List size, screening methods, and other characteristics of practices in relation to preventive care

Quality of care in stroke prevention: results of an audit study among general practitioners

BACKGROUND

In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke.

METHODS

Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel.

RESULTS

A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) (n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment.

CONCLUSIONS

A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.

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.

Relationship between practice organization and cardiovascular risk factor recording in general practice

BACKGROUND

Research findings suggest that the level of cardiovascular risk factor recording in general practice is not yet optimal. Several studies indicate a relation between the organization of cardiovascular disease prevention at practice level and cardiovascular risk factor recording.

AIM

To explore the relation between the organization of cardiovascular disease prevention and risk factor recording in general practice.

METHOD

A cross-sectional study was conducted using data on adherence to selected practice guidelines and on cardiovascular risk factor recording from 95 general practices. Practice guidelines were developed beforehand in a consensus procedure. Adherence was assessed by means of a questionnaire and practice observations. Risk factor recording was assessed by an audit of 50 medical records per practice.

RESULTS

Factor analysis of risk factor recording revealed three dimensions explaining 76% of the variance: recording of health-related behaviour, recording of clinical parameters, and recording of medical background parameters. Adherence to the guideline 'proactively invite patients to attend for assessment of cardiovascular risk' was related to a higher recording level in all three dimensions. Practice characteristics did not show a consistent relationship to the level of risk factor recording.

CONCLUSION

This study indicates that the presence of a system of proactive invitation was related to the recording of cardiovascular risk factors in medical records in general practice.

Factors associated with Pap smear taking in general practice: focusing public health initiatives

This study ascertained the relationships of patient, practitioner and consultation factors with: 1. taking a Pap smear or referral to a specialist in the consultation; and 2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results identify different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers.

Innovation in general practice: is the gap between training and non-training practices getting wider?

BACKGROUND

Training practices are more developed than non-training practices in terms of a wide range of educational and clinical activities, facilities and staff. If training practices are also adopting new innovations at a faster rate than non-training practices the gap between them will increase.

AIM

The aim of this study was to determine whether, between 1982 and 1990, training practices did develop at a faster rate than non-training practices.

METHOD

In 1982 a questionnaire was sent to 153 practices in Gloucestershire, Avon and Somerset which all had one or more partners who were members of the Royal College of General Practitioners. A second questionnaire was sent to the same practices in 1990. Information was sought about practice features including organization, size, facilities, staff and clinical and educational activities. A total of 124 practices (62 training and non-training) completed questionnaires on both occasions.

RESULTS

There were substantial changes in the cohort between the surveys in 1982 and 1990, with many practices gaining, for example, a practice manager, practice nurse and purpose built premises, and introducing audits, screening activities and specific clinics. For each feature of practice a logistic regression was undertaken with training used as an explanatory variable. Training practices were more likely to develop than non-training practices for a number of features including personnel, aspects of practice organization, educational activities, clinical activities and equipment.

CONCLUSION

Training practices are not only more developed than non-training practices but are also more innovative. The gap between training and non-training practices did grow wider between 1982 and 1990. This may be because the members of training practices are inherently more innovative, face fewer obstacles to innovation or that the scheme for approval of practices for training has encouraged specific innovations. Any future accreditation scheme for general practices must be organized to encourage accelerated development in less developed practices rather than only stimulate innovation in already advanced practices.

Practice characteristics associated with audit activity: a medical audit advisory group survey

AIM

A survey of general practices in West Glamorgan was carried out to assess the development of record systems and practice organization and to relate this to audit activity.

METHOD

Following mutual agreement practices were visited by two assessors. Visits were conducted using an agreed protocol and practice data were recorded on a semi-structured questionnaire, which had been sent to the practices in advance of the visits. Practices varied from single handed practices to group practices with six partners.

RESULTS

Fifty seven of the 63 practices in the county suitable for inclusion were visited (90%). Data were analysed from 54 practices (three visits were regarded as a pilot). The practices more likely to be involved in audit were those with three or more partners and which had modern medical record systems. Audit activity had occurred in 87% of practices who kept clinical summaries in the notes (compared with 38% who did not), in 87% of practices with long-term medication summaries in the notes (compared with 40% with no summaries) and in 85% of practices with a computerized age-sex register (compared with 50% with no register). All training practices had undertaken audit compared with 63% of non-training practices.

CONCLUSION

The survey enabled the medical audit advisory group to identify the type and degree of audit undertaken locally and highlighted the characteristics which encourage this activity. As a consequence the group is able to target practices who have limited or no involvement in audit and to offer assistance and advice on record modification likely to enhance audit activity.

Predicting the uptake of health checks in general practice: invitation methods and patients' health beliefs

General practice is in an ideal position to encourage people to adopt healthier lifestyles. One way in which this might be achieved is through the offering of health checks. This paper sought to identify some of the factors which may be important in predicting the uptake of health checks. These were seen to fall into two broad areas--the way in which patients are invited and patients' health beliefs. For the purposes of the study, 299 middle-aged male patients registered at a single practice were randomly allocated to be invited to a health check via two invitation methods. In the first, patients were sent an invitation letter with an appointment. In the second patients' notes were tagged so that they could be invited opportunistically by their GP. After one year, 63.5% of patients invited opportunistically had attended a health check compared with 61.2% of patients sent an invitation letter. However, only 51.6% of the opportunistic group had been invited after one year, meaning that the letter invitation method produced twice as many patients at the health check over the same period of time. Examination of health belief questionnaires sent to patients prior to the commencement of the health checks (50.2% response rate) indicated that attenders had a stronger initial intention to attend and placed a greater value on their health. More detailed analysis revealed intention to show strong relationships with beliefs about the benefits of, and barriers to, attendance at a health check. These results suggest that in order to increase uptake of health checks letter invitations need to be employed.(ABSTRACT TRUNCATED AT 250 WORDS)

Health promotion in the general practice consultation: a minute makes a difference

OBJECTIVE

To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations.

DESIGN

Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient).

SETTING

10 general practices in Nottinghamshire.

SUBJECTS

16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length.

MAIN OUTCOME MEASURES

Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients.

RESULTS

Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity.

CONCLUSIONS

Shortage of time is a major factor in general practitioners' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.

The future of general practice. Caring for larger lists

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The potential and limitations of opportunistic screening: data from a computer simulation of a general practice screening programme

Given the continuing emphasis on preventive medicine in general practice, there is considerable interest in the relative effectiveness of different ways of inviting patients to attend for screening. Recently, opportunistic methods have been advocated as being particularly useful but these methods often fail to reach a high proportion of the target population. Many patients do not consult and when they do they are not always invited to attend for screening. In this study a computer simulation model has been used to examine the effects of these variables in more detail. The notes of a random sample of 190 patients (97 women, 93 men) aged 30-50 years, registered with one general practitioner, were used to provide data for the model. The simulation model showed that increasing the number of screening appointments available each week has only a small effect on screening rates and that a ceiling is reached when 25 appointments per 1000 patients are available. In contrast, increasing the proportion of eligible consulting patients who are invited has a substantial effect such that it could take nearly 12 years to screen 90% of a target population if only one out of every four patients were invited compared with under four years if three out of every four patients were invited. The results suggest therefore that opportunistic screening methods are unlikely to achieve desired screening rates within acceptable time limits. It is argued that to achieve target levels of screening, practices will need to combine opportunistic methods with more formal methods of invitation.

Long to short consultation ratio: a proxy measure of quality of care for general practice

Eighty five general practitioners in the Lothian region recorded information on all surgery consultations on one day in every 15 for a year. On the basis of their mean consultation times with patients the working styles of the general practitioners were described as 'faster' (n = 24), 'intermediate' (n = 40) or 'slower' (n = 21). The 21,707 consultations which they carried out over this period were defined as 'short' (five minutes or less), 'medium' (six to nine minutes) or 'long' (10 minutes or more). Independent of doctor style, 'long' consultations as against 'short' consultations were associated with the doctor: (1) dealing with more of the psychosocial problems which had been recognized and were relevant to the patient's care; (2) dealing with more of the long term health problems which had been recognized as relevant; and (3) carrying out more health promotion in the consultation. Patients also reported greater satisfaction with longer consultations. The ratio of long:short consultations was found to be 0.28:1 for 'faster' doctors as against 2.3:1 for 'slower' doctors. When doctors in either group had more heavily booked surgeries or were running late, the long:short consultation ratio fell, in some cases by over 50%. This paper suggests that the ratio of long to short consultation length for a general practitioner might become the basis of a simply proxy measure of quality of care; and that its use might help monitor the effect of recent and proposed changes in the way in which general practice care is delivered.

A total audit of preventive procedures in 45 practices caring for 430,000 patients

OBJECTIVE

To develop and report the results of a system of audit of computer records in general practice.

DESIGN

A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire.

SETTING

Forty five general practices, widely distributed in England and Wales.

SUBJECTS

All 430,901 patients registered with the practices.

MAIN OUTCOME MEASURES

Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics.

RESULTS

Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor's desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors' list sizes were associated with better performance.

CONCLUSIONS

Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.

Cervical cytology in the Vale of Trent faculty of the Royal College of General Practitioners, 1985-8

OBJECTIVE

To assess changes in the organisation and performance of cervical cytology programmes in the practices of members of the Vale of Trent faculty of the Royal College of General Practitioners.

DESIGN

Retrospective audits completed in 1985 and 1988 by general practitioners on a sequential sample of 100 records of women aged 35-64 in their practice.

SETTING

General practices in which one or more partners were members or associates of the Vale of Trent faculty of the college, of which 76 participated in the first audit and 55 (82% of 67 eligible practices) in the second.

SUBJECTS

Sequential samples of 100 women born between 1 January 1920 and 31 December 1949 (first audit) and between 1 January 1923 and 31 December 1952 (second audit) whose surnames began with P or B respectively.

MAIN OUTCOME MEASURES

Percentage of women in each practice with a record of cervical cytology performed in the previous five years and percentage with no recorded smear.

RESULTS

Of the 76 practices completing the audit in 1985, 55 (82% of those eligible) repeated the exercise in 1988. Performance was not significantly different in practices that did and did not respond. The median percentage of women who had had a smear in the previous five years was 49% and 69% in 1985 and 1988 respectively (p less than 0.001) and that of women with no record of a cervical smear was 28% and 16% respectively (p less than 0.001). All but six practices showed improvement in both outcome measures. In both audits an active call system was associated with a significantly increased performance (p less than 0.05). In nine practices (16%) 80% or more of the samples of women had had a smear in the previous five years.

CONCLUSION

Organisation and performance of practices audited improved between 1985 and 1988. Although this might result from participation in the first audit, it probably represents a more general trend within primary care.

ACTION

Between the two audits more practices (87% v 67%) had developed a policy on screening, and this was more likely to include the aim of performing regular smears on all sexually active women (98% v 80%).

Quality and the use of time in general practice: widening the discussion

To examine the association between different consulting styles in general practice (defined according to the average length of doctor-patient contact time in surgery consultations) and the process of care for those patients presenting with new episodes of respiratory illness, 1787 consultations conducted by 85 general practitioner principals in Lothian from November 1987 to May 1988 were analysed. Short as against long consultations resulted in less attention being given to psychosocial issues that the doctor recognised as relevant. When psychosocial problems were dealt with prescribing of antibiotics decreased. In this volunteer sample of doctors the process of care seemed to reflect decisions as to how time was allocated rather than inherently different patterns of clinical behavior. Organisational and contractual changes will shift the mix of financial and professional incentives for general practitioners in ways that could lead to doctors reallocating their time toward shorter consultations; such a reallocation could have important implications for patient care.

William Pickles lecture 1988. All together now

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Opportunistic health promotion: do patients like it?

In a five doctor general practice 100 adults attending routine surgeries were given questionnaires to assess the influence of discussing health promotion on their satisfaction with the consultation. Health promotion topics were discussed in 74% of the 86 consultations analysed. Of these consultations, blood pressure was mentioned in the largest number (48%) and breast self-examination in the smallest (6%). Patient satisfaction was not significantly influenced by the inclusion or omission of such topics. The highest mean satisfaction score was for those discussing smoking and the lowest for those discussing alcohol. Most patients (84%) found discussion of health promotion helpful and felt comfortable (62%); only two patients felt uncomfortable doing so.

James Mackenzie lecture 1986. Quality of caring--landscapes and curtains

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A computer generated patient carried health check card

A computerized record system has been programmed so a patient's important medical information can be printed out and given to the patient in the form of a ;health check card'. One aim was to enable patients to take more responsibility for their own preventive care. Following the issue of cards to 331 patients in 126 families, there was an increase in the uptake of cervical cytology screening, blood pressure recordings and tetanus immunization. Replies to a questionnaire enclosed with the card were received from 161 patients (in 86 of the families): most found the cards acceptable and believed they would be useful.