Process analysis in general practice--a new perspective?

This paper reports the initial findings from a study of the application of process analysis into a general practice. It discusses the issues surrounding the relationships between clinical and managerial tasks. A new model of primary care is proposed which takes into account management issues and separates out non-patient contact activities. Evidence is presented and conclusions and drawn about front/back office activities, general practice as a small business, patient care and suggestions are made for future work.     

Why do clinical trials in general practice?

Ultimately what we do as doctors is intervene in our patients to alleviate symptoms (palliate), or reduce risk (prevent), or abort (cure) disease processes. Such interventions do not have to be drugs. They can be simple prognostic reassurance, an exercise regimen, counselling, meditation, or any other modality of care.     

Does labour substitution occur in district general hospitals?

A survey of 31 district general hospitals found a large variation in hours of medical and nursing time available per inpatient episode in general medicine and its associated specialties. These differences could not be attributed to case-mix variation or severity. The application of weightings to different grades of nursing and medical staff had little effect on either the rankings of hospitals by staff hours per episode, or the overall degree of variation in staffing levels. The results show no evidence to suggest that hospitals with relatively low levels for one category of staff are compensated by relatively high levels of another. It would appear that those hospitals with high levels for one category of staff are also well provided for the others. This evidence of inequality may reflect historic patterns of resource allocation that recent manpower policies might seek to redress. Studies of the relationship between staffing levels and quality of patient care should be undertaken before adopting a policy of labour redistribution.     

Do minutes count? Consultation lengths in general practice

OBJECTIVE: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. DESIGN: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. SETTING AND SUBJECTS: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. MAIN OUTCOME MEASURES: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. RESULTS: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. CONCLUSIONS: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.     

Do general practitioners recognize mild cognitive impairment in their patients?

Objectives

The need for recognition of mild cognitive impairment (MCI) in primary care is increasingly discussed because MCI is a risk factor for dementia. General Practitioners (GPs) could play an important role in the detection of MCI since they have regular and long-term contact with the majority of the elderly population. Thus the objective of this study is to find out how well GPs recognize persons with MCI in their practice population.

Design

Cross-sectional study.

Setting

Primary care chart registry sample.

Participants

3,242 non-demented GP patients aged 75–89 years.

Measurements

GPs assessed the cognitive status of their patients on the Global Deterioration Scale (GDS). Thereafter, trained interviewers collected psychometric data by interviewing the patients at home. The interview data constitute the basis for the definition of MCI cases (gold standard).

Results

The sensitivity of GPs to detect MCI was very low (11–12%) whereas their specificity amounts to 93–94%. Patients with MCI with a middle or high level of education more often got a false negative assignment than patients with a low educational level. The risk of a false positive assignment rose with the patients’ degree of comorbidity. GPs were better at detecting MCI when memory or two and more MCIdomains were impaired.

Conclusion

The results show that GPs recognise MCI in a very limited number of cases when based on clinical impression only. A further development of the MCI concept and its operationalisation is necessary. Emphasis should be placed on validated, reliable and standardised tests for routine use in primary care encompassing other than only cognitive domains and on case finding approaches rather than on screening. Then a better attention and qualification of GPs with regard to the recognition of MCI might be achievable.     

Bi-linear dose–response relationship in general populations with low-level cadmium exposures in non-polluted areas in Japan

Background and objectives  

Previous findings suggest that the dose (e.g., cadmium in urine)–response (e.g., tubular dysfunction markers in urine) relationship after environmental exposure to cadmium (Cd) may be in a shape of a hockey stick with a steep slope when Cd exposure exceeds a certain level, i.e., the point of flexion. However, less attention has been paid to the relation below the flexion point whether it is linear or not. The present study was initiated to examine through epidemiological analyses whether the assumption of linearity holds true when Cd exposure is low.     

Old boys’ network in general practitioners’ referral behavior?

We analyzed the impact of social networks on general practitioners’ (GPs) referral behavior based on administrative panel data from 2,684,273 referrals to specialists made between 1998 and 2007. For the definition of social networks, we used information on the doctors’ place and time of study and their hospital work history. We found that GPs referred more patients to specialists within their personal networks and that patients referred within a social network had fewer follow-up consultations and less inpatient days thereafter. The effects on patient outcomes (e.g. waiting periods, days in hospital) of referrals within personal networks and affinity-based networks differed. Specifically, whereas empirical evidence showed a concentration on high-quality specialists for referrals within the personal network, suggesting that referrals within personal networks overcome information asymmetry with respect to specialists’ abilities, the empirical evidence for affinity-based networks was different and less clear. Same-gender networks tended to refer patients to low-quality specialists.