Continuity within primary palliative care: an audit of general practice out-of-hours co-operatives

BACKGROUND: The transfer of information between general practitioners (GPs) and their out-of-hours providers on vulnerable patient groups is essential to ensure continuity of care. This will be critical when, in 2006, NHS Direct will triage and route all out-of-hours calls. This study investigates the current use of information handover systems for palliative care patients within four out-of-hours co-operatives. METHODS: Paper records of all 13,460 contacts during August 2002 were scrutinized. Using a standardized data extraction form we recorded details on all palliative or terminal contacts, and the existence of information handover. RESULTS: Across the four co-operatives, 2.1 per cent of all calls were from palliative care patients; co-operatives held handover information for between one (1.2 per cent) and 13 (32.5 per cent) of these patients. CONCLUSION: The systems in place to alert these co-operatives to the needs of palliative care patients are currently under-utilized. As services move towards an integrated approach, scrutiny of information transfer systems and encouragement of GPs and district nurses to update information, may help to ensure better continuity of care     

The quality of life of patients with type 2 diabetes mellitus in general practice

Background: Improving patients' duration and quality of life (QoL) is the long-term goal in treatment of diabetes mellitus.

Aim: To estimate the QoL of patients with type 2 diabetes followed in primary care, using the newly developed and validated 'Well-being Enquiry for Diabetes' (WED) questionnaire. The questionnaire evaluates four subscales of QoL: diabetes-related somatic symptoms (Symptoms); diabetes-related worries (Discomfort); mental health (Serenity); familiar relationship and social network (Impact). Patients and methods: We randomly selected 100 patients with type 2 diabetes mellitus in our practice, of whom 98 completed the questionnaire (mean age ±SD: 64.6±9.5; 44 males, 54 females; duration of disease 8.3±6.0 years; 23.5% on diet only, 67.3% on oral hypoglycaemic agents, 5.1% on both oral hypoglycaemic agents and insulin, and 4.1% on insulin monothe-rapy). Micro- or macroangiopathy was present in 33 patients (33.7%, 15 males, 18 females). In each patient we considered the following variables: age, gender, duration of disease, type of treatment in use, presence of complications. Mann-Whitney test, Kruskal-Wallis test and multiple regression analysis were used for statistical analysis (p<0.05 as significant). Results: Females had lower total WED scores than males (p=0.0001) and lower scores in each of the four subscales. Patients with chronic complications had lower scores than patients without complications (p=0.19). Patients on insulin showed lower total WED scores than patients treated with oral hypoglycaemic agents or diet only. Multivariate analysis showed a correlation between WED scores and gender (p=0.0001) or complications (p=0.049), but not with duration of disease (p=0.28) or age (p=0.15). Conclusion: The WED questionnaire appears to be a simple, reliable measure of diabetes-related QoL in primary care. Females had significantly lower scores than males, with the greatest difference in the area of Serenity. This is in accordance with general data showing higher psychiatric morbidity (anxiety, depression, eating disorders) among females. The WED provides GPs with a tool for auditing care of patients with diabetes and to identify type 2 diabetes patients in whom interventions may be needed to improve their QoL. Eur J Gen Pract 2000;6:93–7.     

Differences in treatment regimes, consultation frequency and referral patterns of diabetes mellitus in general practice in five European countries

BACKGROUND: In many European countries, maturity onset diabetes mellitus (DM) is to a large extent managed in general practice. OBJECTIVE: Our aim was to compare management of DM in general practice in five European countries in order to contribute to international guidelines on the management of DM by GPs. METHODS: Routine monitoring of patients presenting with DM was performed during a 12 month period (1999-2000) to GPs in established sentinel practice surveillance networks in five European countries (Belgium, Croatia, England, Spain and The Netherlands). Results were stratified by age and country. RESULTS: The proportion of patients treated by diet only varied from 13% (The Netherlands) to 25% (Spain); diet and oral antidiabetics from 51% (England) to 62% (Belgium); a combination of diet and insulin varied from 15% (Belgium and Croatia) to 26% (The Netherlands); and a combination of diet, oral antidiabetics and insulin was <10% in all countries. In the older age groups, insulin is prescribed most frequently in The Netherlands. Spain and Croatia show high consultation rates for DM; England and The Netherlands show low rates. Referral percentages vary considerably between countries (highest in Croatia). CONCLUSIONS: National differences found included the use of insulin in the elderly, the consultation frequency in general practice and the referral rate to ophthalmologist and diabetic specialists. Further quantitative and qualitative studies are needed to explore the needs for support in diabetes management in general practice in Europe.     

The care management interface with general practice: a case study

This paper reports on a care management initiative at the interface of social work, general practice and district nursing. The aims were to describe the organizational factors, operational criteria and the views of key managers, professionals and users of the care management pilot based in general practice. A multi-method case study design was used. This comprised: retrospective analysis of general practitioner (GP) referrals to social services, reviews of case records of clients in the care management system, and in-depth interviews with stakeholders, professionals, users and carers. This paper focuses on the analysis of the referral information to social services and district nursing from general practice and the themes arising from the interview data such as communication, referral pathways and professional role boundaries. The views of users and carers are presented in terms of satisfaction with continuity, responsiveness and appropriateness of the assessment and delivery of care. Although this care management pilot was discontinued when the funding ceased, the evaluation showed that there were benefits in terms of improved understanding between general practitioners, social workers, and district nurses of working systems, procedures and the organizational constraints of joint working.     

WHO diagnostic criteria as a validation tool for the diagnosis of diabetes mellitus: A study in five European countries

Objective: In 1999, the World Health Organization (WHO) published new diagnostic criteria for diabetes mellitus (DM). The cut-off value of the fasting plasma glucose concentration was lowered from 7.8 to 7.0?mmol/l. The WHO criteria were used to validate the diagnosis made by the general practitioner, and to compare the diagnostic validity of diabetes mellitus in different countries. Methods: We retrospectively analysed 2556 newly diagnosed diabetics. Incidence was calculated according to the 1999 WHO criteria. Data were collected in general practice networks in five European countries or regions (Belgium, England, the Netherlands, Portugal, Spain). Results: According to the WHO criteria, 82% of the cases were valid diagnoses. Compared to the total group, in Spain, significantly more diagnoses were in agreement with the WHO criteria, whereas this number was significantly lower in England and Portugal. From the patients whose diagnosis was not in agreement with the WHO criteria, significantly more were women than men.

Conclusion: By using the WHO diagnostic criteria, the international standard, as a validation tool, we show that the diagnoses of diabetes mellitus made in primary care are valid. Furthermore, we show that these diagnoses are comparable between countries. Therefore, information from general practice registration networks is a valuable and valid source for international comparisons.     

Logistic support service improves processes and outcomes of diabetes care in general practice

BACKGROUND: Guidelines for type 2 diabetes care in general practice are well known and accepted, but the implementation falls short. OBJECTIVE: To implement these guidelines by introducing a diabetes support service (DSS) to support the care delivered by the GP. METHODS: A controlled, non-randomised study with delayed intervention in the control group; 78 GPs (n=51 for the intervention and n=21 for the control group) in the south of the Netherlands and 613 of their type 2 diabetic patients participated. Data were collected on the frequency, content and results of the check-ups (fasting blood glucose, HbA1c, cholesterol, cholesterol/HDL ratio, triglycerides, creatinine, blood pressure, fundus photography, foot examination, body mass index and smoking status) for 3 years. The year before signing up with the DSS was taken for the pre-measurements and after 2 years of DSS the post-measurements took place. The effect of the DSS was analysed in a mixed model with repeated measurement covariance structure. RESULTS: At baseline the intervention and control group did not differ in control frequency and outcome (HbA1c). After the intervention the percentage of patients that attended four or more quarterly check-ups (with at least testing of fasting blood glucose or HbA1c) increased from 59 to 78%. In contrast, the frequency of check-ups in the control group remained constant. This effect was significant. The HbA1c remained the same in the intervention group while there was a significant deterioration in the HbA1c in the control group. CONCLUSION: Simple logistic support by the DSS proved to have the capacity to implement type 2 diabetes guidelines in general practice.     

Evaluation of welfare rights advice in primary care: the general practice perspective

Income maximisation may reduce enduring poverty-related health inequalities. Specialist welfare rights advice in primary care has been proposed and, in some areas, implemented, but evaluation data from the general practice perspective is needed. The present study aimed to evaluate the impact on general practice of specialist welfare rights advice, comparing practices with and without in-house provision of welfare advice using a cross-sectional postal questionnaire. This study was conducted in general practice surgeries in an inner-London health authority with high indicators of deprivation. Questionnaires were sent to practice managers. Comparative data (according to whether specialist advice was currently offered) addressed processes of identifying and meeting welfare needs and outcomes in terms of efficiency of provision. Seventy-nine surgeries participated. Those with welfare rights advisers (n = 42) were significantly more likely to report that current provision was adequate, that it was easier for staff to access advice on their patients' behalf (and by patients themselves) and that the process of advice provision ran smoothly. Lack of funding and space were the principal reasons for not having in-house advice. Surgeries wish provision to be expanded within practices. Welfare rights advice in surgeries improves ability to meet welfare needs via specialist advisers. Referral processes are simplified, enabling general practitioners to ensure that relevant advice is provided without the need for welfare knowledge themselves. General practices welcome the expansion of provision, with the proviso that adequate resources are identified. The current lack of basic information in surgeries must be addressed (e.g. information on local providers, printed information detailing range and eligibility criteria of welfare benefits).     

A standardised instrument for patient evaluations of general practice care in Europe

Objective: International comparisons of health care systems may provide important insights, but they require internationally standardised and validated instruments. This paper describes the validity and reliability of the EUROPEP instrument for patient evaluation of general practice care. Methods: Surveys were performed in 16 countries among patients who visited the general practice (n=23892), using the 23-item EUROPEP questionnaire. Data were analysed with respect to content validity, reliability, criterion validity, construct validity and sensitivity of the instrument. Results: The item response among responders was good or acceptable for most items. Two internally consistent dimensions were identified, 'clinical behaviour' (17 items) and 'organisation of care' (6 items). The answers to the 23 questions predicted the overall attitudes regarding the general practitioner. Higher age, more visits to the GP and better health status predicted more positive evaluations of care, as was expected beforehand. Differences between countries were significant but moderate for most of the questions. In specific countries problems with respect to validity and reliability were found. Conclusions: An internationally standardised and validated instrument for patients' evaluations of general practice care is now available for international comparisons. Future research should improve its validity to solve the problems that were found in some countries. Eur J Gen Pract 2000;6:82–7.     

全科医疗核心特征功能定义与内涵界定研究——连续性

连续性是基础保健的一个十分重要而独特的特征,与首诊、可及性、综合性和协调性之间以一种互为基础、相互支撑、彼此强化的方式共同作用,形成基础保健的作用机制。本文首先系统梳理目前关于连续性定义与概念内涵的研究,把握连续性内涵要素,明晰服务连续性的显性要素与隐性要素之间的关系;在此基础上,遵循可控性、穷尽性和互斥性原则,厘清基础保健下连续性与其他四个特征功能的内涵边界,给出全科医疗/基础保健连续性这一特征功能的定义与内涵,为后续建立全科医疗特征功能可操作性定义奠定基础。     

Treatment of lateral epicondylitis in general practice

Mechanical low back pain creates a significant economic burden in the industrial world. The costs of treating mechanical back pain in terms of sickness absenteeism and compensation claims are increasing rapidly.^1-3 There is robust evidence that staying active and continuing or resuming ordinary activities is more effective than rest in the management of mechanical back pain.⁴ This evidence in the international literature has been incorporated in a set of Clinical Guidelines produced by the Royal College of General Practitioners (RCGP).⁵ These guidelines recommend that early investigation and referral to a specialist for simple mechanical back pain are unwarranted in most cases. Positive advice to stay active and continue ordinary activities is emphasised. The RCGP guidelines recommend the use of educational material for patients in the form of The Back Book, to reinforce positive messages.⁶ This book has been shown to be clinically effective in a randomised, controlled trial.⁷ A comparative study from Australia⁸ showed that a public education campaign based on The Back Book had a positive effect on GP management of mechanical back pain and related morbidity.     

Organizational values in general practice and public involvement: case studies in an urban district

A multiple case study design was used to explore dimensions of organizational values in general practice with respect to developing public involvement. The study was undertaken in an urban district in England with data collected through in-depth individual and focus group interviews with service providers and service users. Four general practice organizations were randomly selected for study after sorting all in the district according to their record of developing involvement activities. The case studies provide evidence of how organizational values can differ markedly in general practice in relation to ideas of public involvement, with consequences for the quantity and quality of activities for involving local people and service users. The differences manifest themselves in the beliefs and attitudes of service providers about the purpose of the organization and the types of relationships that are appropriate with service users and local people. Service users appear to be very perceptive to the underlying ethos and purpose to their practice organization and this affects their responsiveness to initiatives for their involvement. The dimensions of the different values found in the study appear to be essentially the same as a number of established empirical findings of variations in values in general practice: an orientation to a narrow medical role and to general practice as a business are associated with a low valuation of involvement; an orientation to teamwork and to a broader social role appear more congruent with the development of involvement. Power is a critical issue in this setting with evidence in the study of the dominance of the medical practitioners in establishing organizational values and the nature of public involvement activities.     

Changing clinical practice: evidence-based primary care in Australia

Evidence-based health care (EBHC) is a concept which in the past decade has gained momentum internationally. Its emphasis on linking practice and policy more closely to evidence from research and literature has challenged many assumptions and established practices in health care, whilst helping the move away from an over-reliance on medical authority and accumulated wisdom. Since the concepts of EBHC were first introduced their relevance for primary care has been examined and there has been active debate over the extent to which primary care should be restructured to accommodate these new concepts. Many argue, for example, that they devalue important but less measurable aspects of primary care. Furthermore, little is known about whether EBHC has changed practice in primary care, despite a range of implementation strategies having been put in place. This paper focuses on the response of primary care practitioners and policy makers to the challenges of EBHC in Australia. Government investment in EBHC infrastructure is detailed, and the implementation of EBHC is described from the perspective of primary care providers, individuals with chronic illnesses and other consumers of primary care services. Current issues facing Australian primary care in implementing EBHC include the relative paucity of direction from a policy framework, the dearth of multi-disciplinary primary care teams and the lack of experience in Australia of primary care health service reform.     

HbA1c预测值所引导的2型糖尿病患者个体化自我管理教育研究

目的探讨HbA1c预测值所引导的2型糖尿病患者个体化自我管理教育模式对糖尿病控制效果的影响.方法对60例2型糖尿病患者的糖尿病基本知识、饮食、运动及用药自我管理能力进行问卷调查,检测糖尿病控制指标,建立HbA1c预测值模型.被调查者随机进入用HbA1c预测值所引导的个体化自我管理教育组(A组)和小组教育组(B组),每组30例.干预第3、6、9个月末检测血糖指标.第12个月末,再次进行问卷调查和检测控制指标.结果两组的各项检测指标均较干预前明显变好,糖尿病基本知识积分增加.A组自我管理能力增强的人数比率明显高于B组(Fisher精确概率双侧检验P＜0.05),糖尿病血糖指标控制效果好于B组(t＞2.11,P＜0.05).结论用HbA1c预测值所引导的2型糖尿病患者个体化自我管理教育是一种有效长期维持糖尿病控制效果的干预方法.     

Data quality improvement in general practice

BACKGROUND: The importance of routine data generated by GPs has grown extensively in the last decade. These data have found many applications other than patient care. More attention has therefore been given to the issue of data quality. Several systematic reviews have detected ample space for improvement of data quality. A new review was conducted in order to find out which methods of improvement are effective. METHOD: The Medline database was searched using an iteratively composed set of terms and MeSH (Medical Subject Headings) headings. Only papers that focused on explicit attempts at improving data quality of medical records in general practice were included. RESULTS: Twelve studies met the inclusion criteria. No study used patient-based comparison of records with external sources as the method to assess data quality improvement. Ten studies used internal indicators or markers of data quality instead. Attempts at data quality improvement often involve some sort of individualized feedback, and nearly all attempts seem to have some positive effect. Only one of the included studies fulfilled the basic methodological requirements of an intervention study. The most recent studies used a simple before-after design. CONCLUSION: No intervention to improve data quality has been put to a rigorous enough test. We still lack empirical knowledge as to how improvement can be brought about.     

Research in general practice in Europe: A growing community

Objectives: To find out how a consulting process measure (consultation duration) and one aspect of immediate outcome (patient enablement) are related to personal/relational continuity (how well the patient knows the doctor) in a geographically and professionally diverse sample of general practices.

Methods: A cross-sectional multi-practice questionnaire study set in a random sample of practices in four participating districts in Britain. The participants were 221 GPs in 53 practices consulted by 25,994 patients over a two-week period in March and April 1998.

Results: “Knowing the doctor well” was significantly associated with better patient enablement but “seeing the regular doctor today” was not significantly associated. Patients in practices which encouraged them to see the same doctor or which operated a strict personal list system were not more enabled than those in other practices of similar size.

Conclusions: This confirms that nature and quality of the patient-doctor relationship is more important than merely seeing the same doctor each time.     

The effect of an integrated care approach for heart failure on general practice

BACKGROUND: Recent studies have investigated specific strategies for heart failure management. None has involved collaboration between primary and secondary care. Potential gains for patients may result from collaborative strategies. OBJECTIVE: To assess the effect of an integrated management approach for patients with heart failure on general practice. METHODS: The study design was a cluster randomized controlled trial of integrated primary/ secondary care compared with usual care for heart failure patients. The study took place at Auckland Hospital, New Zealand and involved 197 patients admitted with an episode of heart failure. Patients were randomized to management group or control group (who received "usual" care). Management group patients received early clinical review, education sessions, a personal diary for medications and weight, and regular clinical follow-up alternating between GP and hospital clinic. Follow-up was for 12 months. RESULTS: Patients visited GPs frequently (median 14 visits, range 0-40), with no statistical difference between the two groups. Heart failure was the most common reason for consulting the GP. There was no relationship between GP consultations and patients' attendance at the study clinic, or hospital admissions. Management group GPs and patients expressed a high level of satisfaction. CONCLUSION: GP consultation rates were not affected by the programme. Further research will determine if general practice based programmes result in further gains.