Cervical cancer screening: a comparison of recruitment strategies among older women

OBJECTIVE: To compare the effectiveness of different recruitment strategies in encouraging older women to have a Papanicolaou (Pap) test. DESIGN: A 2 x 2 factorial study. SETTING: Two rural areas of Victoria, Australia. PARTICIPANTS: A total of 10,620 persons aged between 40 and 69 years and designated as female on electoral lists. INTERVENTIONS: A personal letter of invitation and a community-based campaign of 4 weeks' duration alone and in combination. A control group received no active intervention. OUTCOME MEASURE: The proportion of eligible women having a Pap test report issued by the Victorian Cytology Service during the 12 weeks after the intervention compared with the 12 weeks before the intervention, with an intervening two-week washout period. RESULTS: The odds ratio of an eligible woman being screened during the intervention period relative to the pre-intervention period was 3.00 for women who were exposed to the campaign and sent the letter of invitation (95% confidence interval, 2.38-3.77, P less than 0.001), 1.86 for women who were exposed to the campaign (95% confidence interval, 1.49-2.33, P less than 0.001), 1.61 for women who were sent the letter of invitation (95% confidence interval, 1.34-1.92, P less than 0.001). The baseline was a control group who received no active intervention. CONCLUSIONS: Both personal invitation letters and community-based campaigns are effective in recruiting women for Pap test screening. Combined strategies are more effective than single strategies.     

Identifying women with cervical neoplasia: using human papillomavirus DNA testing for equivocal Papanicolaou results

CONTEXT: A Papanicolaou (Pap) test result of atypical squamous cells of undetermined significance (ASCUS) presents a clinical challenge. Only 5% to 10% of women with ASCUS harbor serious cervical disease, but more than one third of the high-grade squamous intraepithelial lesions (HSILs) in screening populations are identified from ASCUS Pap test results. OBJECTIVE: To determine whether human papillomavirus (HPV) DNA testing of residual material from liquid-based Pap tests and referral of cases found to be HPV-positive directly to colposcopy could provide sensitive detection of underlying HSILs in women with ASCUS Pap results, compared with repeat Pap testing. DESIGN AND SETTING: Natural history of women with ASCUS Pap smear results, all of whom had liquid-based cytology, HPV testing, and subsequent repeat Pap tests and colposcopy with histologic evaluation, conducted at 12 gynecology clinics in a large managed care organization between October 1995 and June 1996. PARTICIPANTS: From a cohort of 46009 women who had routine cervical examinations, 995 women with Pap test results of ASCUS who consented to participate were identified. MAIN OUTCOME MEASURES: Cervical histology, HPV test results, and repeat Pap smear results, and sensitivity of HPV testing to identify patients found to have HSIL+ histology. RESULTS: Of 995 participants with ASCUS Pap test results, 973 had both a definitive histologic diagnosis and HPV result. Sixty-five (6.7%) had histologic HSIL or cancer. For women with histologic HSIL+, the HPV test was positive in 89.2% (95% confidence interval [CI], 78.4%-95.2%), and the specificity was 64.1 % (95% CI, 60.9%-67.2%). The repeat Pap smear result was abnormal in 76.2% (95% CI, 63.5%-85.7%). Triage based on HPV testing only or on repeat Pap testing only would refer similar proportions (approximately 39%) to colposcopy. The sensitivity of HPV DNA testing for HSIL was equivalent to, if not greater than, that of the repeat Pap test. We further estimated that an HPV-based algorithm including the immediate colposcopy of HPV-positive women, and then repeat Pap testing of all others, would provide an overall sensitivity of 96.9% (95% CI, 88.3%-99.5%). CONCLUSIONS: For women with ASCUS Pap tests, HPV DNA testing of residual specimens collected for routine cervical cytology can help identify those who have underlying HSIL. By testing the specimen collected at initial screening, the majority of high-risk cases can be identified and referred for colposcopy based on a single screening.     

Chlamydia screening--Australia should strive to achieve what others have not

Chlamydia screening programs overseas have failed to reduce chlamydia prevalence despite screening 20%-30% of young sexually active women. The Australian federal government announced in 2005 that it would provide $12.5 million for chlamydia control. Policymakers must look to chlamydia screening programs in other countries to learn from their experience. Australia has an excellent primary health care system and a strong track record in establishing highly successful public health programs. This experience places it in a strong position to design and implement an innovative chlamydia screening program to reduce chlamydia prevalence.     

Breast self-examination and breast examination by a health care provider: prevalence and predictors of screening in a randomly selected sample of Australian women

Professional organizations recommend the practice of monthly breast self-examination (BSE), and examination of the breasts by a health care provider every three years for women up to the age of 40 and annually thereafter. These practices were examined in a randomly selected sample of 1454 women. Only 39% (95% confidence interval [CI], 36%-42%) of the sample reported monthly BSE. Women were more likely to examine their breasts each month if they had found a breast lump, believed they were likely to get breast cancer, were not single, or were frequent users of general practitioners. Only 51% (95% CI, 45%-53%) of women under the age of 40 reported receiving three-yearly breast examinations; of those women aged 40 or more, 31% (CI, 27%-35%) of those with no additional risk factors and 35% (95% CI, 27%-42%) of those with at least one additional risk factor reported annual examinations. Women were more likely to have received a breast examination in the past three years if they had previously had a breast lump, were not single, had reached a higher educational level, were more frequent users of general practitioners, had private health insurance, or were described as other than ill or retired. There was a substantial association between BSE and breast examination by a health care provider with 25% (95% CI, 23%-27%) practising BSE and being screened by a health care provider. Thirty-five per cent (95% CI, 32%-38%) of women were not being screened by either method. The implications of the results for health education campaigns are discussed.     

基于湖南省第1次卫生服务调查分析孕产期妇女产前检查和#br# 产后访视情况及其影响因素

目的：利用湖南省第1次卫生服务调查数据,评价湖南省2008年至2013年孕产期妇女产前检查和产后访视情况并分析其影响因素。方法：采用2013年湖南省第1次卫生服务调查中孕产期妇女产前检查和产后访视的数据,根据2009年国家基本公共卫生服务规范中孕产期妇女须进行5次及以上产前检查和2次及以上产后访视的要求,计算产前检查和产后访视未达标率,采用率和构成比描述产前检查和产后访视情况,利用logistic回归模型,分析影响产前检查和产后访视未达标率的因素。结果：本研究共纳入1 035名妇女,其中产前检查未达标率为40.12%(95% CI：24.91%~55.33%),产后访视未达标率为64.88%(95% CI：39.70%~90.06%)。调整其他因素后,相较于最低收入家庭,中等、较高收入家庭妇女产前检查未达标率较低,其优势比分别为0.41和0.39;相较于初产妇,经产妇的产前检查未达标率较高,优势比为1.54;相较于15~24岁妇女,25~34,35~64岁组妇女的产后访视未达标率较低,其优势比分别为0.45和0.37;相较于最低收入家庭,较低、中等、较高收入家庭妇女产后访视未达标率较低,其优势比分别为0.50,0.46和0.54;相较于初产妇,经产妇的产后访视未达标率较高,优势比为2.30。结论：湖南省孕产期妇女产前检查和产后访视未达标率较高,当地政府部门可对低收入家庭、低年龄组、经产妇人群等采取措施,以降低未达标的 比例。     

Physical abuse of women before, during, and after pregnancy

CONTEXT: Clinicians who care for new mothers and infants need information concerning postpartum physical abuse of women as a foundation on which to develop appropriate clinical screening and intervention procedures. However, no previous population-based studies have been conducted of postpartum physical abuse. OBJECTIVES: To examine patterns of physical abuse before, during, and after pregnancy in a representative statewide sample of North Carolina women. DESIGN, SETTING, AND PARTICIPANTS: Survey of participants in the North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS). Of the 3542 women invited to participate in NC PRAMS between July 1, 1997, and December 31, 1998, 75% (n = 2648) responded. MAIN OUTCOME MEASURES: Prevalence of physical abuse during the 12 months before pregnancy, during pregnancy, and after infant delivery; injuries and medical interventions resulting from postpartum abuse; and patterns of abuse over time in relation to sociodemographic characteristics and use of well-baby care. RESULTS: The prevalence of abuse before pregnancy was 6.9% (95% confidence interval [CI], 5.6%-8.2%) compared with 6.1% (95% CI, 4.8%-7.4%) during pregnancy and 3.2% (95% CI, 2.3%-4.1%) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medical treatment for their injuries. Virtually all abused and nonabused women used well-baby care; private physicians were the most common source of care. The mean number of well-baby care visits did not differ significantly by maternal patterns of abuse. CONCLUSION: Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.     

A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial

OBJECTIVE: To investigate the effectiveness of an educational Quality Use of Medicines program, delivered at the level of general practice, on medicines use, falls and quality of life in people aged > or = 65 years. DESIGN: Cluster randomised controlled trial conducted in 2002. SETTING: General practices in the Hunter Region, New South Wales, Australia. PARTICIPANTS: Twenty general practitioners recruited 849 patients to participate in the study. INTERVENTION: Education (academic detailing, provision of prescribing information and feedback); medication risk assessment; facilitation of medication review; financial incentives. MAIN OUTCOME MEASURES: Primary measures: a composite score reflecting use of benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) and thiazide diuretics; secondary measures: use of medication reviews, occurrence of falls, quality of life (as assessed by SF-12 and EQ-5D survey scores. RESULTS: Compared with the control group, participants in the intervention group had increased odds of having an improved medication use composite score (odds ratio [OR], 1.86; 95% CI, 1.21-2.85) at 4-month follow-up but not at 12 months. At 4-month follow-up, the intervention group had reduced odds of using NSAIDs (OR, 0.62; 95% CI, 0.39-0.99) and showed a non-significant reduction in use of benzodiazepines (OR, 0.51; 95% CI, 0.20-1.30) and thiazide diuretics (OR, 0.70; 95% CI, 0.48-1.01). Changes in drug use were not significant at 12-month follow-up. At 12 months, intervention-group participants had lower adjusted ORs (AORs) for having a fall (AOR, 0.61; 95% CI, 0.41-0.91), injury (AOR, 0.56; 95% CI, 0.32-0.96), and injury requiring medical attention (AOR, 0.46; 95% CI, 0.30-0.70). Quality-of-life scores were unaffected by the intervention. CONCLUSION: Education and systems for medication review conducted by GPs can be used to improve use of medicines. These interventions are associated with a reduction in falls among older people, without adverse effects on quality of life.     

Prostate-specific antigen testing in Ontario: reasons for testing patients without diagnosed prostate cancer

BACKGROUND: The use of the prostate-specific antigen (PSA) test has been increasing rapidly in Canada since its introduction in 1988. The reasons for using the PSA test in patients without known prostate cancer are unclear. This paper reports on the first study in Canada to use physician records to assess the use of PSA testing. METHODS: A questionnaire was mailed to physicians attending 475 patients without diagnosed prostate cancer. The patients were randomly selected from 2 laboratory databases of PSA test records in the greater Toronto area during 1995. The physicians were asked to consult their patient records to avoid recall bias. Information obtained included physician's specialty, patient's age at time of PSA test and reason(s) for the test. RESULTS: There were 264 responses (56%), of which 240 (91%) were usable. Of these 240, 63% (95% confidence interval [Cl] 58%-70%) indicated that the test was conducted to screen for prostate cancer, 40% (95% Cl 34%-47%) said it was to investigate urinary symptoms, and 33% (95% Cl 27%-40%) responded that it was a follow-up to a medical procedure or drug therapy. More than one reason was permitted. Of 151 responses indicating screening as one reason for testing, 64% (95% Cl 56%-72%) stated that it was initiated by the patient, and 73% (95% Cl 65%-80%) stated that it was part of a routine examination. For 19%, both investigation of symptoms and screening asymptomatic patients were given as reasons for testing, and for another 19% both follow-up of a medical procedure and screening were given as reasons. Screening was recorded as a reason for testing far more commonly for patients seen by family physicians and general practitioners than for patients seen by urologists (67% v. 29%, p < 0.001). In contrast, the use of PSA testing to diagnose urinary symptoms was more common for patients seen by urologists than for those seen by family physicians and general practitioners (52% v. 37%, p = 0.044). No significant difference was found between physician groups in the use of PSA testing as a follow-up of a medical procedure (42% for urologists and 31% for family physicians and general practitioners). About 24% of the PSA test records were for patients younger than 50 and older than 70 years. PSA testing initiated by patients was more common in the practices of family physicians and general practitioners than in the practices of urologists (44% v. 13%, p < 0.001). INTERPRETATION: Screening for prostate cancer was the most common reason for PSA testing in our study group; it occurred most commonly in the family and general practice setting and was usually initiated by the patient. Differences in reasons for testing were identified by practice specialty. Although PSA screening for prostate cancer is sometimes recommended for men between 50 and 70 years of age, it is being conducted in men outside this age group.     

How do Australian patients rate their general practitioner? A descriptive study using the General Practice Assessment Questionnaire

OBJECTIVE: To report patient responses to the General Practice Assessment Questionnaire (GPAQ) as a measure of satisfaction with health care received from Australian general practitioners. DESIGN, SETTING AND PARTICIPANTS: A clustered cross-sectional study involving general practice patients from 30 randomly selected general practices in Victoria. Between January and December 2005, a screening survey, including a postal version of the GPAQ, was mailed to 17 780 eligible patients. MAIN OUTCOME MEASURE: Scores on the six GPAQ items. RESULTS: We analysed data from 7130 patients who completed the screening survey and fulfilled our eligibility criteria. Levels of patient satisfaction with general practice care were generally high: mean GPAQ scores ranged from 68.6 (95% CI, 66.1-71.0) for satisfaction with access to the practice to 84.0 (95% CI, 82.2-85.4) for satisfaction with communication. Intracluster correlations for the GPAQ items ranged from 0.016 for overall satisfaction with the practice to 0.163 for satisfaction with access to the practice. Compared with national benchmarks in the United Kingdom, the GPs and practices participating in our study were rated higher on all six GPAQ items. Multivariable mixed effects linear regression showed that patients who were older, rated their health more highly, visited their GP more frequently and saw the same GP each time tended to express greater satisfaction with their care. CONCLUSION: Generally patients reported high levels of satisfaction with GP care. Greater satisfaction with care was associated with older patients, good health, more frequent contact with the GP, and seeing the one GP consistently.     

Colonoscopy screening for colorectal cancer: the outcomes of two recruitment methods

OBJECTIVES: To determine the response to colorectal cancer (CRC) screening by colonoscopy, through direct invitation or through invitation by general practitioners. DESIGN AND SETTING: Two-way comparison of randomised population sampling versus cluster sampling of a representative general practice population in the Australian Capital Territory, May 2002 to January 2004. INTERVENTION: Invitation to screen, assessment for eligibility, interview, and colonoscopy. SUBJECTS: 881 subjects aged 55-74 years were invited to screen: 520 from the electoral roll (ER) sample and 361 from the general practice (GP) cluster sample. MAIN OUTCOME MEASURES: Response rate, participation rate, and rate of adenomatous polyps in the screened group. RESULTS: Participation was similar in the ER arm (35.1%; 95% CI, 30.2%-40.3%) and the GP arm (40.1%; 95% CI, 29.2%-51.0%) after correcting for ineligibility, which was higher in the ER arm. Superior eligibility in the GP arm was offset by the labour of manual record review. Response rates after two invitations were similar for the two groups (ER arm: 78.8%; 95% CI, 75.1%-82.1%; GP arm: 81.7%; 95% CI, 73.8%-89.6%). Overall, 53.4% ineligibility arose from having a colonoscopy in the past 10 years (ER arm, 98/178; GP arm, 42/84). Of 231 colonoscopies performed, 229 were complete, with 32% of subjects screened having adenomatous polyps. CONCLUSIONS: Colonoscopy-based CRC screening yields similar response and participation rates with either random population sampling or general practice cluster sampling, with population sampling through the electoral roll providing greater ease of recruitment.     

Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999

CONTEXT: Most sore throats are due to viral upper respiratory tract infections. Group A beta-hemolytic streptococci (GABHS), the only common cause of sore throat warranting antibiotics, is cultured in 5% to 17% of adults with sore throat. The frequency of antibiotic use for pharyngitis has greatly exceeded the prevalence of GABHS, but less is known about specific classes of antibiotics used. Only penicillin and erythromycin are recommended as first-line antibiotics against GABHS. OBJECTIVES: To measure trends in antibiotic use for adults with sore throat and to determine predictors of antibiotic use and nonrecommended antibiotic use. DESIGN, SETTING, AND SUBJECTS: Retrospective analysis of 2244 visits to primary care physicians in office-based practices in the National Ambulatory Medical Care Survey, 1989-1999, by adults with a chief complaint of sore throat. MAIN OUTCOME MEASURES: Treatment with antibiotics and treatment with nonrecommended antibiotics, extrapolated to US annual national rates. RESULTS: There were an estimated 6.7 million annual visits in the United States by adults with sore throat between 1989 and 1999. Antibiotics were used in 73% (95% confidence interval [CI], 70%-76%) of visits. Patients treated with antibiotics were given nonrecommended antibiotics in 68% (95% CI, 64%-72%) of visits. From 1989 to 1999, there was a significant decrease in use of penicillin and erythromycin and an increase in use of nonrecommended antibiotics, especially extended-spectrum macrolides and extended-spectrum fluoroquinolones (P<.001 for all trends). In multivariable modeling, increasing patient age (odds ratio [OR], 0.86 per decade; 95% CI, 0.79-0.94) and general practice specialty (OR, 1.54 compared with family practice specialty; 95% CI, 1.10-2.14) were independent predictors of antibiotic use. Among patients receiving antibiotics, nonrecommended antibiotic use became more frequent over time (OR, 1.17 per year; 95% CI, 1.11-1.24). CONCLUSIONS: More than half of adults are treated with antibiotics for sore throat by community primary care physicians. Use of nonrecommended, more expensive, broader-spectrum antibiotics is frequent.     

Increasing cervical screening in women of more than 40 years of age: an intervention in general practice

An intervention that was aimed at increasing cervical screening in women of more than 40 years of age was undertaken, with general practitioners as the primary point of contact. The intervention consisted of the practice receptionist giving female patients pamphlets about Papanicolaou smear-tests and the general practitioner offering a Papanicolaou smear-test. Nineteen general practitioners and their female patients (n = 466) of more than 40 years of age who presented for consultation over a 10-day period were involved in this study. Each woman in the study was asked when she had last undergone a Papanicolaou smear-test. All women who were found to be "at risk", that is, who had not undergone a Papanicolaou smear-test in the previous two years (57% of those women who were asked) were offered cervical screening. Over-all about 50% of the women who were found to be "at risk" underwent a Papanicolaou smear-test at the general practitioner initiated request, either at the same consultation (26% of those "at risk") or on their return at a later date (23% of those "at risk"). Therefore, the intervention appears to have been effective in encouraging a relatively high-risk group of patients to undergo Papanicolaou smear-tests. However, the strategy was differentially effective depending on age: more women of less than 65 years of age underwent a Papanicolaou smear-test than did women of more than 65 years of age. The feasibility of using the intervention in everyday general practice depends on the willingness of medical practitioners to ask female patients to undergo a Papanicolaou smear-test, the ability to take a Papanicolaou smear during the consultation or soon after, and the acceptance of the invitation by women as based on an understanding of the need.     

Characteristics of respondents to a cervical cancer screening program in a developing country

BACKGROUND: Characteristics associated with the response to a personalized, mailed invitation for the Papanicolaou (Pap) test vary among women. This study assesses the relationship between selected characteristics (e.g., demographic, obstetric, Pap history) and the response to a letter of invitation to undergo a Pap test among Mexican women affiliated with the Mexican Social Security Institute (IMSS). METHODS: Study subjects were 328 women affiliated with the IMSS who received and responded to a mailed letter of invitation, and 247 age- and clinically matched controls who received but did not respond to the letter of invitation. Statistical analysis consisted of multivariate conditional regression model. RESULTS: Having better housing conditions was one of the factors associated with letter response (medium level vs. low level, odds ratio [OR] = 3.17, 95% confidence interval [95% CI] = 2.46-4.09; high level vs. low level, OR = 2.65, 95% CI = 2.06-3.41). Other factors positively associated with letter response were greater number of pregnancies, previous Pap testing, being pleased at receipt of the letter of invitation, and knowing another woman who had received the invitation. Factors associated negatively to letter response were 7 or more years of formal education (> or =7 years vs. 0-6 years, OR = 0.50, 95% CI = 0.40-0.63), having a current job, availability of other medical services in addition to the IMSS, and willingness to receive Pap results by mail. CONCLUSIONS: Low educational level is not a limitation for cervical cancer screening call and recall among women affiliated with the IMSS.     

Promotion of attendance for mammographic screening through general practice: a randomised trial of two strategies.

OBJECTIVE: To compare the effectiveness of two strategies--patient education and practitioner recommendation--in encouraging women to attend for mammographic screening. DESIGN: The study was a prospective randomised controlled trial. Women aged between 40 and 70 years attending a general practitioner participated in the study. Consenting, eligible women were randomly allocated to one of the two strategy groups. SETTING: The study was conducted in private general practice in Newcastle, New South Wales. PARTICIPANTS: The general practitioners who took part in the study were a non-random sample of practitioners: 20 were approached, two declined to participate, and five failed to begin recruitment, leaving 13 practitioners who took part in the study. A total of 302 women aged 40-69 were recorded as attending the surgeries during recruitment sessions. Twenty women did not consent to the study and 73 were ineligible. Thirty-four women were not given the intervention because the general practitioner forgot or did not have time. There were 92 women in the simple recommendation group and 83 women in the patient education group. INTERVENTIONS: An intensive patient education approach based on health belief principles was compared with a simple recommendation by the general practitioner that the woman have a mammogram. MAIN OUTCOME MEASURE: Attendance rates were calculated from screening service attendance records. RESULTS: No significant difference in attendance rates was observed between the two groups, 82% of the simple recommendation group and 91% of the patient education group attended for screening. CONCLUSIONS: These results suggest that mammographic screening can be effectively promoted in general practice without extensive patient education.     

Using checklists and reminders in clinical pathways to improve hospital inpatient care

OBJECTIVES: To determine whether the quality of hospital inpatient care can be improved by using checklists and reminders in clinical pathways. DESIGN: Comparison of key indicators before and after the introduction of clinical pathways incorporating daily checklists and reminders of best practice integrated into patient medical records. SETTING AND PARTICIPANTS: The study, at Wimmera Base Hospital in Horsham, Victoria, included patients admitted between 1 January 1999 and 31 December 2002 with ST-elevation acute myocardial infarction (AMI) and patients admitted between 31 July 1999 and 31 December 2002 with stroke. MAIN OUTCOME MEASURES: Compliance with key process measures determined as best practice for each clinical pathway. RESULTS: 116 patients with AMI and 123 patients with stroke were included in the study. ST-elevation AMI. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 21.4% (95% CI, 7.3%-32.7%) for patients receiving aspirin in the emergency department; 42.7% (95% CI, 26.3%-59.0%) for eligible patients receiving beta-blockers within 24 h of admission; 48.1% (95% CI, 31.4%-64.8%) for eligible patients being prescribed beta-blockers on discharge; 43.7% (95% CI, 28.4%-59.1%) for patients having fasting lipid levels measured; and 41.2% (95% CI, 19.0%-63.5%) for eligible patients having lipid therapy. Stroke. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 40.7% (95% CI, 21.0%-60.2%) for dysphagia screening within 24 h of admission; 55.4% (95% CI, 32.9%-77.9%) for patients with ischaemic stroke receiving aspirin or clopidogrel within 24 h of admission; and 52.4% (95% CI, 33.8%-70.9%) for patients having regular neurological observations during the first 48 h after a stroke. There was a fall of 1.0 percentage point (ie, a difference of -1% [95% CI, -4.7% to 10.0%]) in the proportion of patients having a computed tomography brain scan within 24 h of admission. CONCLUSION: Significant improvements in the quality of patient care can be achieved by incorporating checklists and reminders into clinical pathways.     

The positive experience of screening quality among users of a cervical cancer detection center

BACKGROUND: Our objective was to determine the main factors associated with increased utilization of a cervical cancer screening program (CCSP) in a population with a high mortality rate due to cervical cancer. METHODS: A population-based study was carried out in the Mexican state of Morelos, Mexico. The study population included 3,197 women between the ages of 15 and 49 years who were selected at random using a State Household Sampling Framework in the State of Morelos's 33 municipalities. The sample included 2,094 women with a history of a previous Papanicolaou (Pap) test. RESULTS: A previous experience of good screening quality is strongly associated with greater use of the CCSP (OR = 4.2; 95% confidence interval [CI], 1.6-10.9). The educational level of the head of the family is related to more frequent use of Pap smear services. Women whose husbands have 13 or more years of education (OR = 1.8; 95% CI 1.1-2.9) were more likely to have been screened. Similarly, women who had used two or more family planning methods (OR = 1.6; 95% CI 1.2-2.1) and those who knew why the Pap test was given (OR = 3.0; 95% CI 2.1-4.3) had a better history of Pap screening. CONCLUSIONS: In areas where coverage of cervical cancer screening is low, a CCSP that guarantees the quality of all the different elements of care is essential if obstacles to cervical cancer prevention are to be eliminated. It is of particular importance to take into account and satisfy the perceptions and expectations of the women at risk.     

General practitioners' awareness of their own drug prescribing profiles after postal feedback and outreach visits

Abstract

Background. General practice accounts for the vast majority of drug prescribing in the Nordic countries. Various methods have been used to promote rational drug prescribing. Awareness of own prescribing profile may be a first crucial step in the quality assessment and improvement process.

Aim of the study. To analyse awareness among general practitioners of their drug prescribing profile during two outreach visits one year apart.

Methods. All 94 practices with a total of 166 general practitioners in the former Storstrøm County, Denmark, were invited to participate in a project launching outreach visits led by a general practitioner; 88 practices with 160 general practitioners agreed to participate.

Results. During the first round of outreach visits the general practitioners were asked to rate their own prescribing level of 13 major drug groups as being in the lowest 25%, the middle 26%–74%, or the highest 25% of the distribution across all 88 practices. The result was better than chance (chi-square = 337, 4 df, r = 0.37, both P < 0.0001). After the assessment a one-hour discussion on rational drug prescribing was held. One year later a new round of outreach visits was held. This time the assessment accuracy was generally greatly improved (chi-square = 724, 4 df, r = 0.48, both P < 0.0001). The main determinants for the improved accuracy during the second round were high accuracy during the first round, and the number of general practitioners in the practice.

Conclusions. General practitioners' awareness of their prescribing volumes was substantially improved by a single outreach visit with discussion on rational drug prescribing.     

Occupational stress: a survey of management in general practice

OBJECTIVES: To identify approaches to and barriers associated with the management of patients with work-related stress by general practitioners (GPs). DESIGN: Cross-sectional postal survey using a self-administered questionnaire which included a case vignette of a patient with work-related stress and questions ascertaining perceived barriers to the effective general practice management of work-related stress. PARTICIPANTS AND SETTING: 450 Western Australian GPs on the mailing list of a GP journal. The survey was conducted between 22 March and 28 April 2000. MAIN OUTCOME MEASURES: Likelihood that GPs would (i) choose to open a workers compensation claim and (ii) provide time off work for the patient described in the vignette. RESULTS: Response rate was 50.1%. Eighty-five percent (95% CI, 79.6%-19.7%) of respondents advised the hypothetical patient to take time away from work; however, only 44.0% (95% CI, 37.2%-50.7%) chose to initiate a workers compensation claim. GPs with training or experience in occupational health were less likely to advise the patient to stay away from work (odds ratio [OR], 0.30; 95% CI, 0.12-0.73), but were just as likely to initiate a claim. GPs were reluctant to involve the employer in management decisions, because of concern about patient confidentiality and the potential to make matters worse for the patient. These, and the adversarial nature of the workers compensation system, were the strongest perceived barriers to effective management of the condition. CONCLUSIONS: Our findings indicate that general practitioners take a pragmatic and varied approach to the management of work-related stress. The perceived difficulties with contacting employers challenges the principles of injury management within a workers compensation system which is dependent on liaison between system stakeholders.