Educational visiting and hypnosedative prescribing in general practice

Public concern about the prescription of hypnosedative drugs (mostly benzodiazepines) led to a controlled trial of an educational intervention to promote rational prescribing by general practitioners (GPs). This paper describes the educational intervention and its process evaluation. In urban and rural New South Wales 137 GPs were visited in office hours by a GP or pharmacist who had undergone communication skills training. Material offered to GPs included relaxation tapes and a booklet of problem-orientated management guidelines. The interview had three stages: rapport was established, then educational material was introduced and finally the visitor sought the doctor's agreement to review five patients on long-term benzodiazepines. The visits were well received. Several measures were composed to reflect doctors' motivation and interest in non-drug management; there was virtually no correlation between any of these process measures and the trial outcome: a change in prescribing behaviour. Self-rating of benzodiazepine prescribing greatly underestimated actual self-reported incidents of prescribing. We interpret this as a reminder that we do not always do what we mean to do, and that we do not always do what we think we do.

The diagnostic difficulties of abdominal pain

When the patient presents with the words, "I've got a pain in the gut", what are the most common diagnoses and how often does the problem remain undiagnosed? This paper describes what usually happens at encounters initiated by patient presentation of abdominal pain and is based on the results of the Australian Morbidity and Treatment Survey 1990-1991.

Quality of care in general practice. A delphi study of indicators and methods

OBJECTIVE

To identify methods for measuring quality of care in general practice, and to assess general practitioners' views about their acceptability, practicality and usefulness.

DESIGN

A delphi design was used. Questionnaires consisting mainly of open-ended questions were sent to 50 general practice teachers in New South Wales. A second questionnaire derived from the responses from the first round was sent to the same GPs who were asked to rate each of the responses.

RESULTS

The response rate by the general practitioners was 46 per cent for the first questionnaire and 64 per cent for the second one. A total of 29 indicators of quality of care and 20 strategies for assessing quality were suggested. The most favoured indicators were appropriate prescribing, communication skills, and participation in continuing medical education. A mixture of methods assessing both performance and competence was suggested.

CONCLUSION

A good consensus was achieved by teaching general practitioners criteria for defining and measuring quality of care.

A comparison of country and metropolitan general practice

OBJECTIVE

To provide a description of country general practice in Australia, and to determine the extent to which country and metropolitan general practice differ in terms of the characteristics of the practitioners, the morbidity managed, treatments provided and the availability of support services.

METHOD

A survey requiring the recording of details of all direct and indirect patient encounters on encounter forms by a sample of general practitioners (GPs). Each GP recorded for two one-week periods separated by an interval of six months, between October 1990 and October 1991. The recording weeks were spread as evenly as possible throughout the year.

SAMPLE

Participants were drawn from a list of medical practitioners in Queensland, NSW and Victoria who provided more than 1500 general practice Medicare items of service during the previous year. The sample was stratified within States by population of postcode, into metropolitan areas and three country strata: "small country towns" (population less than 5000); "medium country towns" (5000-15,000); and "large country towns" (more than 15,000). The total country sample is referred to as "country areas". Planned sample size was 180 country GPs (20 in each stratum in each State) and 60 metropolitan GPs (20 in each of the three State capital cities). The final data set was weighted to be representative of the distribution of the source population.

DATA COLLECTION

The variables studied included: GP characteristics; practice isolation factors; patient age, sex and status to the practice; patient reasons for encounter (up to three per encounter); problems managed (up to four); drugs prescribed and other treatments provided (up to four per problem); tests and investigations ordered and referrals made at these encounters; and planned follow-up. Data were centrally coded. Participation rate: The final sample of 231 GPs (177 country and 54 metropolitan) recorded information during 435 recording weeks (336 country and 99 metropolitan). These practitioners represented 50.7% of those contacted and available, the response rate being better in country (57.5%) than in metropolitan (36.5%) areas. A practice profile questionnaire which included questions regarding the doctor and the practice was completed by 97.4% of participants, while a questionnaire on distance from support services was completed by 93.8% of country participants. The final weighted data set included 51,741 encounters with country GPs and 11,351 with metropolitan GPs.

RESULTS

The general practitioners: Country GPs were less likely to be female or to conduct consultations in a language other than English, and were more likely to do some work on a salaried or sessional basis. GPs from small country towns were older, more likely to be in solo practice, and more likely to belong to a professional organisation. "Remoteness" of towns: Nearly all towns were within 25 km of a hospital, but far fewer small and medium country towns were within 50 km of a base hospital than large country towns. X-ray services were almost universally available within 50 km, and with the exception of small country towns so were pathology services. Access to medical specialists and to a lesser degree other health professionals decreased with population size--patients in 30% of small towns had to travel over 100 km to see many specialists and some health professionals. Self-reported procedural work: GPs in small and medium country towns were more likely than those in large towns to report performing procedural work, the largest difference being in the area of em

The impact of a mass communications campaign on the reported management of asthma by general practitioners

There have been recent campaigns in many countries to address the increasing morbidity and mortality of asthma by promoting better management. This study aimed to evaluate the National Asthma Campaign (NAC), in Australia, and to assess the extent of its impact on reported asthma management. It was a cross-sectional, before and after study using the same self-administered questionnaire in postal surveys involving 472 general practitioners (GPs) before the campaign and 540 GPs 6 months after the start of the campaign. Both samples were random samples of GPs in active practice. The campaign was effective in making GPs more aware of the principles of good asthma management. Most (74%) GPs in the post-campaign survey were aware of a current asthma education programme compared with 53% in the pre-campaign survey, although only 23% cited the NAC. After the campaign there were significant improvements reported in airway function measurement practices, the use of preventive therapy and the use of written action plans.

Childhood immunisation in general practice

General practitioners provide 50% of childhood vaccination services in Australia. The routine schedule has been relatively stable for over 20 years, but new vaccine developments and an improved understanding of the epidemiology of the vaccine-preventable diseases will soon result in several major changes. General practitioners should review vaccination documentation and storage of vaccines, to ensure that the service they provide is of the highest standard. National targets for "age-appropriate" vaccination could be the basis for individual practices to assess their own performance.

Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at 2 months

BACKGROUND

Optimal therapy for acute otitis media (AOM) is controversial and there is no consensus regarding which antibiotic to use, how long to administer it, or whether antibiotics are effective at all. Knowledge of the effects of patient characteristics and disease manifestations is needed to individualize treatment and to evaluate large-scale trials.

METHODS

Data originated from 2251 patients with AOM, aged newborn to 15 years, who participated in a prospective primary care study in eight countries. At the initial visit, medical history, symptoms, physical findings, and treatment data were recorded. Follow-up 2 months later identified changes in treatment and outcome.

RESULTS

Patients younger than 13 months were less likely to have recovered than those aged 13 months to 15 years (P = .05). Using univariate analysis for infants aged 12 months or younger, male sex, prior episodes of AOM, and serous otitis media were associated with poor outcome. For older patients, poor outcome was associated with initial history of ear tubes, prophylactic antibiotic use, ear discharge, decreased hearing, serous otitis media; and past episodes of AOM; the symptom of decreased hearing; and the finding of pus exuding from the tympanic membrane. Using multivariate analysis for infants aged 12 months or younger, a history of serous otitis media (odds ratio [OR], 2.3; 95% confidence interval [CI], 0.95-5.7), past episodes of AOM (OR, 1.9; 95% CI, 0.82-4.5), and male sex (OR, 1.7; 95% CI, 1.0-3.0) made independent contributions to poor outcome. For children aged 13 months to 15 years, significant variables included pus drainage (OR, 2.2; 95% CI, 1.5-3.3), a history of ear tubes (OR, 2.3; 95% CI, 1.5-3.6), past episodes of AOM (OR, 1.8; 95% CI, 1.3-2.34), and a history of serous otitis media (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSIONS

Patient characteristics and disease manifestations are significant determinants of AOM outcome.

Acute otitis media in adults: a report from the International Primary Care Network

BACKGROUND

Of 22 million visits annually to United States physicians for acute otitis media, almost 4 million are by patients 15 years old or older. Yet the clinical spectrum and variables related to recovery have not been reported for adults.

METHOD

Data originated from 3224 primary care patients with acute otitis media, of whom 500 were 15 years old or older, who were enrolled in a prospective study in eight countries. At the initial visit, history, symptoms, physical findings, and treatment were recorded. At a 2-month follow-up visit, changes in treatment and recovery were recorded.

RESULTS

Compared with children, adults sought care more quickly after symptom onset; were more likely to have had a tonsillectomy or adenoidectomy; and were more likely to complain of ear pain, decreased hearing, sore throat, and ear discharge. Children were more likely to have a history of recent upper respiratory tract infection, serous otitis media, and ear tubes; symptoms of fever, diarrhea, and vomiting; and tympanic membrane findings of redness, bulging, and ear tubes in place. History of reduced hearing, allergy, prophylactic antibiotics, and tympanic membrane findings characterized as opaque or dull, fluid, draining pus, perforation, and not visualized were equally frequent in both age groups. For adults, neither type nor duration of antibiotic affected outcome. Patients receiving antibiotics had lower rates of recovery than those who did not. The likelihood of a poor outcome increased with an increasing number of past episodes of acute otitis media and with increasing age.

CONCLUSION

Although history and symptoms differ in adults and children, the similarity of tympanic membrane findings is consistent with previous reports of a similar bacterial spectrum in both groups. Recovery is related more to individual patient characteristics and history than to antibiotic therapy. Adults have an increased rate of poor outcome at 2 months compared with children.

Asthma management in general practice

OBJECTIVE

To provide guidelines for management of asthma in general practice.

DATA SOURCES

Selected articles, particularly those relating to general practice.

CONCLUSION

Better management of asthma requires strategies for dealing with long-term management as well as acute attacks. Planning such strategies and implementing personal management plans for each patient requires assessment of asthma severity; determination and maintenance of best achievable lung function, with avoidance of trigger factors, regular monitoring, and appropriate drug therapy; a written self-management plan as a basis for patient and family education; and regular review.

Antibiotics in acute respiratory infections

In the absence of clear research-based guidelines, this paper gives practical empirical directions for deciding when to prescribe antibiotics in acute respiratory infections, and how not to prescribe them when their use is inappropriate. Antibiotics probably have no effect on the outcome of most respiratory infections, viral or bacterial. When even the small chance of benefit seems to outweigh the risks and disadvantages, penicillin remains the best first-line agent for most respiratory infections, owing to the range of pathogenic bacteria likely to be encountered and its low side effect profile. Convincing some patients that antibiotics are not necessary is a sometimes difficult, but worthwhile task.

Recruiting general practitioners for survey research

Recruitment is often a lengthy process and sometimes a frustrating one. It is not simply a matter of contacting those selected and asking for this participation. After obtaining a list from which to select a sample, a contact list must be created, initial contact must be made and direct contact initiated, often requiring great powers of persuasion. It is often difficult to convince someone that your project is important. However, the time and energy expended is ultimately worth it. Just one positive enthusiastic response is enough to make you forget all the difficulties. What could be done to make it simpler in the future? Some kind of list, regularly updated, of all general practitioners would make researchers' jobs much easier by providing a reliable and current sampling frame. It would also promote general practice as a specialty. The problem of a definition of general practice is currently being considered. Overall, there needs to be more recognition of the time practitioners put in to such surveys and the additional demands it places on their already busy lives. General practice research has to be designed to fit into the practitioner's schedule. Researchers should co-ordinate their projects so that repeated requests are not made to the same practitioner. To some extent this problem is being tackled in New South Wales at present by the Royal Australian College of General Practitioners and University researchers. There is also a need for feedback from participating practitioners as to their own thoughts about the direction and design of general practice research. This would help to encourage continued participation and create goodwill for future surveys.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma in general practice. Opportunities for recognition and management

OBJECTIVE

To describe the prevalence of asthma-related symptoms and asthma among patients attending general practitioners.

SETTING

Sydney.

DESIGN

Cross-sectional survey by written questionnaire.

SAMPLE

1933 patients of 21 general practitioners.

RESULTS

1. Wheeze and asthma were common in patients attending general practitioners; 19 per cent of patients reported recent wheeze, 9 per cent reported recent asthma. 2. Less than half of all patients with recent wheeze (47%) reported having asthma. 3. Recent wheeze without asthma was more common in boys (4.8%) than girls (0%) and more common in men (10%) than women (7%). 4. Although most patients reporting asthma (95%) had had their asthma treated by a doctor, three-quarters of those patients had experienced asthma related symptoms in the previous year.

CONCLUSION

Asthma remains under-recognised and under-treated among patients attending general practitioners.

Morbidity and treatment in general practice in Australia

More detailed analysis of this data will continue. It will be combined with other more specific studies to provide a more focused view of some aspects of general practice. Requests for individual analyses of selected data will be accepted by the Family Medicine Research Unit. Contact Helena Britt on (02) 745 2633. The Unit has provided Australian Family Physician with 500 copies of the full report for distribution to interested practitioners. Such copies can be obtained by contacting Mrs Judy Brook, Secretary, Australian Family Physician, 2nd Floor, 70 Jolimont Street, Jolimont 3002. Fax: (03) 289 1211. Telephone: (03) 654 3000.

Quality assurance in general practice

The Royal Australian College of General Practitioners has been a leader in quality assurance in Australia, requiring members to participate in its Quality Assurance Programme since 1987. This paper presents the underlying philosophy and requirements of the programme, the results of the first 1987-89 triennium, and the likely future development based on an evaluation of the problems and successes of the first triennium.

Reasons for encounter and diagnosed health problems: convergence between doctors and patients

This study of 521 encounters in 25 urban general practices in Australia, compares both patient and doctor reported reasons for encounter (RFE) and diagnoses. Although doctors and their patients generally agreed on the overall distribution of RFE and diagnoses that arose, there was disagreement in at least 30% of paired comparisons within individual encounters. There was better agreement for RFE than for diagnoses. This may have been partly due to differences in the classification systems used. However, it suggests that diagnoses recalled by patients at later household interview are at best only a rough approximation of the diagnoses recorded by the doctor. These findings are important both for patient care and for the conduct of general practice morbidity research.

Using general practitioners to measure community morbidity

Randomly-selected patients drawn from randomly-selected General Practitioners (GPs) (two-stage cluster sample) were compared with a sample of the general population, who had visited a GP, selected using close approximations to standard household survey methods (area probability) of the Australian Bureau of Statistics. If GP patients drawn in this way resemble a random sample of the Australian community who have recently used GP services, then confidence should increase in this much cheaper method as a source of morbidity statistics. Interviews focused upon each person's last visit to the GP, with questions about reasons for attending, diagnoses and treatments, and various demographic items. In univariate analyses of 22 demographic items, 17 consultation items and 27 diagnoses and treatments, only five items were differently distributed between the GP patients and the area sample. Pairs of data items were also similar in the two groups. Items were examined using multidiscriminant analysis, to determine those that discriminated between the two groups and to calculate predicted group membership on the basis of these items. This analysis correctly classified only 56.7% of study subjects into their true group (GP patient or area sample) when based on items that were differently distributed between the groups, and 53.3% when all items were used, indicating that discrimination was only slightly better than chance. This result increases the confidence with which GP patients can be used to estimate levels of morbidity in the community if random selection is used to select GPs and if their patients are also randomly selected.

How representative are patients in general practice morbidity surveys?

This study examined differences arising from the sampling of patients from general practice and household surveys. When 25 general practitioners, who agreed to participate in one week morbidity survey in inner western Sydney, were compared with all general practitioners (192) identified in the area, they were not significantly different in terms of socio-demographic variables and practice details. When the demographic characteristics of a sample of patients at 539 encounters with the 25 participating general practitioners were compared with those of a sample of 500 patients identified from a household survey who had consulted with any general practitioner within 2 weeks of the interview, few differences were found. Few significant differences were found in the reasons for encounter and diagnoses treated as recalled by the patients of the two groups. No differences were found in management--specifically prescription, investigations and referral--or with respect to health status. This study suggests that sampling of patients from randomly selected general practitioners can produce useful representative samples for studies of morbidity even when doctor participation rates are as low as 29%.