Group interviews in primary care research: advancing the state of the art or ritualized research?

BACKGROUND: Focus groups have become an important data gathering technique in primary care research. OBJECTIVES: This study provides an integrated review of recent articles that used focus groups as a data collection method to gather information from family physicians. METHODS: Medline was searched for articles that used focus groups with family physicians in a North American setting during the 1990s. Articles that met this criteria were critically evaluated to determine who participated, the number of groups conducted, setting, length, inclusion and exclusion criteria, sampling technique and whether the groups were used as part of a larger study. RESULTS: The twenty articles discussed herein revealed tremendous variation in how focus group research is conducted and reported. CONCLUSIONS: Focus group research is a popular form of qualitative research in primary care research. Journals reporting qualitative research should require that certain basic information be present, thereby advancing the state of the art and permitting readers to better evaluate these articles.     

Postoperative wound infections: a useful indicator of quality of care?

An indicator can be defined as a measurable element of care that gives an impression of the quality of care. It can be used for screening on potential quality problems, for monitoring of well-defined processes and for a check after the introduction of quality improvement activities. Although the notion of an indicator appears to be an attractive concept in quality management, some questions have to be answered before a specific indicator can be used. The first question regards the validity of the indicator: to what extent does the indicator reflect the quality of the care? Next is the question of registration: can the indicator be measured in a valid and reliable way? The third question is whether appropriate activities will be initiated after the indicator has given a signal. Postoperative wound infections appears to be a valid outcome indicator because of the relationship between process of care (infection prevention policy) and outcome of care (the number of infections). The weak point lies in the reliability of the registration of wound infections.     

What happens next? Evaluation of a scheme to support primary care practitioners with a fledgling interest in research

INTRODUCTION: Various initiatives have been implemented in recent years to support primary care practitioners new to research. We describe the evaluation of one particular scheme, the NHS Eastern Region Primary Care R&D Enterprise Award Scheme, and discuss the implications of the results for future policy. METHODS: Representatives from both the funders (NHS R&D) and the award holders were involved in the design of an evaluation questionnaire and in the interpretation of the results. RESULTS: and Discussion. The evaluation demonstrated value in relation to traditional research outcomes and also, notably, in relation to professional contribution. Future policies may need to address: the indicators used in measuring the success of such schemes; the relationship between what individuals choose to do and its context within national policy on research and development; and the sustainability of involvement in research.     

Literacy in primary care populations: is it a problem?

BACKGROUND: Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets. METHODS: We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula. RESULTS: The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level. CONCLUSION: Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.     

Defining primary care sensitive conditions: a necessity for effective primary care delivery?

Primary care is a major component of England''s National Health Service (NHS), responsible for approximately 300 million consultations per year with GPs in England, which represents 70–90% of all patient contacts with the NHS. In addition to providing healthcare to the registered population, GPs are charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers. As GPs will be assuming a key role in commissioning health services in England, there is a clear opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. It is essential that there is evidence to inform what conditions are most sensitive to management in primary care – commonly referred to as primary care sensitive conditions or ambulatory care sensitive conditions. Such definitions would aid resource planning, drafting of local management protocols and simplification of the interface between primary and secondary care for a number of chronic conditions. Indeed, inappropriate utilization of secondary care resources is likely to represent a significant opportunity cost to healthcare providers and may be less desirable for patients.Primary care is a major component of England''s National Health Service (NHS), responsible for approximately 300 million consultations per year with general practitioners (GPs) in England,¹ which represents 70–90% of all patient contacts with the NHS.² In addition to providing healthcare to the registered population, GPs are charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers.While primary care has a role to play in the management of acute conditions, there are a number of alternative means by which individuals can directly access appropriate advice and care for acute problems via services such as NHS Direct, Walk-in Centres and Accident & Emergency Departments. In contrast, the management of chronic conditions generally lies within the remit of GPs, and patients are usually only able to obtain ongoing specialist care for their condition if referred to a specialist by their GP.Primary care consultation rates in England are rising year-on-year,¹ and the role of primary care in managing chronic conditions will increase, against a backdrop of a drive to contain costs, as a result of both an ageing population and changes in healthcare policy.^3,4 In addition to the increasing demand for management of chronic conditions in primary care that an ageing population will place upon health services, the way in which services are designed and delivered also needs to change to ensure that primary healthcare is both accessible and appropriate to the needs of an increasingly ageing population with a rising burden of chronic disease.⁵ As GPs will be assuming a key role in commissioning health services in England, there is a clear opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care.^6,7It is essential that there is evidence to inform what conditions are most sensitive to management in primary care – commonly referred to as primary care sensitive conditions (PCSCs) or ambulatory care sensitive conditions (ACSCs). Such definitions would aid resource planning, drafting of local management protocols and simplification of the interface between primary and secondary care for a number of chronic conditions. Indeed, inappropriate utilization of secondary care resources is likely to represent a significant opportunity cost to healthcare providers and may be less desirable for patients.     

Managing depression in primary care: another example of the inverse care law?

BACKGROUND: Depression is a common problem, often being recurrent or becoming chronic. The National Service Framework for Mental Health (published by the Department of Health, 1999) states that people with depression should continue to be predominantly managed in primary care. There is much evidence that the detection and management of depression by GPs could be improved, but little work has focused on GPs' views of their work with depressed patients. OBJECTIVES: This was a qualitative study exploring GP attitudes to the management of patients with depression. Views of GPs in socio-economically deprived areas are compared with those serving more affluent populations. METHODS: Semi-structured interviews were conducted with two groups of GPs in north-west England. One group of GPs (22) were practising in inner-city areas, and a second group (13) in suburban and semi-rural practices. All were Principals in practices that participated in undergraduate teaching. The interviews were audio-taped and subsequently transcribed verbatim. Analysis was by constant comparison until category saturation of each theme was achieved. RESULTS: Subjects conceptualized depression as an everyday problem of practice, rather than as an objective diagnostic category. Thematic coding of their accounts suggests a tension between three kinds of views of depressed people: (i) That depression is a common and normal response to life events or change and that it reflects the medicalization of these conditions; (ii) That the label or diagnosis of depression offers a degree of secondary gain to both patients and doctors, particularly to those GPs practising in inner-city areas and (iii) That inner-city GPs experienced on-going management of depressed people as an interactional problem, in contrast to those GPs serving a less deprived population who saw depression as a treatable illness and as rewarding work for the GP. CONCLUSION: Depression is commonly presented to GPs who feel that the diagnosis often involves the separation of a normal reaction to environment and true illness. For those patients living in socio-economically deprived environments, the problems, and therefore the depression, are seen to be insoluble. This has an important implication for the construction of educational interventions around improving the recognition and treatment of depression in primary care: some doctors may be reluctant to recognize and respond to such patients in depth because of the much wider structural and social factors that we have suggested in this paper. That it is the doctors working with deprived populations who express these views, means that the 'Inverse care law' [Tudor Hart J. The inverse care Law. Lancet 1971; 1(7696): 405-412] operates in the management of depression.     

Integrated care pathways: pathways to change in health care?

PURPOSE: The purpose of this paper is to demonstrate that, if teams in healthcare focus on the patient using the framework of a care pathway, change can occur without the overt need to "manage" it directly. DESIGN/METHODOLOGY/APPROACH: In this paper the relevant literature is reviewed and it is demonstrated that if this approach is used it also provides a means for addressing difficult professional and organisational issues that are often unresolved in broader projects of organisational change. This is not presented as a panacea or the solution to all change projects, rather the contention here is that it is one means among many that can be used to bring about important changes in practice. FINDINGS: The paper finds that care pathways represent a useful tool, which teams can use to work through the contextual and practical issues involved in changing practice. ORIGINALITY/VALUE: The paper describes the development of integrated care pathways, which can be regarded as a fortunate fusion of managerial and professional concerns.