Quality at general practice consultations: cross sectional survey

The role of culture in the general practice consultation process

In this paper, we will examine the importance of culture and ethnicity in the general practice consultation process. Good communication is associated with positive health outcomes. We will, by presenting qualitative material from an empirical study, examine the way in which communication within the context of a general practitioner (GP) consultation may be affected by ethnicity and cultural factors. The aim of the study was to provide a detailed understanding of the ways in which white and South Asian patients communicate with white GPs and to explore any similarities and differences in communication. This paper reports on South Asian and white patients' explanations of recent videotaped consultations with their GP. We specifically focus on the ways in which issues of ethnic identity impacted upon the GP consultation process, by exploring how our sample of predominantly white GPs interacted with their South Asian patients and the extent to which the GP listened to the patients' needs, gave patients information, engaged in social conversation and showed friendliness. We then go on to examine patients' suggestions on improvements (if any) to the consultation. We conclude, by showing how a non-essentialist understanding of culture helps to comprehend the consultation process when the patients are from Great Britain's ethnicised communities. Our findings, however, raise generic issues of relevance to all multi-racial and multi-ethnic societies.

Communication between South Asian patients and GPs: comparative study using the Roter Interactional Analysis System

BACKGROUND

The UK South Asian population has poorer health outcomes. Little is known about their process of care in general practice, or in particular the process of communication with GPs.

AIM

To compare the ways in which white and South Asian patients communicate with white GPs.

DESIGN OF STUDY

Observational study of video-recorded consultations using the Roter Interactional Analysis System (RIAS).

SETTING

West Yorkshire, UK.

METHOD

One hundred and eighty-three consultations with 11 GPs in West Yorkshire, UK were video-recorded and analysed.

RESULTS

Main outcome measures were consultation length, verbal domination, 16 individual abridged RIAS categories, and three composite RIAS categories; with comparisons between white patients, South Asian patients fluent in English and South Asian patients nonfluent in English. South Asians fluent in English had the shortest consultations and South Asians non-fluent in English the longest consultations (one-way ANOVA F = 7.173, P = 0.001). There were no significant differences in verbal domination scores between the three groups. White patients had more affective (emotional) consultations than South Asian patients, and played a more active role in their consultations, as did their GPs. GPs spent less time giving information to South Asian patients who were not fluent in English and more time asking questions. GPs spent less time giving information to South Asian patients fluent in English compared with white patients.

CONCLUSIONS

These findings were expected between patients fluent and non-fluent in English but do demonstrate their nature. The differences between white patients and South Asian patients fluent in English warrant further explanation. How much of this was due to systematic differences in behaviour by the GPs, or was in response to patients' differing needs and expectations is unknown. These differences may contribute to differences in health outcomes.

Practitioner empathy, patient enablement and health outcomes: a prospective study of acupuncture patients

OBJECTIVE

To measure acupuncture patients' perceptions of practitioner empathy at the initial consultation and its relationship with patient enablement, and prospectively reported changes in symptoms.

METHODS

Fifteen acupuncturists asked consecutive new patients to complete a questionnaire within 2 days of the first consultation. The questionnaire included the Consultation and Relational Empathy (CARE) measure (a consultation process measure), the Patient Enablement Instrument (PEI, a consultation outcome measure) and the Measure Yourself Medical Outcome Profile (MYMOP), a patient-centred symptom, well-being and activity outcome measure. A postal follow-up questionnaire was completed at 8 weeks, which repeated these measures.

RESULTS

Fifty-two patients (58% of all new patients) completed the initial questionnaire. Of these, 41 (79%) completed the follow-up questionnaire. From a multiple regression analysis, which controlled for known confounders, empathy was found to be associated with enablement at the initial consultation (Beta coefficient=0.16, 95% CI: 0.02-0.31, p=0.03) and empathy-predicted changes in health outcome (MYMOP) at 8 weeks (Beta=0.07, 95% CI: 0.004-0.13, p=0.04).

CONCLUSION

Patients' perception of practitioner empathy was associated with patient enablement at initial consultation and predicted changes in health outcome at 8 weeks.

PRACTICE IMPLICATIONS

The empathy of practitioners, as perceived by patients, has a direct impact on patient enablement and health outcome.

How are different types of continuity achieved? A mixed methods longitudinal study

BACKGROUND

In the context of developments in healthcare services that emphasise swift access to care, concern has been expressed about whether and how continuity of care, particularly interpersonal continuity, will continue to be achieved.

AIM

To explore how patients regard and use primary care services in relation to continuity of provider and access to care, to identify factors that promote or hinder their success in achieving their preferences, and to describe what this means for how different types of continuity are achieved.

DESIGN OF STUDY

Longitudinal, mixed methods.

SETTING

Community in London and Leicester.

METHOD

Purposive sample of 31 patients recruited from general practices, walk-in centres and direct advertising. Data collection involved in-depth interviews, consultation record booklets completed over 6 months and general practice records for the year including the study period. Data were analysed qualitatively.

RESULTS

Four patterns were identified in the way patients used primary care. These were shaped by their own preferences, by the organisation and culture of their primary care practices, and by their own and their provider's efforts to achieve their preferences. Different configurations of these factors gave rise to different types of continuity. Patients were not always able to achieve the type they wanted. Patients with apparently similar consulting patterns could experience them differently.

CONCLUSION

Within a programme of modernisation, policies that promote a commitment to meeting the preferences of different patients with flexibility and understanding are most likely to provide continued support for interpersonal and other types of continuity of care.

Preferences for access to the GP: a discrete choice experiment

BACKGROUND

Access to primary care services is one of the key components of the NHS Plan which states that patients should be able to see a health professional within 24 hours and a GP within 48 hours. However, it is not clear how patients value speed of access in comparison with other aspects of primary care.

AIM

To investigate patient preferences when making an routine appointment for a GP, and to describe the trade-offs and relationships between speed of access, choice of time and choice of doctor in different patient groups.

DESIGN OF STUDY

Discrete choice experiment.

SETTING

Adults consulting a GP in six general practices in Sunderland.

METHOD

Choice sets based on three attributes (time to appointment, choice of time, choice of doctor) were presented in a self-completion questionnaire.

RESULTS

We obtained 6985 observations from 1153 patients. We found that the waiting time to make an appointment was only important if the appointment is for a child or when attending for a new health problem. Other responders would trade-off a shorter waiting time and be willing to wait in order to either see their own choice of doctor or attend an appointment at their own choice of time. For responders who work, choice of time is six times more important than a shorter waiting time and they are willing to wait up to 1 day extra for this. Those with a long-standing illness value seeing their own GP more than seven times as much as having a shorter waiting time for an appointment and will wait an extra 1 day for an appointment with the GP of their choice, women will wait an extra 2 days, and older patients an extra 2.5 days.

CONCLUSION

Speed of access is of limited importance to patients accessing their GP, and for many is outweighed by choice of GP or convenience of appointment.

Can doctors predict patients' satisfaction and enablement? A cross-sectional observational study

BACKGROUND

Patient satisfaction surveys are increasingly used to measure consulting quality and outcome, but little is known of how good doctors are at judging their patients' satisfaction with their consultations.

OBJECTIVES

To determine if patient satisfaction and enablement following a consultation are correlated with both inexperienced and experienced doctors' predictions of patient satisfaction and doctors' own satisfaction with the consultation.

DESIGN

Cross-sectional questionnaire-based observational study.

SETTING

Scottish general practices.

MAIN OUTCOME MEASURES

Using a post-consultation questionnaire we compared doctors' estimates of patient satisfaction with the consultation; doctors' own satisfaction with the consultation; scores on the Patient Enablement Instrument (PEI) and the Consultation Satisfaction Questionnaire (CSQ).

RESULTS

Twenty-nine doctors and 1848 patients took part. Each doctor recorded an average of 63.7 (SD: 32.1) consultations. Patient measures of satisfaction and enablement were only weakly correlated with doctor predictions of patient satisfaction (rs=0.07 for PEI and 0.13 for CSQ; both P<0.01) or doctor satisfaction (rs=0.10 for PEI and 0.12 for CSQ; both P<0.01) with the consultation. They were, however, moderately well correlated (rs=0.50 P<0.01) with one another.

CONCLUSION

Doctors are poor at predicting patient satisfaction in the consultation. Further research is required to determine the reasons for this.

CQI-2--a new measure of holistic interpersonal care in primary care consultations

BACKGROUND

The Consultation Quality Index (CQI) is a holistic quality marker for GPs based on patient enablement, continuity of the care and consultation length.

AIM

To evaluate the CQI-2, a new version of the CQI incorporating a process measure of GP empathy (the Consultation and Relational Empathy Measure).

DESIGN OF STUDY

Cross-sectional questionnaire study.

SETTING

General practice in the west of Scotland.

METHOD

Empathy, enablement, continuity, and consultation length were measured in 3044 consultations involving 26 GPs in 26 different practices in the west of Scotland. CQI-2 scores were calculated and correlated with additional data on GPs' and patients' attitudes. Comparisons were also made with the UK-wide data from which the original CQI had been calculated.

RESULTS

CQI-2 scores were independent of deprivation, access, demographics, and case-mix. GPs with lower CQI-2 scores valued empathy and longer consultations less than these GPs with higher CQI-2 scores. 'Below average CQI-2' GPs (those in the bottom 25%) also felt less valued by patients and colleagues. Patients' showed less confidence in and gained less satisfaction from these doctors. Data ranges from the study were comparable with the UK data ranges used to construct the original CQI.

CONCLUSIONS

The CQI-2 is a new measure of holistic interpersonal care. In a small but representative sample of GPs it appears to differentiate between below and above average doctors. CQI-2 scores may reflect important aspects of morale, core values and patient-centred care. There may be potential for its use as part of professional development and as a component of the general medical services contract.

Measuring changes in self-concept: a qualitative evaluation of outcome questionnaires in people having acupuncture for their chronic health problems

Background

Changes in self-concept are an important potential outcome for many interventions for people with long-term conditions. This study sought to identify and evaluate outcome questionnaires suitable for quantifying changes in self-concept in people with long-term conditions, in the context of treatment with acupuncture and Chinese medicine.

Methods

A literature search was followed by an evaluation of three questionnaires: The Wellbeing Questionnaire W-BQ12, the Patient Enablement Instrument (PEI), and the Arizona Integrative Outcome Scale (AIOS). A convenience sample of 23 people completed the questionnaires on two occasions and were interviewed about their experience and their questionnaire responses. All acupuncturists were interviewed.

Results

Changes in self-concept were common and emerged over time. The three questionnaires had different strengths and weaknesses in relation to measuring changes in self-concept. The generic AIOS had face validity and was sensitive to changes in self-concept over time, but it lacked specificity. The PEI was sensitive and specific in measuring these changes but had lower acceptability. The sensitivity of the W-BQ12 was affected by initial high scores (ceiling effect) and a shorter timescale but was acceptable and is suitable for repeated administration. The PEI and W-BQ12 questionnaires worked well in combination.

Conclusion

Changes in self-concept are important outcomes of complex interventions for people with long-term illness and their measurement requires carefully evaluated tools and long-term follow-up. The literature review and the analysis of the strengths and weaknesses of the questionnaires is a resource for other researchers. The W-BQ12 and the PEI both proved useful for this population and a larger quantitative study is planned.

Choosing between public and private or between hospital and primary care: responsiveness, patient-centredness and prescribing patterns in outpatient consultations in Bangkok

OBJECTIVE

To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand.

METHOD

Analysis of the characteristics of 211 taped consultations with simulated patients.

RESULTS

Private hospitals and clinics were significantly more responsive. Private clinics but not private hospitals were also significantly more patient-centred. All doctors, but particularly those in private hospitals, prescribed unnecessary and potentially harmful technical investigations and drugs. The direct cost to the patient varied between 1.5 (in public health centres) and 12 (in private hospitals) times the minimum daily wage. The combined cost--to the patient and to the state--in public hospitals and health centres exceeded the cost of consultations in private clinics.

CONCLUSION

Market incentives favour responsiveness and a patient-centred approach, but not more appropriate therapeutic decisions. Excessive use of pharmaceuticals is observed among public as well as private providers, but is most pronounced in private hospitals. If patients in Bangkok want to maximize responsiveness and degree of patient-centred care and yet minimize costs and iatrogenesis, they would benefit from avoiding hospitals, both public and private, and, to a lesser extent, specialists. Choosing to use primary facilities, health centres and clinics, particularly when consultations are carried out by general practitioners (GPs), is more beneficial than choosing between public and private providers.

Effect of treatment success and empathy on surgeon attributions for back surgery outcomes

This study examined the effect of conservative and surgical treatment success/failure on attributions by surgeons for low back surgical outcomes. It also examined empathy as a moderator of these attributions. Forty surgeons attributed surgical outcome in a hypothetical patient to physical and psychological factors. Results indicated that surgeons were less likely to attribute the cause of surgical failure to physical factors when the patient had already failed conservative treatment for low back pain. Surgeons also were more likely to attribute failed surgery, relative to successful surgery, to patient psychological factors. An interaction effect indicated that the latter difference was significant only when the patient had previously succeeded at conservative treatment. Empathy moderated this effect: empathic surgeons were less likely to see the failed surgery patient as psychologically culpable. This self-serving attributional style, as moderated by empathy, is discussed regarding its potential impact on patient care and physician judgment processes.

Patient expectations from consultation with family physician

AIM

To assess patient expectations from a consultation with a family physician and determine the level and area of patient involvement in the communication process.

METHOD

We videotaped 403 consecutive patient-physician consultations in the offices of 27 Estonian family physicians. All videotaped patients completed a questionnaire about their expectations before and after the consultation. Patient assessment of expected and obtained psychosocial support and biomedical information during the consultation with physician were compared. Two investigators independently assessed patient involvement in the consultation process on the basis of videotaped consultations, using a 5-point scale.

RESULTS

Receiving an explanation of biomedical information and discussing psychosocial aspects was assessed as important by 57.4-66.8% and 17.8-36.1% patients, respectively. The physicians did not meet patient expectations in the case of three biomedical aspects of consultation: cause of symptoms, severity of symptoms, and test results. Younger patients evaluated the importance of discussing psychological problems higher than older patients. The involvement of the patients was high in the problem defining process, in the physicians' overall responsiveness to the patients, and in their picking up of the patient's cues. The patients were involved less in the decision making process.

CONCLUSION

Discussing biomedical issues was more important for the patients than discussing psychological issues. The patients wanted to hear more about the cause and seriousness of their symptoms and about test results. The family physicians provided more psychosocial care than the patients had expected. Considering high patient involvement in the consultation process and the overall responsiveness of the family physicians to the patients during the consultation, Estonian physicians provide patient-centered consultations.

Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients'heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new 'technological' solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices--technogovernance--in which the heterogeneous narratives of the patient-centred encounter can be resituated and guided.

Effects of interventions aimed at changing the length of primary care physicians' consultation

BACKGROUND

Observational studies have shown differences in process and outcome between the consultations of primary care physicians whose average consultation lengths differ. These differences may be due to self selection.

OBJECTIVES

To assess the effectiveness and efficiency of interventions to alter the length of primary care physicians' consultations.

SEARCH STRATEGY

The following electronic databases were searched: Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (October 2002); CENTRAL (The Cochrane Library June 2003); MEDLINE (1966 to October 2002);EMBASE (1981 to October 2002); NHS National Research Register (June 2003). The search strategies combined subject terms for 'general practice', 'consultation' and 'length' with methodological filters.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of interventions to alter the length of primary care physicians' consultations.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors using agreed criteria. Disagreements were resolved by discussion. Where data were missing attempts were made to contact authors. Given the heterogeneity of studies meta-analysis was not attempted, and results are presented as a narrative summary.

MAIN RESULTS

Six articles describing four UK trials met the inclusion criteria. All tested short term changes in the consultation time allocated to each patient and all had methodological weaknesses, particularly due to non-random allocation of patients. Altering appointment length resulted in modest changes in average length of consultation. There were no consistent differences in problem recognition, examination, prescribing, referral or investigation rates. There was some evidence that blood pressure was checked and smoking discussed more often when more time was available. None of the interventions were associated with differences in patient satisfaction. No trials examined efficiency.

AUTHORS' CONCLUSIONS

The findings of this review do not provide sufficient evidence to support or resist a policy of altering the lengths of primary care physicians' consultations. Further trials are needed that focus on health outcomes and cost effectiveness.

A pilot prospective study on the consultation and relational empathy, patient enablement, and health changes over 12 months in patients going to the Glasgow Homoeopathic Hospital

OBJECTIVE

To relate prospectively initial consultation characteristics-length, empathy, and patient enablement- with perceived health changes in patients going to the Glasgow Homoeopathic Hospital (GHH).

METHODS

Consecutive outpatients completed the Consultation and Relational Empathy (CARE) measure and the Patient Enablement Instrument (PEI) immediately after their first consultations, again at 3 months, and the PEI also at 12 months. The Short Form-12 was completed immediately before and the Measure Yourself Medical Outcome (MYMOP) Profile during the first consultation, and both were repeated at 3 and 12 months. Perceived changes in main complaint and well-being were assessed using the Glasgow Homoeopathic Outcome Scale (GHHOS).

RESULTS

Empathy score at first consultation was highly predictive of ongoing empathy score at 3 months (Spearman's rho, 0.572, p < 0.0001). Empathy scores at first consultation also correlated significantly with enablement score at first consultation (rho, 0.325, p < 0.0001) and overall enablement at 12 months (rho, 0.281; p < 0.05). Controlling for the number of subsequent consultations, initial empathy scores were also predictive of change in main complaint, and general well-being, at 3 months (rho, 0.225, 0.213 respectively; p < 0.05). Enablement score at first consultation also predicted overall enablement at 3 months (rho, 0.255; p < 0.05) and 12 months (rho, 0.282; p < 0.05). Initial enablement predicted GHOSS well-being score at 3 months after controlling for number of consultations (rho, 0.279; p < 0.05). Both empathy and enablement at 3 months predicted overall enablement at 12 months (rho, 0.327; p < 0.01 and rho, 0.577; p < 0.0001, respectively). Empathy at 3 months was not significantly related to GHHOS scores at 12 months, whereas enablement scores at 3 months were highly predictive of both GHHOS main complaint and well-being scores at 12 months (rho, 0.459 and 0.507, respectively; p < 0.0001). Empathy and enablement scores did not correlate significantly with changes in SF-12 and MYMOP scores at any of the time points. The length of the first consultation was related to initial and subsequent CARE scores, overall enablement, and GHHOS scores at 3 and 12 months.

CONCLUSIONS

Empathy is crucial for enablement, which, in turn, is strongly related to perceived change in main complaint and well-being. The length of time the clinician spends with a patient at initial consultation appears to be an important factor in these complex relationships among process and outcome.

Is success in postgraduate examinations associated with family practitioners' attitudes or patient perceptions of the quality of their consultations? A cross-sectional study of the MRCGP examination in Great Britain

BACKGROUND

Postgraduate examinations are ubiquitous in medicine worldwide, but studies to validate them are rare. The Royal College of General Practitioners of the UK, over the years in an evolving format, has offered a membership examination (MRCGP) which it believes acts as a quality marker for those who sit it and also positively influences the development of family practice generally. It is not clear, however, if this process identifies quality markers that patients can perceive.

OBJECTIVES

To determine if possession of the MRCGP (a doctor defined measure of doctor quality) is associated with the patient enablement score (a patient based consultation outcome measure) and family practitioners' attitudes to the work of family practice.

DESIGN

survey using the Patient Enablement Instrument (PEI) with linked survey data on family practitioner (FP) demography and possession of the MRCGP, and FPs' attitudes and beliefs using the Cockburn attitudinal questionnaire.

SUBJECTS

15 534 adult patients attending 154 FP principals.

SETTING

50 family practices in the UK.

OUTCOME MEASURES

the association between possession of MRCGP, and PEI and Cockburn scores was assessed using regression analysis controlling for known confounders.

RESULTS

There was no association between PEI score and possession of the MRCGP. Only one scale of the Cockburn attitude questionnaire (the belief that patients should be involved in decision making) was positively associated with possessing the MRCGP.

CONCLUSION

Any advantage in physician quality conferred by passing the MRCGP exam was not detected in this study. Further research into the predictive validity of postgraduate examinations is required preferably using a wider variety of patient and audit based methods.

Training professionals to engage with and promote self-management

We have set out to investigate an approach to improve patients' ability to self-manage chronic illness. For effective health care in chronic disease, we believe patients need to work in partnership with their doctor; patient-centred consultations are one way to achieve this. This report describes our experience of training specialists in gastroenterology to consult in a patient-centred style as part of a complex self-management intervention in a randomized controlled trial (RCT) involving 700 patients with established inflammatory bowel disease (IBD) attending outpatient clinics. The training session aimed to provide specialists from nine randomly selected intervention sites with the basic skills to carry out the intervention. The training lasted 2 hours, and included background on the research and intervention, a demonstration video, role-play, and video-feedback training. The main findings of the RCT are presented (service use, enablement and satisfaction), and discussed in the light of the views of consultants and patients on the experience of putting the training into practice. The findings of our study confirm and highlight the value of training in patient-centred communication and its potential for promoting self-management effects; the training proved effective in enabling consultants in gastroenterology to establish guided self-management in patients with IBD.

Relevance and practical use of the Consultation and Relational Empathy (CARE) Measure in general practice

BACKGROUND

The Consultation and Relational Empathy (CARE) Measure has been developed as a tool for assessing the patients' perceptions of relational empathy in the consultation.

OBJECTIVES

The present paper provides performance data on the CARE measure in a large sample of general practice consultations in areas of high and low deprivation.

METHODS

The CARE Measure was included in a self-completed questionnaire study involving 3044 patients attending 26 GPs in 26 different practices (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland).

RESULTS

GPs and patients, in both high and low deprivation settings, endorsed the relevance of the CARE Measure. Overall, 76% of patients rated the measure as being 'very important' to their current consultation. Higher rating of importance were observed in older patients, patients consulting with psycho-social problems, patients with long-standing illness or disability, and patients with significant emotional distress. Few patients rated individual CARE Measure items as being 'not applicable' to their current consultation; only 3.1% of patients felt that more than 2 of the 10 items in the measure did not apply to their current consultation. Mean values were not influenced by deprivation, gender, reason for consulting, chronic illness, or emotional distress. Correlational analysis indicated that a sample size of 50 patients is sufficient to reliably estimate mean CARE score for an individual GP.

CONCLUSIONS

These results indicate that the CARE Measure is considered by GPs and patients alike as being of direct relevance to everyday consultations in general practice, in both high and low deprivation settings. The measures is stable across patient groups and a reliable estimate of perceived GP empathy requires 50 completed questionnaires per doctor.

Interpersonal continuity of care and care outcomes: a critical review

PURPOSE

We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence.

RESULTS

Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity.

CONCLUSIONS

Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.

A randomised controlled trial to assess the effectiveness and cost of a patient orientated self management approach to chronic inflammatory bowel disease

OBJECTIVES

We developed a patient centred approach to chronic disease self management by providing information designed to promote patient choice. We then conducted a randomised controlled trial of the approach in inflammatory bowel disease (IBD) to assess whether it could alter clinical outcome and affect health service use.

DESIGN

A multicentre cluster randomised controlled trial.

SETTING

The trial was conducted in the outpatient departments of 19 hospitals with randomisation by treatment centre, 10 control sites, and nine intervention sites. For patients at intervention sites, an individual self management plan was negotiated and written information provided.

PARTICIPANTS

A total of 700 patients with established inflammatory bowel disease were recruited.

MAIN OUTCOME MEASURES

Main outcome measures recorded at one year were: quality of life, health service resource use, and patient satisfaction. Secondary outcomes included measures of enablement-confidence to cope with the condition.

RESULTS

One year following the intervention, self managing patients had made fewer hospital visits (difference -1.04 (95% confidence interval (CI) -1.43 to -0.65); p<0.001) without increase in the number of primary care visits, and quality of life was maintained without evidence of anxiety about the programme. The two groups were similar with respect to satisfaction with consultations. Immediately after the initial consultation, those who had undergone self management training reported greater confidence in being able to cope with their condition (difference 0.90 (95% CI 0.12-1.68); p<0.03).

CONCLUSIONS

Adoption of this approach for the management of chronic disease such as IBD in the NHS and other managed health care organisations would considerably reduce health provision costs and benefit disease control.

The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda

PURPOSE

Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices.

METHODS

This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations.

RESULTS

For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).

CONCLUSION

Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.

The effect of a distance-learning programme on patient self-management of Lower Urinary Tract Symptoms (LUTS) in general practice: a randomised controlled trial

OBJECTIVE

To determine whether a distance-learning programme on LUTS provided to the general practitioner affected patient self-management.

METHODS

A randomised trial was performed to examine the effects of the distance-learning programme (an educational package for the GP and a patient information leaflet) compared with written guidelines on LUTS mailed to the GP. In 63 general practices (32 intervention and 31 control) across the Netherlands all patients older than 50 years presenting LUTS for the first time were invited to participate. Main outcome measures were patient evaluation of quality of care received and perceptions of enablement.

RESULTS

A total of 151 patients was included. The intervention increased patient enablement regarding maintenance of independence (OR = 3.14) and coping with illness (OR = 2.21). Overall enablement scores were not changed. Patients in the intervention group had more positive evaluations of general practice care received (OR = 2.28 to 3.95). An explorative analysis suggested that the effects of the intervention were mediated in particular by handing out of patient information leaflets.

CONCLUSIONS

A distance-learning programme on LUTS for general practitioners had positive effects on patient self-management. Handing out leaflets appeared to be a crucial mediating factor.

Physician-patient relationship and medication compliance: a primary care investigation

PURPOSE

We assessed the relationship between 4 attributes of the physician-patient relationship and medication compliance.

METHODS

We conducted a waiting room survey of patients consulting 22 general practitioners in 14 randomly selected practices in Auckland, New Zealand (81% response rate). A total of 370 consecutive patients (75% response rate) completed survey instruments about 4 attributes of the physician-patient relationship. Continuity of care (assessed from use of a usual physician, length of continuity, and perceived importance of continuity) and trust in the physician were ascertained before the consultation. After the consultation the Patient Enablement Index measured the physician's ability to enable patients in self-care, and concordance between the patient and physician was measured by a 6-item inventory of perceived agreement about the presenting problem and management, were ascertained immediately after the consultation. Compliance with prescribed medication therapy was ascertained by telephone follow-up 4 days after the consultation.

RESULTS

Overall, 220 patients (61%) received a prescription, and 79% of these patients were taking the medication at follow-up. In a univariate analysis adjusted for clustering, only trust and physician-patient concordance were significantly related to compliance. In analysis further adjusted for health and demographic factors, physician-patient concordance was independently related to compliance (odds ratio = 1.34, 95% confidence interval, 1.04-1.72).

CONCLUSIONS

Primary care consultations with higher levels of patient-reported physician-patient concordance were associated with one-third greater medication compliance. An emphasis on understanding and facilitating agreement between physician and patient may benefit outcomes in primary care.

The quality of GP consultation in two different salary systems

OBJECTIVE

To compare the quality of consultations between two Finnish employment contract systems: the capitation-based contract (CB) and the time-based contract (TB).

DESIGN

Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs).

SETTING AND SUBJECTS

81 GPs with their patients from four health care centres in Finland, 2191 encounters.

MAIN OUTCOME MEASURES

Both patients' and GPs' opinions on the role of personal doctor, medico-professional quality, quality of communication, consultation conditions, economic quality (= number of examinations and treatments), and duration of consultation.

RESULTS

Patients were more satisfied than the doctors with the quality of consultations. We found no differences between the groups in the patients' opinions on the quality. The GPs in the CB group rated their work quality higher than the GPs in the TB group. The patients' and the GPs' understanding of the GP as a personal doctor varied so that the patients considered their GP as their personal doctor more often than the GPs in question.

CONCLUSIONS

The GPs with a capitation-based contract evaluated the quality of their work higher than other GPs. Patient satisfaction was not dependent on the GP's contract.

The 21st century: the age of family medicine research?

Family medicine has matured as an academic and scientific discipline with its own core concepts, knowledge, skills, and research domains. It has acquired much expertise in studying common illnesses; the integration of medical, psychological, social, and behavioral sciences; patient-centered care; and health services delivery. Many health care challenges in the 21st century will place a great demand on primary care, which can serve its purpose only if it is of high quality and evidence based. Family medicine research can contribute to many areas of primary care, ranging from the early diagnosis to equitable health care. Stakeholders, such as the World Health Organization, governments, and funding agencies, are becoming more supportive to family medicine research because they recognize its key importance in improving the quality of primary care and bridging the gap between biomedical research and clinical practice. Family medicine can play a leading role in shifting the paradigm of medical research from the laboratory to the person. The 21st century should be a golden age of family medicine research because the time is right for the discipline, the health care environment is most suitable, and stakeholders are supportive. Family medicine must prepare for it by building up its research track record and capacity.

Nurses as information providers: facilitating understanding and communication of statistical information

Nurses are increasingly being called upon to be the conveyers of important statistical information to patients. This trend is particularly evident in the domains of genetics and cancer screening. These new roles, however, demand new competencies, such as the ability to solve statistical problems, and the skill to communicate the answers effectively, as effective communication is an important ingredient in shared decision making. Genetic testing, perhaps more than other medical domains, relies heavily on the use of statistics. Being able to convey statistical information effectively is vital. In this paper, we illustrate the problems health care professionals have had in tackling and communicating statistical information. We introduce the natural frequencies method of solving Bayesian inference problems and review empirical evidence that shows the superiority of this format. Being able to transform probabilities into natural frequencies facilitates correct Bayesian inferences. It is argued that the conventional approach to educating nurses in Bayesian problem solving should be reconsidered and their statistical curriculum should be supplemented with instruction in using the natural frequency format.

A qualitative study of patient's views on the consultation at the Glasgow Homoeopathic Hospital, an NHS integrative complementary and orthodox medical care unit

We investigated consultations at the Glasgow Homoeopathic Hospital (GHH), by the use of in-depth, semi-structured interviews with a purposive sample of 14 patients. Interviews (lasting 1-2 h) were taped and transcribed verbatim. Analysis was based on a grounded theory approach. Two main categories of themes emerged: (1) those "outside" the consultation, related to expectations, initially formed from experiences of family and friends, but then strengthened by ongoing attendance at GHH; and (2) themes "inside" the consultation including length of consultations, the whole-person approach, being treated as an individual, and telling and having their "story" listened to in depth. Equality of relationship, mutual respect, and sharing decisions were also prominent themes. In conclusion, patients attending the GHH highly value the holistic approach, and view time, empathy, and the therapeutic relationship as being of key importance.

Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care

OBJECTIVE

To assess the impact of leaflets encouraging patients to raise concerns and to discuss symptoms or other health related issues in the consultation.

DESIGN

Randomised controlled trial.

SETTING

Five general practices in three settings in the United Kingdom.

PARTICIPANTS

636 consecutive patients, aged 16-80 years, randomised to receive a general leaflet, a depression leaflet, both, or neither.

MAIN OUTCOMES

Mean item score on the medical interview satisfaction scale, consultation time, prescribing, referral, and investigation.

RESULTS

The general leaflet increased patient satisfaction and was more effective with shorter consultations (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to-0.009), with similar results for subscales related to the different aspects of communication. Thus for a 10 minute consultation the leaflet increased satisfaction by 7% (seven centile points) and for a five minute consultation by 14%. The leaflet overall caused a small non-significant increase in consultation time (0.36 minutes, -0.54 to 1.26). Although there was no change in prescribing or referral, a general leaflet increased the numbers of investigations (odds ratio 1.43, 1.00 to 2.05), which persisted when controlling for the major potential confounders of perceived medical need and patient preference (1.87, 1.10 to 3.19). Most of excess investigations were not thought strongly needed by the doctor or the patient. The depression leaflet had no significant effect on any outcome.

CONCLUSIONS

Encouraging patients to raise issues and to discuss symptoms and other health related issues in the consultation improves their satisfaction and perceptions of communication, particularly in short consultations. Doctors do, however, need to elicit expectations to prevent needless investigations.

Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study

OBJECTIVE

To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.

DESIGN

Observational study nested within a randomised controlled trial.

SETTING

Five general practices in three settings in the United Kingdom.

PARTICIPANTS

847 consecutive patients, aged 16-80 years.

MAIN OUTCOMES MEASURES

Patient preferences and doctors' perception of patient pressure and medical need.

RESULTS

Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.

CONCLUSIONS

Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.

Empathy, Enablement, and Outcome: An Exploratory Study on Acupuncture Patients' Perceptions

OBJECTIVES

To conduct an exploratory, retrospective study of acupuncture patients' perceptions of practitioner empathy, patient enablement, and health outcome, and to investigate the associations between them.

METHODS

In a retrospective, observational study, questionnaires were distributed to 192 patients randomly selected from a population of 6348 who, several months previously, had participated in a survey of acupuncture safety, and had agreed to be contacted again. The main measures included patients' perceptions of their practitioners' empathy using the Consultation and Relational Empathy Measure, the Patient Enablement Instrument, and the Glasgow Homeopathic Hospital Outcome Scale (measuring change in main complaint and well-being).

RESULTS

A total of 143 (74%) patients responded (27% men and 73% women) with an average age of 51 years. Comparisons between the population, the sample selected, and the responding sample showed reasonable equivalence. The majority of patients (71%) were in the middle of an ongoing course of treatment at the time of completing the questionnaires for this study. 36% of patients were attending for reasons of "general well-being," 34% for musculoskeletal problems, 11% for emotional or psychological problems, and 19% for other reasons. Empathy and enablement scores were not influenced by age or reason for attendance, but men showed significantly lower scores than women (p < 0.05). Patient enablement was significantly positively correlated with perception of their practitioners' empathy (Spearman's rho = 0.256, p < 0.01). Enablement in turn was strongly positively correlated with the outcome of both the main complaint (rho = 0.457, p < 0.0001) and improved well-being (rho = 0.521, p < 0.0001).

CONCLUSION

Patients' perceptions of consultations with their acupuncturists suggest that their experience of empathy is significantly associated with patient enablement, which in turn is highly correlated with improved self-reported health outcomes.

Human resources policies and continuity of care

Explores the implications for continuity of care of the wide range of policy initiatives currently affecting the management and use of human resources in the UK National Health Service. Draws on the findings of a short study undertaken in 2001 comprising a policy document analysis and a series of expert seminars discussing the impact of the policies in practice. A variety of potential long-term gains for continuity of care were identifiable in the current raft of policy initiatives and seminar participants agreed that, when these policies are fully implemented, continuity of care should be enhanced in several ways. However, the impact to date has been rather more equivocal because of the damaging effects of the process of policy implementation on continuity within the system and on staff attitudes and values. If continuity of care is accepted as an important element of quality in health care, more attention must be given to developing strategies which support system continuity.

Defining and measuring interpersonal continuity of care

BACKGROUND

In an effort to learn more about the importance of continuity of care to physicians and patients, I reviewed the medical literature on continuity of care to define interpersonal continuity and describe how it has been measured and studied.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted to find articles focusing on the keyword "continuity of patient care," including all subheadings. Titles and abstracts of the resulting articles were screened to select articles focusing on interpersonal continuity in the physician-patient relationship or on the definition of continuity of care. These articles were systematically reviewed and analyzed for study method, measurement technique, and research theme.

RESULTS

A total of 379 original articles were found that addressed any aspect of continuity as an attribute of general medical care. One hundred forty-two articles directly related to the definition of continuity or to the concept of interpersonal continuity in the physician-patient relationship. Although the available literature reflects little agreement on how to define continuity of care, it is best defined as a hierarchy of 3 dimensions; informational, longitudinal, and interpersonal continuity. Interpersonal continuity is of particular interest for primary care. Twenty-one measurement techniques have been defined to study continuity, many of which relate to visit patterns and concentration rather than the interpersonal nature of the continuity relationship.

CONCLUSIONS

Future inquiry in family medicine should focus on better understanding the interpersonal dimension of continuity of care.

Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population

BACKGROUND

Patient-provider communication is essential for effective care of diabetes and other chronic illnesses. However, the relative impact of general versus disease-specific communication on self-management is poorly understood, as are the determinants of these 2 communication dimensions.

DESIGN

Cross-sectional survey.

SETTING

Three VA heath care systems, 1 county health care system, and 1 university-based health care system.

PATIENTS

Seven hundred fifty-two diabetes patients were enrolled. Fifty-two percent were nonwhite, 18% had less than a high-school education, and 8% were primarily Spanish-speaking.

MEASUREMENTS AND MAIN RESULTS

Patients' assessments of providers' general and diabetes-specific communication were measured using validated scales. Self-reported foot care; and adherence to hypoglycemic medications, dietary recommendations, and exercise were measured using standard items. General and diabetes-specific communication reports were only moderately correlated (r =.35) and had differing predictors. In multivariate probit analyses, both dimensions of communication were independently associated with self-care in each of the 4 areas examined. Sociodemographically vulnerable patients (racial and language minorities and those with less education) reported communication that was as good or better than that reported by other patients. Patients receiving most of their diabetes care from their primary provider and patients with a longer primary care relationship reported better general communication. VA and county clinic patients reported better diabetes-specific communication than did university clinic patients.

CONCLUSIONS

General and diabetes-specific communication are related but unique facets of patient-provider interactions, and improving either one may improve self-management. Providers in these sites are communicating successfully with vulnerable patients. These findings reinforce the potential importance of continuity and differences among VA, county, and university health care systems as determinants of patient-provider communication.

[Models to explain and predict medical case-loads: their use in calculating the maximum family medicine list that allows at least ten minutes per consultation]

OBJECTIVE

To calculate the maximum family medicine list that gives at least ten minutes per consultation.Design. Transversal.

SETTING

Three health centres.

SUBJECTS

45 826 inhabitants.

MEASUREMENTS

We used the appointments made at three centres to calculate the annual time employed per patient and we adjusted it to allocate a minimum of ten minutes per consultation. We established a cubic regression model to predict the mean case-load per age of patient in general medicine and calculated the maximum list if 70% of the working day were dedicated to care. The results contrasted two centres with greater nursing involvement and one with less. We showed the R2 coefficients. We calculated the maximum lists for the health centres of Navarra and showed them in five clusters worked out on the basis of the percentage of patients >=65.

RESULTS

Age explained 86.1% of variability in mean case-load at each age (84% in children and 93.5% in adults). According to the mean percentage of those >=65 years old, the average maximum lists for centres with more or less nursing involvement are as follows: 7.0%>=65 (2025 and 1989); 14.0% (1834 and 1715); 21.2% (1691 and 1558); 27.0% (1648 and 1460), 34.0% (1560 and 1340).

CONCLUSION

To a great extent, age explains the variability in case-load and lets us calculate the maximum number of patients on the list that still ensures a minimum time for each consultation.

I am a good patient, believe it or not

What issues will the “good patient” of the future have to deal with?

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND

Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs.

OBJECTIVES

Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice.

METHOD

A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices.

RESULTS

The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice.

CONCLUSION

The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.

The effect of decision aids on the agreement between women's and physicians' decisional conflict about hormone replacement therapy

The aim of this secondary analysis was to compare the effects of a tailored decision aid (DA) with those of a pamphlet on the agreement between women's and physicians' decisional conflict about hormone replacement therapy (HRT). A total of 40 physicians and 184 women provided data. The agreement between women's and physicians' decisional conflict scores was measured using the intraclass correlation coefficient (ICC). The ICC was higher for dyads in the DA group (ICC=0.44; 95% confidence interval (CI)=0.25-0.59) compared to the pamphlet group (ICC=0.28; 95% CI=0.06-0.47). When the average score of decisional conflict of women nested within a physician and of each physician were used, the ICC for the DA group and the pamphlet group was 0.41 (95% CI=-0.04 to 0.72) and 0.06 (95% CI=-0.41 to 0.49), respectively. Compared to pamphlets, DAs appear to improve the agreement between women's and physicians' decisional conflict about HRT.

Exploring dental patients' preferred roles in treatment decision-making - a novel approach

AIMS

To assess the transferability of the Control Preferences Scale to dental settings and to explore patients' preferred and perceived roles in dental treatment decision-making.

SETTING AND PARTICIPANTS

A convenience sample of 40 patients, 20 recruited from the University Dental Hospital of Manchester and 20 from a general dental practice in Cheshire.

METHODS

A cross-sectional survey, using the Control Preferences Scale, a set of sort cards outlining five decisional roles (active, semi-active, collaborative, semi-passive, passive), slightly modified for use in dental settings. A second set of cards was used to identify perceived decisional role. Rationale for choice of preferred role was recorded verbatim.

RESULTS

The Control Preferences Scale was found to be transferable to dental settings. All patients in the sample had identifiable preferences regarding their role in treatment decision-making. A collaborative decisional role, with patient and dentist equally sharing responsibility for decision-making, was most popular at both sites. However, patients at both sites typically perceived themselves as attaining a passive role in treatment decisions. Lack of knowledge about dentistry and trust in the dentist were reported contributors to a passive decisional role preference, whilst those with more active role preferences gave rationales consistent with a consumerist stance.

CONCLUSIONS

This exploratory study's findings suggest that dental patients have distinct preferences in relation to treatment decision-making role and that these may not always be met during consultations with their dentist. The Control Preferences Scale appears to be appropriate for use in dental settings.

Are patients' decision-making preferences being met?

OBJECTIVE

To investigate the information and decision-making expectations of general practice patients during real life consultations.

DESIGN

Post-consultation, quantitative patient preference and enablement questionnaire.

SETTING AND PARTICIPANTS

Patients attending for routine appointments in general practice surgeries in Oxfordshire, UK.

RESULTS

Thirteen Oxfordshire general practitioners (GPs) volunteered to take part and a total of 171 patients completed and returned the questionnaire. Between a quarter and one-third of patients reported receiving less information than they desired, particularly in relation to the risks and benefits of medical treatments. Patients who preferred the doctor to make decisions for them (35%), were more likely to have their preferences met (64%) compared with patients wishing to share decisions (47%) or make their own (18%) who were less likely to achieve this role (52 and 41%, respectively). However, it could not be demonstrated unequivocally that these differences were statistically significant. In total, 61% of patients perceived that they achieved their preferred decision-making role. No significant differences were found in post-consultation enablement scores between any of the decision preference groups. Patients' assessments indicated that some doctors were more successful at achieving congruence than others.

CONCLUSION

The decision-making preferences of general practice patients tend to vary. However, there was a substantial mismatch between the stated preferences of patients for the role they wanted to have in decision-making and what they felt actually took place in their consultation. Therefore, it remains a challenge for doctors to match their consultation style to the decision-making preferences of individual patients.

Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial

OBJECTIVE

To determine whether routine review by telephone of patients with asthma improves access and is a good alternative to face to face reviews in general practices.

DESIGN

Pragmatic, randomised controlled trial.

SETTING

Four general practices in England.

PARTICIPANTS

278 adults who had not been reviewed in the previous 11 months.

INTERVENTION

Participants were randomised to either telephone review or face to face consultation with the asthma nurse.

MAIN OUTCOME MEASURES

Primary outcome measures were the proportion of participants who were reviewed within three months of randomisation and disease specific quality of life, as measured by the Juniper mini asthma quality of life questionnaire. Secondary outcome measures included the validated "short Q" asthma morbidity score, nursing care satisfaction questionnaire score, and length of consultation.

RESULTS

Of 137 people randomised to telephone consultation, 101 (74%) were reviewed, compared with 68 reviewed (48%) of the 141 people in the surgery group, a difference of 26% (95% confidence interval 14% to 37%; P<0.001; number needed to treat 3.8). Three months after randomisation the two groups did not differ in the Juniper score (risk difference -0.07 (95% confidence interval -0.40 to 0.27) or in satisfaction with the consultation (risk difference -0.07 (-0.27 to 0.13)). Telephone consultations were on average 10 minutes shorter than reviews held in the surgery (mean difference 10.7 minutes (12.6 to 8.8; P<0.001)).

CONCLUSIONS

Compared with face to face consultations in the surgery, telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction. A shorter duration means that telephone consultations are likely to be an efficient option in primary care for routine review of asthma.

The relationship between consultation length, process and outcomes in general practice: a systematic review

The aim of the study was to examine differences in consultation process and health outcomes between primary care physicians who consult at different rates. A systematic review of observational studies was carried out, restricted to English language journal papers reporting original research or systematic reviews. Qualitative analysis with narrative overview of methodology and key results was undertaken, using MEDLINE (1966 to 1999), EMBASE (1981 to 1999), and the NHS National Research Register. Secondary references from this search were also considered for inclusion. Main outcome measures were objectively measured process or healthcare outcomes. Thirteen papers, describing ten studies, were identified. There were consistent differences in several elements of process and outcome between general practitioners (GPs) who consult at different rates. Although average consultation length may be a marker of other doctor attributes, the evidence suggests that patients seeking help from a doctor who spends more time with them are more likely to have a consultation that includes important elements of care.

The importance of empathy in the enablement of patients attending the Glasgow Homoeopathic Hospital

BACKGROUND

Patient enablement in general practice is known to be limited by consultation length. However, the processes within the consultation that lead to enablement are not well understood.

AIMS

To investigate patient enablement in a setting where time is less of a constraint than in primary care, in order to determine the importance of other factors in enablement.

DESIGN OF STUDY

Exploratory questionnaire-based study.

SETTING

Two hundred consecutive outpatients attending four doctors at the Glasgow Homoeopathic Hospital, an NHS-funded integrated complementary and orthodox medicine unit.

METHOD

Information was collected on enablement and a range of other factors, including the patients expectations, their perception of the doctors empathy, and the doctors own confidence in the doctor-patient relationship.

RESULTS

Although there were many factors that correlated with enablement, multi-regression analysis showed patients expectation, doctor's empathy (as perceived by the patient), and doctor's own confidence in the therapeutic relationship to be the three key factors. Together they accounted for 41% of the variation in enablement, with empathy being the single most important factor (66% of the explained variation in enablement).

CONCLUSION

Patient enablement at the Glasgow Homoeopathic Hospital is mainly related to the patients perception of the doctor's empathy.

Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study

OBJECTIVE

To investigate patients' perceptions of entitlement to time in general practice consultations for depression.

DESIGN

Qualitative study based on interviews with patients with mild to moderate depression.

SETTING

Eight general practices in the West Midlands and the regional membership of the Depression Alliance.

PARTICIPANTS

32 general practice patients and 30 respondents from the Depression Alliance.

RESULTS

An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult.

CONCLUSIONS

Patients' self imposed restraint in taking up doctors' time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients' anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients' sense of entitlement to time. Far from acting as "consumers," patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.

The inverse care law revisited: impact of disadvantaged location on accessing longer GP consultation times

OBJECTIVE

To compare the rate of provision of longer consultations per head of population across practice locations categorised by socioeconomic status.

DESIGN

Retrospective analysis of Medicare data for all consultations for all general practitioners in Australia for the 1998-99 and 1999-2000 financial years, grouped by postcode of practice location. Postcodes were categorised by the Socio-Economic Indexes for Areas, Index of Relative Socio-Economic Disadvantage score.

MAIN OUTCOME MEASURES

Number of consultations and number of brief, standard, long and prolonged consultations per capita in each postcode grouping.

RESULTS

The absolute number of long plus prolonged consultations showed no trend across postcode groups, but the rate ratio per person was significantly higher in more advantaged postcode areas. This represents an example of care provision in inverse relationship to need.

DISCUSSION

Despite higher rates of chronic disease and lower rates of preventive care uptake, patients in low socioeconomic status areas receive longer GP consultations at a lower rate than patients in more advantaged areas. Possible strategies to overcome this inverse care provision include increased numbers of GPs in disadvantaged communities, removal of financial disincentives to longer consultations, and strengthening health promotion and community health services in disadvantaged areas.