How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

CONTEXT: Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease and how the frontline community doctors respond to it is not known. OBJECTIVES: To explore the impact of SARS on general practitioners (GPs) in Hong Kong. DESIGN: A cross sectional survey. SETTING: Community based primary care clinics. PARTICIPANTS: 183 family medicine tutors affiliated with a local university. Postal survey sent to all tutors with a 74.8% response rate. MAIN OUTCOME MEASURES: Change of clinical behaviour and practices during the epidemic; anxiety level of primary care doctors. RESULTS: All agreed SARS had changed their clinical practices. Significant anxiety was found in family doctors. Three quarters of respondents recalled requesting more investigations while a quarter believed they had over-prescribed antibiotics. GPs who were exposed to SARS or who had worked in high infection districts were less likely to quarantine themselves (10.8% versus 33.3%; p<0.01; 6.5% versus 27.5%; p<0.01 respectively). Exposure to SARS, the infection rates in their working district, and anxiety levels had significant impact on the level of protection or prescribing behaviour. CONCLUSION: The clinical practice of GPs changed significantly as a result of SARS. Yet, those did not quarantine themselves suggesting other factors may have some part to play. As failure to apply isolation precautions to suspected cases of SARS was one major reason for its spread, a contingency plan from the government to support family doctors is of utmost importance. Interface between private and public sectors are needed in Hong Kong to prepare for any future epidemics.     

An evaluation of public health interventions during a pertussis outbreak in the ACT, 2003

OBJECTIVE: To assess whether issuing information alerts increased the proportion of pertussis cases notified within the 21-day infectious period during a pertussis outbreak in the Australian Capital Territory (ACT) in 2003. METHOD: The study included all persons resident in the ACT for whom a notification of pertussis was received with onset of disease between 1 March and 31 December 2003. Cases notified within 21 days of onset were called 'early notifications'. The effectiveness of information alerts was assessed by comparing the proportion of early notifications before and after each alert and over the course of the outbreak. MAIN OUTCOME MEASURE: The proportion of early notifications. RESULTS: The proportion of early notifications ranged from 1/36 (2.7%) prior to the first intervention to 29/52 (55.7%) after the final intervention (p < 0.001). CONCLUSIONS: This study supports the hypothesis that information alerts by ACT Health increase the proportion of cases notified within the infectious period of 21 days. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Early diagnosis of pertussis cases (within the infectious period) has the potential to limit transmission and protect susceptible infants.     

Information in general medical practice: a qualitative approach

The aims of the study reported here were to describe the information-related behavior of general medical practitioners, to study information communication in general practices, and to establish guidelines for good practice. General practitioners (GPs) were interviewed, and information and communication audits also involving other staff at the practices were undertaken. The main reasons why GPs needed information were for patient care, managing the practice, legal and ethical matters, and teaching trainee GPs. Most practices had problems with internal and external communication and the storage and retrieval of information. The main conclusion is that practices need to have an information strategy that considers human, manual, and computer aspects of information handling.     

Information in primary health care

The results of two recently completed studies, one in the Trent Region and the other in the Anglia and Oxford Region, of the information-related behaviour of general medical practitioners (GPs) and of information activities within the general practices illustrating the information seeking behaviour of GPs, their generation of information, and communication within, to and from the practice. GPs stated that there is a need for more information to enable practices to function within the changing NHS environment. The increasing emphasis on evidence-based medicine also creates the need for appropriate information sources. The Trent study resulted in guidelines for best information practice, especially the need for each practice to have an information strategy. The Anglia and Oxford Study examined the role which the library and information services could play in supporting primary health care.     

The limits of leadership: opinion leaders in general practice

OBJECTIVE: To explore the importance and characteristics of opinion leaders in general practice, particularly in relationship to the use of laboratory tests. DESIGN: Focus group discussions and a mailed survey. SUBJECTS: Five focus groups (n = 29 participants) in four different municipalities and a random sample of 85 general practitioners (GPs) in Norway. RESULTS: While Norwegian GPs recognised colleagues who were influential in determining how they practised, they found it difficult to identify opinion leaders specifically with respect to the use of laboratory tests. Opinion leaders were thought to be less important in influencing the use of laboratory tests than continuing medical education activities and practice guidelines, but more important than industry, patients or personal financial interests. Norwegian GPs recognised and characterised opinion leaders in much the same way as physicians in the USA. Influential colleagues were characterised as being good conveyers of information and willing to take time, as well as being up-to-date and having a high level of clinical expertise. GPs expressed a negative attitude towards 'superspecialists' who give advice without knowing the epidemiology of general practice, people who are arrogant and people who do not show respect towards GPs. CONCLUSIONS: The potential to identify and use opinion leaders to improve the use of laboratory tests by GPs in Norway appears to be limited.     

There is no association between a measure of clinical care and the response rate of GPs to postal surveys: A methodological study

Background: There has been much research into factors that can be modified to improve the response rates of general practitioners to surveys and to the demographic characteristics of those who do and do not respond. However, response is yet to be considered with respect to the quality of clinical care provided by GPs. In the UK, one measure of quality of care is the Quality and Outcomes Framework (QOF) score achieved by a general practice. Objective: This study considers the association of QOF score with response to self-completion postal surveys of general practitioners. Methods: Data are taken from two postal surveys of general practitioners (GPs) in the UK regarding their attitudes to osteoarthritis (OA) and sickness certification respectively. Logistic regression was used to assess the association between survey response and QOF score (as a proxy for quality of clinical care), adjusting for other characteristics of GPs and their practices (list size, number of partners, geographical region). Results: There was no significant association of QOF score with survey response in either study, before or after adjustment for the other characteristics. Conclusion: There is no evidence of an association between QOF score and the response of GPs to postal surveys. This gives reassurance that samples for studies of GP attitudes and practices should not suffer from response bias in relation to this core characteristic that represents the clinical achievement of their practice.     

Australian general practitioners' views and use of tests to detect early prostate cancer

To describe general practitioners' current beliefs, knowledge and self-reported practices in prostate cancer screening, we conducted a national survey of 1,271 general practitioners, obtaining 855 completed questionnaires (67% response rate). Available tests for prostate cancer screening, namely DRE and PSA alone and in combination, were indicated to be effective by 49%, 43% and 68% of respondents respectively, with older GPs significantly more likely to hold these views. The effect of guidelines was mixed. Less than 8% of respondents indicated they did not recommend screening. Although the majority of GPs were unlikely to adopt an opportunistic approach to prostate cancer screening, 63%, 57% and 46% indicated they would recommend DRE, PSA or both respectively during a dedicated health check up. Awareness of relevant guidelines was low, with nearly half of respondents unable to recall publications from the RACGP or ACS. Counter-intuitively, awareness of ACS guidelines for prostate cancer screening (which advise against screening) was significantly associated with the converse behaviour. Findings from this first national study behove proactive and highly targeted dissemination in general practice of the AHTAC policy announced by the Commonwealth Health Minister in August 1996.     

Integrating genetics as practices of primary care

This study examines the responses of general practitioners (GPs) in Vic., Australia to an increased emphasis on genetics in primary care. A qualitative analysis of focus group interviews with GPs in regional and metropolitan areas and one focus group interview with genetics experts showed that despite the emphasis placed on genetics by the experts, GPs remained ambivalent to the routine integration of genetics into general practice. This response from GPs has been noted in several studies and is most commonly attributed to GPs' lack of knowledge about genetics. In this study we argue that a 'cognitive deficit' understanding of the problem excludes many of the factors that GPs regard as important in relating genetics to primary care. We show that GPs' ambivalence emerges from how they situate genetics within practices of patient care and in relation to what they regard as good patient management. We found that GPs respond most enthusiastically to genetics and genetic testing if they feel it changes their management in ways they consider of benefit to their patients. GPs have specialist skills in managing the heterogeneity of patient care and these skills enable them to situate genetics relative to the overall needs of patients. Preparing GPs to 'do' genetics when the need arises by finding ways to make genetics information available to them as the need arises would facilitate the integration of genetics as practices of primary care.     

Survey on colorectal cancer screening knowledge, attitudes, and practices of general practice physicians in Lazio, Italy

BACKGROUND: Several international guidelines have recommended the involvement of general practitioners (GPs) in screening programs, but current evidence suggests this is very difficult. We implemented a survey to understand the attitudes, knowledge, and practices regarding colorectal cancer screening of GPs in the Lazio region. METHODS: Survey of all GPs working in 13 of the 50 districts in Lazio using a mail-in questionnaire. RESULTS: Out of 1192 GPs, 699 responded (59%). Ninety-four percent consider CRC a preventable disease. Knowledge about oncological screenings is higher in GPs using the guidelines as source of information. Twenty-five percent properly recommend the available screening tests for colorectal cancer, 22% do not recommend any, 6% under-recommend, and 47% over-recommend. Adequate knowledge of oncological screenings is positively associated with correct recommendation. Thirty-two percent of GPs recommend inappropriate follow-up tests for patients with positive fecal occult blood test. CONCLUSIONS: The low response rate reveals the lack of GP's interest in screening. Knowledge about screening and use of guidelines as sources of scientific information are important factors to improve attitudes about screening, but there is a large percentage of well-informed GPs who do not recommend colorectal cancer screening at all. Currently, many GPs do not properly follow the patients up after a positive FOBT.     

Power and influence in clinical effectiveness and evidence-based medicine

BACKGROUND: The need to base clinical interventions on valid findings of research has been a dominant theme in clinical practice during the last quarter of a century. However, there is much evidence showing that research evidence reaches everyday practice slowly. Solutions to this problem include evidence-based practice and implementation by guidelines and audit. Studies of these methods have included surveys of clinicians' views, implementation projects and evaluations of educational interventions, but they have not examined their implications for the power structure of clinical organizations. This is surprising, given the emphasis placed on medical power in sociological studies of health care. METHODS: A framework derived from management theory defines and summarizes theories of power and influence under the headings: sources of power, overt methods of influence, unseen or covert methods of influence and individual response to influence. This framework is then used to analyse the power and influence possessed and exerted by general practitioners (GPs) and hospital consultants and how these are affected by evidence-based practice and guidelines and audit programmes. OUTCOMES: GPs are seen as having less expert power than consultants and to be more compliant with externally managed guidelines and audit programmes. It is pointed out that compliance with guidelines and audit programmes helps GPs to meet their contractual requirement to be involved in clinical audit activities. Evidence-based practice, which directly challenges the authority of expert opinion is seen as a threat to the power of consultants, but a potential opportunity for GPs and other clinicians whose status is traditionally lower.     

Public health management of increased incidence of meningococcal disease in the Australian Capital Territory: 2003 to 2004

This paper describes a sudden increase of meningococcal notifications in the Australian Capital Territory within a 3 month period, and the public health strategies used to manage it. There were 15 cases of meningococcal disease notified to the Communicable Disease Control (CDC) section, Australian Capital Territory Health (ACT Health), between 6 November 2003 and 5 February 2004. This was much higher than the annual average of 6 cases. The cases were notified in 2 clusters. The first cluster of 8 cases, all serogroup C, was notified between 6 November to 8 December 2003. Seven of these cases had an identical phenotype C:2a:P1.4 suggesting a common source. The second cluster of 7 cases was notified between 30 December 2003 and 5 February 2004. Of these, 5 were serogroup B, 1 was serogroup W-135 and 1 was serogroup C, whose phenotype (C:2a:P1.4) was identical to the phenotype of the first cluster of serogroup C cases. Phenotypes were not available for the serogroup B cases. There were 4 main interventions developed to manage the increased incidence based on the epidemiology of the cases; these were implemented concurrently. Factors that supported investigation and management were good surveillance systems, quick turnover of laboratory tests, regular communication with relevant health agencies and maintaining public awareness. As the number of cases notified was much higher than the annual average, the possibility of a community outbreak was considered. The Guidelines for the Early Clinical and Public Health Management of Meningococcal Disease in Australia (national guidelines) were consulted to determine whether there was an outbreak and the influence this had on management is also discussed.     

Follow up of test results after hours

This article examines a recent Coronial inquest in which the Coroner made recommendations to general practitioners regarding the process of notification by pathology practices of abnormal and life threatening results and how GPs respond to such notifications. An addendum to the Standards for general practices provides guidance for GPs and their staff on the systems to manage the follow up of test results outside normal general practice opening hours.     

Control of Severe Acute Respiratory Syndrome in Singapore

A Severe Acute Respiratory Syndrome (SARS) outbreak occurred in Singapore from February to May 2003. A high vigilance for the disease, frequent and regular temperature monitoring, early case identification and isolation of patients, as well as tracing and home quarantine of contacts, played major roles in controlling the outbreak. Hospitals were dedicated to the screening and treatment of SARS patients. Within and between hospitals, movement by healthcare workers, patients and visitors were restricted, as was the number of hospital visitors. Staff education and audits of infection control practices also featured prominently. To prevent cross-border transmission, incoming travellers from SARS affected areas had to complete health declaration cards. They, as well as all outgoing travellers from Singapore, were monitored for fever. In the meantime, the public was urged to refrain from travelling to SARS affected regions. Containment elements targeting the community included school closure, public education on good hygiene and readily accessible public information. In response to a laboratory acquired SARS infection, laboratories were audited, and directives issued on the mandatory use of biosafety level 3 laboratories for SARS virus culture, and compliance of laboratory workers to biosafety guidelines.     

Lessons from the severe acute respiratory syndrome outbreak in Hong Kong

Severe acute respiratory syndrome (SARS) is now a global public health threat with many medical, ethical, social, economic, political, and legal implications. The nonspecific signs and symptoms of this disease, coupled with a relatively long incubation period and the initial absence of a reliable diagnostic test, limited the understanding of the magnitude of the outbreak. This paper outlines our experience with public health issues that have arisen during this outbreak of SARS in Hong Kong. We confirmed that case detection, reporting, clear and timely dissemination of information, and strict infection control measures are essential in handling such an infectious disease outbreak. The need for an outbreak response unit is crucial to combat any future outbreak.     

Saying 'goodbye' to single-handed practices; what do patients and staff lose or gain?

BACKGROUND: The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices. OBJECTIVE: The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. METHODS: Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included 'single-handed/group practice', 'rural/ urban' 'part-time/full-time' and 'male/female'. RESULTS: Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education. DISCUSSION AND CONCLUSION: The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.     

Nurses' attitudes to active voluntary euthanasia: a survey in the ACT

National public opinion polls show a large majority of Australians are in favour of active voluntary euthanasia (AVE). However, most members of the public have had only limited direct experience with dying people. For this reason, surveys of the opinions of medical practitioners and nurses on this issue are of great interest. The present study involved a postal survey in late 1996 of 2,000 randomly selected registered nurses from the Australian Capital Territory (ACT). The ACT has had extensive public debate about this issue. The questionnaire included some questions asked in earlier Australian surveys of the general public and health practitioners. Responses were received from 1218 nurses (61%). A majority of nurses who responded supported AVE as 'sometimes right', be it homicide by request (72%) or physician-assisted suicide (71%). A slightly smaller majority believed the law should be changed to allow homicide by request (69%) and physician-assisted suicide (67%). If AVE were legal, 66% of the nurses indicated they were willing to be involved in the procedure. Only 30% were willing to assist patients to give themselves the lethal dose, while 14% were willing to administer the lethal dose to the patient. Comparing these results with previous surveys, it appears that nurses are less in favour of AVE than the public, but more in favour than medical practitioners.     

Severe acute respiratory syndrome (SARS): knowledge, attitudes, practices and sources of information among physicians answering a SARS fever hotline service

In June 2003, Taiwan introduced a severe acute respiratory syndrome (SARS) telephone hotline service to provide concerned callers with rapid access to information, advice and appropriate referral where necessary. This paper reports an evaluation of the knowledge, attitude, practices and sources of information relating to SARS among physicians who staffed the SARS fever hotline service. A retrospective survey was conducted using a self-administered postal questionnaire. Participants were physicians who staffed a SARS hotline during the SARS epidemic in Taipei, Taiwan from June 1 to 10, 2003. A response rate of 83% was obtained. All respondents knew the causative agent of SARS, and knowledge regarding SARS features and preventive practices was good. However, only 54% of respondents knew the incubation period of SARS. Hospital guidelines and news media were the major information sources. In responding to two case scenarios most physicians were likely to triage callers at high risk of SARS appropriately, but not callers at low risk. Less than half of all respondents answered both scenarios correctly. The results obtained suggest that knowledge of SARS was generally good although obtained from both medical and non-medical sources. Specific knowledge was however lacking in certain areas and this affected the ability to appropriately triage callers. Standardized education and assessment of prior knowledge of SARS could improve the ability of physicians to triage callers in future outbreaks.     

General practitioners' perceptions of asynchronous telemedicine in a randomized controlled trial of teledermatology

We studied the perceptions of general practitioners (GPs) towards teledermatology, before and after its introduction into eight general practices for the purposes of a randomized controlled trial. A postal questionnaire was distributed before the trial and again one year later. Thirty-six of the 42 GPs responded on each occasion (a response rate of 86%). In the second survey, only 21% of respondents indicated that they were satisfied with teledermatology in their practice, while 47% said that they were dissatisfied. Thirty-one per cent said that they felt confident about diagnosis and management of care through teledermatology, and 28% reported that they were unconfident. Only 23% of respondents said that they would consider using a telemedicine system in the future, while 34% said they would not (43% were unsure). There were no significant findings to suggest that the GPs' perceptions changed over time. Less favourable responses to telemedicine were found than has been observed in previous studies, which suggests that the model of telemedicine described in this study would not be widely acceptable to GPs.