ‘White’ areas to return to the bantustans.They help to establish the credibility of the bantustans andtheir leaders, and of the representatives in the new segregatedparliament. They also provide a lever with which the governmentcan pressurize bantustan governments into accepting ‘independence’.Thirdly, the health services are part of a strategy to co-optsome Blacks while dividing the opposition. Thus health policyis shown to be an instrument of the state's twin imperatives:reproducing the conditions of capitalist accumulation and maintainingWhite supremacy.     

Use of the ISO 9308-1 procedure for the detection of E. coli in water utilizing two incubation temperatures and two confirmation procedures and comparison with defined substrate technology

Disinfected and non-disinfected samples have been used to determine the accuracy of the ISO procedure (ISO 9308-1) for detection of E. coli in drinking water. Samples were analysed using the ISO procedure at both 36 and 44°C and using the defined substrate technology method Colilert-18^®/Quanti-Tray^® (Colilert-18). Utilizing the confirmation procedure described in ISO 9308-1, large numbers of false positive E. coli results were obtained using the ISO primary isolation procedure at 36°C. However, when glucuronidase production was used as the confirmation procedure, the ‘confirmed’ count of E. coli was lowest with ISO 9308-1 performed at 36°C. When TTC medium was incubated at 36°C confirmation using production of indole at 44°C resulted in 29% more ‘E. coli’ being recovered than when confirmation was performed using production of glucuronidase. When 44°C was used as the primary isolation temperature the difference between the number of ‘confirmed’ E. coli identified using the two confirmation procedures was less than 1% and was not significant. Identification of isolates which ‘confirmed’ when using production of indole at 44°C as the test method but °which failed to produce b-D-glucuronidase, showed that the majority of these isolates were Klebsiella oxytoca.     

Screening, Detection and Management of Depression in Elderly Primary Care Attenders. I: The Acceptability and Performance of the 15 Item Geriatric Depression Scale (GDS15) and the Development of Short Versions

One-hundred and ninety-eight elderly subjects attending theirgeneral practitioners (GPs) were asked to complete the 15 itemGeriatric Depression Scale (GDS15). Analysable results wereobtained from 194 (98%). Of these, 67 (34%) scored above theGDS15 cut-off (4/5) for significant depressive symptomatology.87.6% found the questionnaire to be acceptable and only 3.6%found it very difficult or very stressful. The GDS15 had a highlevel of internal consistency (Cronbach's alpha = 0.80). Allthe individual items of the GDS15 associated significantly (P<0.01) with total score and ‘caseness’. A singlequestion "do you feel that your life is empty?" identified 84%of ‘cases’. In an attempt to devise short scalesto screen elderly primary care patients for depression, thedata were subjected to logistic regression analysis. Ten (GDS10),four (GDS4) and one (GDS1) item versions were generated. Agreementbetween these short scales and the GDS15 in the original samplewas 95, 91 and 79% respectively. Cronbach's alpha was 0.72 forthe GDS10 and 0.55 for the GDS4. The short scales were thenvalidated in an independent sample of 120 patients in whom bothGDS data and the results of a detailed psychiatric interview(the Geriatric Mental Status Schedule, GMS) were available.The sensitivity and specificity of the GDS10 against GMS casenesswere 87 and 77% (cut-off 3/4); those of the GDS4 were 89 and65% (cut-off 0/1) and 61 and 81% (cut-off 1/2). Sensitivityand specificity for the GDS1 were 59 and 75%. It is concludedthat these short scales may be useful in helping GPs and practicestaff to identify elderly patients with significant depressivesymptoms.     

Prevalence of distress and symptom severity from the lower urinary tract in men: a population-based study with the DAN-PSS questionnaire

Background. Lower urinary tract symptoms (LUTS) are a commonand costly public health issue. The prevalence varies greatlyin published reports. The distress caused by each symptom isimportant to assess the primary care required before therapeuticdecisions or a referral to an urologist are made. Objectives. LUTS are highly prevalent in men, but less is knownregarding the distress caused by each symptom. The aim of thisstudy was to examine symptom severity and different levels ofdistress using the Danish Prostatic Symptom Score (DAN-PSS)questionnaire in men affected by symptoms from the lower urinarytract. Methods. The study included all men aged 41–81 years (n= 504) that, 12 months earlier in a population-based survey,had reported stress incontinence, urgency or post-micturitiondribbling in a postal questionnaire. The DAN-PSS questionnairewas used to measure severity and distress from LUTS. Results. In total, 311 (80%) of the 387 responders who reportedat least one symptom experienced some level of distress. Themost distressing symptom overall was urinary incontinence. Nineof 10 men with storage symptoms (stress, urge and ‘other’urinary incontinence) reported distress even if the symptomoccurred only seldom. Moreover, two-thirds of the men with themost frequent symptom, post-micturition dribbling, characterizedtheir symptom as moderate or severe; the most distressing voidingsymptom was weak stream. In general, LUTS were well tolerated. Conclusion. Urge incontinence was the most distressing LUTSeven when occurring only seldom. The DAN-PSS questionnaire maybe a potentially useful tool for health professionals to identifypatients with pronounced distress from LUTS to offer therapeuticand nursing care on the relevant level. Keywords. DAN-PSS, distress, LUTS, population-based, postal questionnaire.