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1.
Mark Ashworth Peter Schofield Stevo Durbaba Sanjiv Ahluwalia 《The British journal of general practice》2014,64(620):e168-e177
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’. 相似文献2.
Fiona Fox Michael Harris Gordon Taylor Karen Rodham Jane Sutton Brian Robinson Jenny Scott 《The British journal of general practice》2009,59(568):811-818
Background
Current evidence about the experiences of doctors who are unwell is limited to poor quality data.Aim
To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.Design of study
Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.Setting
Two primary care trusts in the West of England.Method
A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysisResults
Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.Conclusion
Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service. 相似文献3.
Chris Shiels Mark Gabbay Jim Hillage 《The British journal of general practice》2014,64(620):e137-e143
Background
The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.Aim
To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.Design and setting
Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.Method
Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.Results
The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.Conclusion
Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers). 相似文献4.
Magin P Joyce T Adams J Goode S Cotter G 《The British journal of general practice》2009,59(565):578-583
Background
The significance of occupational violence in general practice is well established, but research has focused almost exclusively on the experiences of GPs.Only limited research has examined the role of general practice receptionists despite their acknowledged vulnerability to violent patient behaviour. No qualitative research has explored this problem.Aim
To explore the experiences of general practice receptionists regarding occupational violence and the effects of violence on their psychological and emotional wellbeing and on their work satisfaction and performance.Design of study
Qualitative study.Setting
Constituent practices of an Australian network of research general practices. Practices were located in a range of socioeconomic settings.Method
Semi-structured interviews were conducted with practice receptionists. The interviews were audiotaped, transcribed, and subjected to thematic analysis employing a process of constant comparison in which data collection and analysis were cumulative and concurrent. Qualitative written responses from a cross-sectional questionnaire-based study performed concurrently with the qualitative study were similarly analysed.Results
Nineteen interviews were conducted and 12 written responses were received. Violence was found to be a common, sometimes pervasive, experience of many receptionists. Verbal abuse, both ‘across the counter’ and telephone abuse, was the most prominent form of violence, although other violence, including assault and threats with guns, was reported. Experiences of violence could have marked emotional and psychological effects and could adversely affect job satisfaction, performance, and commitment.Conclusion
It is apparent that occupational violence is a whole-of-practice problem and strategies for GP and staff safety will need to take a whole-of-practice approach. 相似文献5.
Stefan B?sner Simone Hartel Judith Diederich Erika Baum 《The British journal of general practice》2014,64(626):e532-e537
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. 相似文献6.
Jane Roberts Ann Crosland John Fulton 《The British journal of general practice》2014,64(622):e254-e261
Background
Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.Aim
To explore the relationship between the above three influences to develop an overarching conceptual model.Design and setting
Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.Method
Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.Results
In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.Conclusion
The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents. 相似文献7.
8.
Trevor Lambert Raph Goldacre Fay Smith Michael J Goldacre 《The British journal of general practice》2012,62(605):e851-e858
Background
Less than one-third of newly qualified doctors in the UK want a career in general practice. The English Department of Health expects that half of all newly qualified doctors will become GPs.Aim
To report on the reasons why doctors choose or reject careers in general practice, comparing intending GPs with doctors who chose hospital careers.Design and setting
Questionnaire surveys in all UK medical graduates in selected qualification years.Method
Questions about specialty career intentions and motivations, put to the qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, and 2009, 1 year after qualification, and at longer time intervals thereafter.Results
‘Enthusiasm for and commitment to the specialty’ was a very important determinant of choice for intending doctors, regardless of chosen specialty. ‘Hours and working conditions’ were a strong influence for intending GPs (cited as having had ‘a great deal’ of influence by 75% of intending GPs in the first year after qualification), much more so than for doctors who wanted a hospital career (cited by 30%). Relatively few doctors had actually considered general practice seriously but then rejected it; 78% of the doctors who rejected general practice gave ‘job content’ as their reason, compared with 32% of doctors who rejected other specialties.Conclusion
The shortfall of doctors wanting a career in general practice is not accounted for by doctors considering and rejecting it. Many do not consider it at all. There are very distinctive factors that influence choice for, and rejection of, general practice. 相似文献9.
Carl de Wet Catherine O’Donnell Paul Bowie 《The British journal of general practice》2014,64(620):e159-e167
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. 相似文献10.
Sabrina Grant Sheila M Greenfield Arie Nouwen Richard J McManus 《The British journal of general practice》2015,65(640):e776-e783
Background
Self-monitoring blood pressure (SMBP) is becoming an increasingly prevalent practice in UK primary care, yet there remains little conceptual understanding of why patients with hypertension engage in self-monitoring.Aim
To identify psychological factors or processes prompting the decision to self-monitor blood pressure.Design and setting
A qualitative study of patients previously participating in a survey study about SMBP from four general practices in the West Midlands.Method
Taped and transcribed in-depth interviews with 16 patients (6 currently monitoring, 2 used to self-monitor, and 8 had never self-monitored). Thematic analysis was undertaken.Results
Three main themes emerged: ‘self’ and ‘living with hypertension’ described the emotional element of living with an asymptomatic condition; ‘self-monitoring behaviour and medication’ described overall views about self-monitoring, current practice, reasons for monitoring, and the impact on medication adherence; and ‘the GP–patient transaction’ described the power relations affecting decisions to self-monitor. Self-monitoring was performed by some as a protective tool against the fears of a silent but serious condition, whereas others self-monitor simply out of curiosity. People who self-monitored tended not to discuss this with their nurse or GP, partly due to perceiving minimal or no interest from their clinician about home monitoring, and partly due to fear of being prescribed additional medication.Conclusion
The decision to self-monitor appeared often to be an individual choice with no schedule or systems to integrate it with other medical care. Better recognition by clinicians that patients are self-monitoring, perhaps utilising the results in shared decision-making, might help integrate it into daily practice. 相似文献11.
Trevor Lambert Fay Smith Michael Goldacre 《The British journal of general practice》2013,63(616):e726-e733
Background
In the UK many practising GPs did not choose general practice as their first choice of career when they originally graduated as doctors.Aim
To compare job satisfaction of GPs who chose general practice early or later in their career.Design and setting
Questionnaires were sent to all UK-trained doctors who graduated in selected years between 1993 and 2000.Method
Questionnaires were sent to the doctors 1, 3, 7 and 10 years after graduation.Results
Of all 3082 responders working in general practice in years 7 and 10, 38% had first specified general practice as their preferred career when responding 1 year after graduation, 19% by year 3, 21% by year 5, and 22% after year 5. Job satisfaction was high and, generally, there was little difference between the first three groups (although, when different, the most positive responses were from the earliest choosers); but there were slightly lower levels of job satisfaction in the ‘more than 5 years’ group. For example, in response to the statement ‘I find enjoyment in my current post’, the percentages agreeing in the four groups, respectively, were 91.5%, 91.1%, 91.0% and 88.2%. In response to ‘I am doing interesting and challenging work’ the respective percentages were 90.2%, 88.0%, 86.6% and 82.6%.Conclusions
Job satisfaction levels were generally high among the late choosers as well as the early choosers. On this evidence, most doctors who turn to general practice, after preferring another specialty in their early career, are likely to have a satisfying career. 相似文献12.
Isobel M Cameron Kenneth Lawton Ian C Reid 《The British journal of general practice》2009,59(566):644-649
Background
Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.Aim
To assess whether GPs prescribe antidepressants appropriately.Design of study
Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.Setting
Four practices in Grampian, Scotland.Method
Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.Results
A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.Conclusion
There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively. 相似文献13.
Clare R Goyder Caroline HD Jones Carl J Heneghan Matthew J Thompson 《The British journal of general practice》2015,65(641):e838-e844
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. 相似文献14.
15.
Wenche Haugen Ole Rikard Haavet Manjit Kaur Sirpal Kaj Sparle Christensen 《The British journal of general practice》2016,66(643):e65-e70
Background
Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.Aim
To determine if three verbally asked key questions are valid for identifying depression in adolescents.Design and setting
A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.Method
A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14–16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger’s H, Cronbach’s α, and prevalence of depression.Results
The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer ‘yes’ to either screening question and of 0.73 for the answer ‘yes’ to the help question. The positive predictive value was 31% and the negative predictive value was 97%.Conclusion
The three key questions are useful for identifying depression in adolescents in primary health care. 相似文献16.
Yvette van Ierland Gijs Elshout Henri?tte A Moll Ruud G Nijman Yvonne Vergouwe Johan van der Lei Marjolein Y Berger Rianne Oostenbrink 《The British journal of general practice》2014,64(618):e1-e9
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. 相似文献17.
18.
Amy Waller Mariko Carey Danielle Mazza Serene Yoong Alice Grady Rob Sanson-Fisher 《The British journal of general practice》2015,65(634):e312-e318
Background
GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.Aim
To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.Design and setting
Cross-sectional survey of patients attending Australian general practice clinics.Method
Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.Results
In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).Conclusion
Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required. 相似文献19.
Jette M?ller Ahrensberg Rikke Pilegaard Hansen Frede Olesen Henrik Schr?der Peter Vedsted 《The British journal of general practice》2012,62(600):e458-e465
Background
Knowledge of how children with cancer present in general practice is sparse. Timely referral from general practice is important to ensure early diagnosis.Aim
To investigate the presenting symptoms and GPs’ interpretations of symptoms of children with cancer.Design and setting
A Danish nationwide population-based study including children (<15 years) with an incident cancer diagnosis (January 2007 to December 2010).Method
A questionnaire on symptoms and their interpretation was mailed to GPs (n?=?363). Symptoms were classified according to the International Classification of Primary Care (ICPC)-2 classification.Results
GPs’ response rate was 87% (315/363) and GPs were involved in the diagnostic process of 253 (80.3%) children. Symptoms were few (2.4 per child) and most fell into the category ‘general and unspecified’ (71.9%), apart from patients with tumours of the central nervous system (CNS), whose symptoms fell mostly in the category ‘neurological’ (for example, headache). Symptoms like pain, swelling/lump, or fatigue were reported in 25% of the patients and they were the most commonly reported symptoms. GPs interpreted children’s symptoms as alarm symptoms in 20.2%, as serious (that is, not alarm) symptoms in 52.9%, and as vague symptoms in 26.9%. GPs’ interpretation varied significantly by diagnosis (P<0.001).Conclusion
Children with cancer presented with few symptoms in general practice, of which most were ‘general and unspecified’ symptoms. Only 20% presented alarm symptoms, while 27% presented vague and non-specific symptoms. This low level of alarm symptoms may influence the time from symptom presentation in general practice to final diagnosis. 相似文献20.
Paul Little Peter White Joanne Kelly Hazel Everitt Shkelzen Gashi Annemieke Bikker Stewart Mercer 《The British journal of general practice》2015,65(635):e357-e365