Who is targeted for lifestyle advice? A cross-sectional survey in two general practices.

BACKGROUND: Recent health promotion guidelines reimbursed primary health care teams for targeting lifestyle advice to patients at risk of cardiovascular disease. However, it is unclear whether primary health care teams do target advice, who is targeted, and whether the advice is acted upon. AIM: To assess which factors predict the targeting and recall of lifestyle advice. METHOD: A total of 370 patients with, and 192 without, a computer record of risk factors for cardiovascular disease (hypertension, diabetes, ischaemic heart disease/myocardial infarction/angina, a body mass index > or = 30) from two contrasting Wessex practices were sent a postal questionnaire about medical conditions, recall of lifestyle advice, current lifestyle, and their perceptions about the health of their lifestyle. RESULTS: Seventy-seven per cent of patients responded. There was good agreement between listed risk factors and patients reporting a risk factor (kappa = 0.60), which was similar for both sexes and better in older age groups. Recall of lifestyle advice was not significantly affected by practice, but was more likely in patients with listed risk factors (adjusted odds ratio [OR] = 4.62, 95% confidence intervals [CI] = 2.89-7.37) and in men (OR = 1.64, 95% CI = 1.07-2.52), and less likely in older age groups (age < or = 64 years = 1.00; 65-74 years = 0.47, 95% CI = 0.27-0.81; 75+ years = 0.34, 95% CI = 0.20-0.60). Of patients with listed risk factors, 27% could not recall having received any advice, and recall varied with medical condition. Only 40% of patients with reported high blood pressure recalled being given advice about salt. Those who recalled advice were more likely to report a healthier current lifestyle. Of those with unhealthy lifestyles, 30-50% were unaware that their lifestyle was unhealthy. CONCLUSION: Lifestyle advice is not recalled for some important risk factors, and some patients are unaware of their unhealthy lifestyle. Although advice is being preferentially targeted to those with risk factors, women and older patients recall advice less. Research is needed to assess the cost-effectiveness of advice for both sexes and different ages.     

Factors associated with patients' trust in their general practitioner: a cross-sectional survey.

This study aimed to identify factors that are associated with patients' overall trust in their general practitioner (GP). A survey of patients in ten general practices in the East Midlands was conducted. Most patients (76%) reported high levels of trust in their GP. Regression analysis showed that measures of the quality of the GP-patient relationship (GP-patient communication, interpersonal care, and knowledge of the patient) were strongly associated with trust in a patient's usual GP, whereas patients' reports of duration of registration with the practice, and proportion of visits to the usual GP were not.     

Do patients care about the age of their general practitioner? A questionnaire survey in five practices.

BACKGROUND. Previous work has suggested that some patients like their doctors to adopt a paternal or maternal role. AIM. This study set out to establish whether or not patients had preferences with regard to the age of their general practitioner and also to see whether they attributed various characteristics to younger or older doctors. METHOD. A self-administered questionnaire was given to 500 patients attending five general practices in Lothian, Scotland. RESULTS. Significant numbers of patients attributed different characteristics to older or younger doctors. Older doctors were more likely to be attributed positive attributes such as being thorough, kind, and willing to listen. The mean preferred age was 42 years. This varied slightly with the age of patients, from 40 years for patients under the age of 25 years to 45 years for those over 60 years. Of patients, 58% thought the age of their doctor was unimportant, but many were unhappy about seeing very young doctors (20-25 years, n = 195) or old doctors (66-75 years, n = 193). CONCLUSION. Patients did not seem concerned about the age of their doctor as long as he or she was of an age normally practising in the United Kingdom (27-65 years). They had some stereotyped views on the characteristics of older and younger doctors, but these were not held particularly strongly. Patients appeared to want a balance with the doctor being experienced and being up to date.     

Actual practices in nephropathology: a survey and comparison with best practices

Nephropathology is a specialized field requiring routine tissue evaluation by immunofluorescence (IF), electron microscopy (EM), and light microscopy, and has published standards of best practice. Actual practices are less well documented. We therefore evaluated actual practices in nephropathology and their divergence from best practices. One hundred and twenty Renal Pathology Society members were given questionnaires regarding tissue handling, processing, and staining. Appropriate statistics for each question were calculated from results compiled into Microsoft Excel. Responses from 75 members showed that most received 16 or 18 gauge core biopsies, examined 9 slides for native kidneys, 8 slides for transplant kidneys, and for both used hematoxylin and eosin, periodic acid-Schiff, trichrome, and silver stains. For native kidney biopsies, most collected for IF and EM if tissue was adequate, while clinical input could influence the rest. Almost all performed IF on adequate samples, with a minimum of 8 antibodies, including both light chains, those from Europe sometimes without proof of adequacy. Half performed EM unconditionally, the remainder based on specimen adequacy or clinical input. For transplant kidney biopsies, most collected tissue for IF and EM only with specific clinical indications, performed C4d IF on frozen tissue if available, but few used the native kidney IF panel. Very few performed EM unconditionally, but most would if given specific indications. We conclude that actual nephropathology practices within the Renal Pathology Society are geographically uniform and similar to published best practices, with divergence in performing IF and EM on the basis of specimen adequacy and clinical input, particularly in transplant biopsies.     

Online data on opening hours of general practices in England: a comparison with telephone survey data

Background

The NHS Choices website (www.nhs.uk) provides data on the opening hours of general practices in England. If the data are accurate, they could be used to examine the benefits of extended hours.

Aim

To determine whether online data on the opening times of general practices in England are accurate regarding the number of hours in which GPs provide face-to-face consultations.

Design and setting

Cross-sectional comparison of data from NHS Choices and telephone survey data reported by general practice staff, for a nationally representative sample of 320 general practices (December 2013 to September 2014).

Method

GP face-to-face consultation times were collected by telephone for each sampled practice for each day of the week. NHS Choices data on surgery times were available online. Analysis was based on differences in the number of surgery hours (accounting for breaks) and the times of the first and last consultations of the day only between the two data sources.

Results

The NHS Choices data recorded 8.8 more hours per week than the survey data on average (40.1 versus 31.2; 95% confidence interval [CI] = 7.4 to 10.3). This was largely accounted for by differences in the recording of breaks between sessions. The data were more similar when only the first and last consultation times were considered (mean difference = 1.6 hours; 95% CI = 0.9 to 2.3).

Conclusion

NHS Choices data do not accurately measure the number of hours in which GPs provide face-to-face consultations. They better record the hours between the first and last consultations of the day.     

A follow-up survey of patients with dyspepsia in one general practice

Eighty-three patients who had been investigated by cholecystogram, barium meal and fibreoptic endoscopy more than two years previously were interviewed to enquire into their reactions to the investigations carried out, their present symptoms, and their present smoking and alcohol consumption. Comparisons were made with previously recorded observations. Those who still complained of severe dyspepsia were asked to attend for a repeat endoscopy. Sixty-three per cent of patients were asymptomatic; 13 per cent had recurrent dyspepsia, and 24 per cent had persistent dyspepsia. Thirty-nine per cent of smokers were found to have stopped altogether following medical advice.

Both radiological and endoscopic methods of investigation proved acceptable. A majority of patients preferred endoscopy to barium meal.

     

A cross-sectional survey of patients' beliefs about stress and their help-seeking behaviour

BACKGROUND: Stress has become an increasingly common presentation in general practice. This may relate to an increase in stress in people's lives or a change in the meaning of stress and its conceptualisation as a legitimate problem for the GP. AIM: To explore patients' beliefs about stress, their association with help-seeking behaviour, and to examine differences by ethnic group. DESIGN OF STUDY: Cross-sectional survey of general practice patients attending to see their GP. SETTING: An inner-city London practice. METHOD: Consecutive general practice patients completed a questionnaire, which involved rating a series of symptoms for the extent to which they were associated with stress and describing their help-seeking behaviour. In total, 548 patients completed the questionnaire. Most patients described themselves as black Caribbean (n = 163), black African (n = 48), or white British (n = 187). RESULTS: The symptoms most frequently associated with stress were sleeping problems, feeling depressed, feeling panicky, having high blood pressure and feeling anxious; feeling ashamed, experiencing indigestion, having diarrhoea, feeling hot or cold, and suffering from constipation were least commonly associated to stress. This model of stress did not vary by ethnic group. Ethnic group differences were found for the association between the model of stress and help-seeking behaviour. Although white British patients consistently reported that the more a symptom was seen as indicative of stress, the more likely they would be to visit the doctor for that symptom, this association was not found for either black Caribbean or black African patients. CONCLUSIONS: The belief that stress-related symptoms are a legitimate problem for the GP is not universal and varies according to ethnic group. Stress is used by different patients in different ways and offers a variable pathway to the doctor.     

Family physicians' information seeking behaviors: A survey comparison with other specialties

Background  

Using technology to access clinical information has become a critical skill for family physicians. The aims of this study were to assess the way family physicians use the Internet to look for clinical information and how their patterns vary from those of specialists. Further, we sought a better understanding of how family physicians used just-in-time information in clinical practice.     

Non-English speakers consulting with the GP in their own language: a cross-sectional survey.

The Patient Enablement Instrument (PEI) gives counterintuitive results with patients who normally speak non-English languages at home. The aim of this study was to find out more about why patients speaking languages other than English were more enabled in a shorter time than English-speaking patients. A cross-sectional consultation-based questionnaire survey was conducted of 2052 adult patients speaking languages other than English compared with 23790 English-speaking patients in four contrasting study areas in the UK Highest PEI scores in shortest consultation times were associated with South Asian language-speaking patients consulting in their own language. Multiple regression analysis showed that the language factors had an independent effect. We therefore conclude that these patients derive particular benefit from general practice consultations in their own language. Enablement may have a different meaning for patients speaking languages other than English.     

Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England

Background

Demand for England’s accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood.

Aim

To conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services.

Design and setting

This study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011–2012.

Method

Multivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care.

Results

The strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = −0.2, B = −128.7 [95% CI =149.3 to −108.2]). Other significant predictors included the practice list size (β = −0.1, B = −0.002 [95% CI = −0.003 to −0.002]) and the proportion of patients aged 0–4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services.

Conclusion

Demographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates.     

Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey

Background

General practice is a common setting for the provision of weight-management advice, as well as the treatment of depression. While there is some evidence of a reciprocal relationship between obesity and depression, there are limited data about the rates of depression among general practice patients who are underweight, normal weight, overweight, and obese.

Aim

To explore the prevalence of depression among underweight, normal weight, overweight, and obese general practice patients.

Design and setting

A cross-sectional survey was conducted in 12 Australian general practices.

Method

Patients aged ≥18 years and older who were presenting for general practice care were eligible to participate. Consenting patients completed a touchscreen computer survey assessing self-reported weight and height. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9), with a score of ≥10 used to indicate possible depression.

Results

Data were obtained from 3361 participants. The prevalence of depression was 24% (95% confidence interval [CI] = 11.86 to 39.28) among underweight participants, 11% (95% CI = 8.5 to 14.0) among normal weight participants, 12% (95% CI = 0.9 to 15.2) among overweight participants, and 23% (95% CI = 17.8 to 29.0) among obese participants. The prevalence of depression was higher for women than for men across all weight categories except underweight.

Conclusion

Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. These conditions may act as red flags for opportunistic screening of depression in the general practice setting.     

Management of acute asthma exacerbations by general practitioners: a cross-sectional observational survey.

BACKGROUND: General practitioners (GPs) have a central place in the management of asthma, particularly in the context of acute exacerbations. AIM: To evaluate the management of asthma exacerbations by GPs, and to investigate the ability of risk factors for near fatal asthma to predict the severity of asthma attacks in the community. Design of study: A 1-month multicentre cross-sectional survey. SETTING: One thousand and ninety-four GPs of the French Sentinel Network were contacted; 365 responded. METHOD: Asthma exacerbations were classified according to severity at presentation. Univariate and multivariate analyses were performed by logistic regression to identify those factors associated with severe exacerbations. RESULTS: Exacerbations were described in 219 patients with asthma. Over half (54%) of exacerbations were severe. Peak expiratory flow was recorded during the consultation in 55% of patients who were more than 5 years old. beta(2) agonists were prescribed to 93% of patients, systemic corticosteroids to 71%, and antibiotics to 64%. Only 42% of patients had a written action plan for self-management of exacerbations. Risk factors for near fatal asthma, identified in 26% of patients, were not significantly associated with severe asthma exacerbations. Short duration of exacerbation before consultation (<3 hours) was associated with an increase in relative risk of severe exacerbation of 3.38, 95% confidence intervals (CIs) = 1.19 to 9.61, compared with duration of >3 hours. CONCLUSION: Risk factors for near fatal asthma identified in previous studies were not predictive of a severe exacerbation in general practice, with the exception of short duration of exacerbation before consultation. This suggests that new methods to predict risk in the outpatient settings should be developed.     

A comparison of individual and population smoking data from a postal survey and general practice records.

BACKGROUND: Data on smoking held by general practitioners (GPs) may contribute to clinical care and to an assessment of population health. However, these data are prone to several biases and their validity has not been tested. AIM: To examine the accuracy of general practice data as an estimate for population prevalence of smoking and to estimate the accuracy of GP data on individuals' smoking habit compared with self-report. METHODS: A postal questionnaire on smoking habit over the past six years was sent to a random sample of individuals aged 15 to 74 years and registered with five out of seven general practices in one part of Leicester. GP records of those sampled were examined for an entry of smoking status over this period. RESULTS: Response rate to the postal questionnaire was 1906 out of 2490 (76.5%). Reported smoking prevalence was 35.2%. Of those notes sampled, 1784 out of 2432 (73.4%) had an entry about smoking recorded between 1991 and 1996. Patients recorded as smokers were less likely to respond to the postal questionnaire than non-smokers. Using practice data to ascribe smoking status to non-responders produced an estimated prevalence of 38.6%. Using questionnaire data alone as the 'gold standard', the last practice record collected since 1991 overestimated current smoking prevalence by a factor of 1.22; using questionnaire data supplemented by practice data for non-responders as the 'gold standard' meant that the overestimate was by a factor of 1.11. Data from notes and the questionnaire were available for 1398 individuals and 2188 observations. Levels of agreement were high (kappa = 0.83). CONCLUSION: GP-held data are valid for individuals but over-estimate smoking prevalence at a population level.     

Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study

Background

Health care is increasingly provided in general practice. To meet this demand, the English Department of Health recommends that 50% of all medical students should train for general practice after qualification. Currently 19% of medical students express general practice as their first career choice. Undergraduate exposure to general practice positively influences future career choice. Appropriate undergraduate exposure to general practice is therefore highly relevant to workforce planning

Aim

This study seeks to quantify current exposure of medical students to general practice and compare it with past provision and also with postgraduate provision.

Design and setting

A cross-sectional questionnaire in the UK.

Method

A questionnaire regarding provision of undergraduate teaching was sent to the general practice teaching leads in all UK medical schools. Information was gathered on the amount of undergraduate teaching, how this was supported financially, and whether there was an integrated department of general practice. The data were then compared with results from previous studies of teaching provision. The provision of postgraduate teaching in general practice was also examined.

Results

General practice teaching for medical students increased from <1.0% of clinical teaching in 1968 to 13.0% by 2008; since then, the percentage has plateaued. The total amount of general practice teaching per student has fallen by 2 weeks since 2002. Medical schools providing financial data delivered 14.6% of the clinical curriculum and received 7.1% of clinical teaching funding. The number of departments of general practice has halved since 2002. Provision of postgraduate teaching has tripled since 2000.

Conclusion

Current levels of undergraduate teaching in general practice are too low to fulfil future workforce requirements and may be falling. Financial support for current teaching is disproportionately low and the mechanism counterproductive. Central intervention may be required to solve this.     

Implementation of Advanced Access in general practice: postal survey of practices

BACKGROUND: Advanced Access has been strongly promoted as a means of improving access to general practice. Key principles include measuring demand, matching capacity to demand, managing demand in different ways and having contingency plans. Although not advocated by Advanced Access, some practices have also restricted availability of pre-booked appointments. AIM: This study compares the strategies used to improve access by practices which do or do not operate Advanced Access. DESIGN OF STUDY: Postal survey of practices. SETTING: Three hundred and ninety-one practices in 12 primary care trusts. METHOD: Questionnaires were posted to practice managers to collect data on practice characteristics, supply and demand of appointments, strategies employed to manage demand, and use of Advanced Access. RESULTS: Two hundred and forty-five from 391 (63%) practices returned a questionnaire and 162/241(67%) claimed to be using Advanced Access. There were few differences between characteristics of practices operating Advanced Access or not. Both types of practice had introduced a wide range of measures to improve access. The proportion of doctors' appointments only available for booking on the same day was higher in Advanced Access practices (40 versus 16%, difference = 24%, 95% CI = 16% to 32%). Less than half the practices claiming to operate Advanced Access ((63/140; 45%) used all four of this model's key principles. CONCLUSION: The majority of practices in this sample claim to have introduced Advanced Access, but the degree of implementation is very variable. Advanced Access practices use more initiatives to measure and improve access than non-Advanced Access practices.     

Practice organization before and after the new contract: a survey of general practices in Sheffield.

In order to assess the effects of the new contract on practice organization, all general practices in Sheffield were surveyed just before the new contract came into effect in April 1990, and again one year later. Of the 120 practices, 57% responded in 1990 and 61% in 1991, with 47% responding in both years. There were significant increases in the mean number of clinics and employed staff for the practices responding to both questionnaires and in the proportion of these practices which had a computer. These changes represent a response to the incentives and stated aims of the new contract.     

A survey of audit activity in general practice.

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care.