Set menus and clinical freedom

Private medical practitioners and managed care in Malaysia: a survey of knowledge and attitudes held by Federal Territory based doctors

This paper considers the subject of managed care in Malaysia, providing a questionnaire-based analysis of the position adopted by private medical practitioners. Managed care is now seen as the dominant health care system in the United States, with many other countries around the world including Malaysia beginning to selectively use component parts to tackle particular health care problems. In this survey it was found that three out of four respondents have concerns regarding the implementation of managed care. The survey was used to identify and categorise these concerns. At the same time, three out of four respondents held the opinion that principles of managed care were already a reality or would be in the next 5 years. This group expressed an eagerness to be trained in managed care principles and be given the opportunity to be part of managed care organisations. It is argued that clinicians' knowledge and interest perceptions are an important influence on the implementation of managed care based systems. The survey-based evidence presented in this article is intended as a measure of current understandings and beliefs, in relation to clinical micro-management process associated with managed care.

Knowledge and attitudes of Malaysian private medical practitioners toward guidelines-based medicine

This paper describes a study of the knowledge and attitudes of a sample of private medical practitioners in Malaysia in relation to questions posed on guidelines-based medicine. The study was conducted through a postal questionnaire sent to a sample of 2,000 private practitioners. Placing the research in context, a description of Malaysia and its health-care system is provided. Issues surrounding guidelines-based medicine in the Malaysian context are discussed. An analysis of the sample population's personal and professional characteristics is presented. Key research findings include identifying a substantial knowledge deficit--less than half of the respondents claimed to understand "guidelines". A majority of doctors (64 per cent) think guidelines are useful. Only 29 per cent of respondents knew where to find guidelines, with 22 per cent claiming to have used guidelines. The paper concludes with a discussion of issues in the implementation of guidelines-based medicine in Malaysia based on the study's findings.

Quality of care in reproductive health programmes: monitoring and evaluation of quality improvement

As 200 million women become pregnant every year, at least 30 million will develop life-threatening complications requiring emergency treatment at any level of society where they live. But it is a basic human right that pregnancy be made safe for all women as complications are mostly unpredictable. This requires reproductive health programmes which are responsive to women's and their families' needs and expectations on the one hand and enhancement of community participation, high quality obstetric services, and both provider collaboration and satisfaction on the other. Monitoring and evaluation of these facets need to be an integral part of any safe motherhood programme, not only to assess progress, but also to use this information for subsequent planning and implementation cycles of national programmes. Lessons learned from ten years' implementation of Safe Motherhood programmes indicate that process and outcome indicators are more feasible for short-term evaluation purposes than impact indicators, such as maternal mortality reduction. The former are described in this paper with relevant country examples. This is the third, and last, article in a series on quality of care in reproductive health programmes. The first (Kwast 1998a) contains an overview of concepts, assessments, barriers and improvements of quality of care. The second (Kwast 1998b) addresses education issues for quality improvement.

Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact

OBJECTIVE

To determine Australian general practitioners' (GPs') views about and recall of clinical practice guidelines.

DESIGN

Self-administered questionnaire survey.

SUBJECTS

Randomly selected Australian GPs.

RESULTS

286 of 373 GPs returned questionnaires (77% response rate). GPs' recall of each of nine guidelines ranged from 52% to 94%; 49% considered that their practice had changed as a result of a guideline. While 92% of respondents agreed that guidelines were "good educational tools", 85% indicated that guidelines were "developed by experts who don't understand general practice". Factors most frequently identified as important in deciding whether to follow the guideline recommendations were whether the guideline was based on evidence and credible endorsement.

CONCLUSIONS

Australian GPs have positive views about the purpose of clinical practice guidelines and an evidence-based approach to guidelines development. However, respondents rating of the perceived impact of available guidelines in everyday practice was low. The dissemination of specific guidelines is patchy and there is little evidence of systematic implementation.

Clinical practice and medical research: bridging the divide between the two cultures

The failure of the results of many research studies to be integrated into everyday clinical practice is both well documented and much decried. In the writings on why medical research and clinical practice have remained separate cultures, two issues have not been sufficiently debated. First, are medical researchers addressing the problems that cause clinicians the most concern in their consultations with patients, and secondly, are the results of research studies being presented in a manner that clinicians can both understand and use? This discussion paper highlights primary care clinicians' urgent need for information on the predictive value of the symptoms and signs seen in everyday clinical practice. Medical research has still to provide this information, often leaving general practitioners with inadequate predictive information on which to make early diagnoses, for example, on whether a patient with chest pain has a pulmonary embolus, or a child with pyrexia and rash has meningococcal septicaemia. The format in which research information is commonly presented is discussed; it has been shown that epidemiological terms used in studies are impenetrable to most clinicians. Additional ways of framing research information need to be devised that present such research information in a narrative format and numerical format, emphasizing the effects of management decisions as well as diagnostic categories, and for use in individual consultations as well as describing populations. Only then will clinicians be able to integrate into their everyday clinical practice the potentially valuable information provided by medical research.

Clinical guidelines: their implementation in general practice

In recent years the development of clinical guidelines has received increasing attention from medical educators and those involved in standard setting, and has been initiated at both central and local levels. This review article outlines the current state of knowledge with regard to clinical guideline implementation in medical practice. It deals with the main aspects of the current guideline debate, such as, clinical freedom and doctor autonomy, the importance of ownership in guideline implementation, the effectiveness of guidelines in changing practice and, in particular, the strategies needed to implement clinical guidelines in general practice. Mechanisms of behavioural change that have been recognized as being important for implementation are also discussed. If implementation strategies are not treated as an integral part of the development process then clinical guidelines may fail to achieve their potential in changing clinical practice.

Epidemiological perspective of body position and arm level in blood pressure measurement

According to official recommendations, indirect blood pressure (BP) measurement should be performed in the brachial artery at heart level in the seated position. At lower levels the hydrostatic pressure of the column of blood in between the heart and the point of measurement is added. The clinical relevance of deviations from the recommendations was investigated in a population-based sample of 401 healthy men and women of ages 15-84 years. In the seated position, the systolic BP measured with the upper arm parallel to the sternum was higher than that with the forearm elevated at heart level. The difference was 9.4 (SD 6.6) mm in men and 8.2 (6.9) mm in women. The corresponding differences in diastolic BP were 13.6 (4.4) mm in men and 12.4 (4.5) mm in women. At heart level, the supine systolic BP was 7.9 (7.5) mm higher than the seated in men, and 8.2 (8.0) mm higher in women, while the diastolic BP was the same up to the age of 40. It is concluded that deviations from the recommended body position and arm level are clinically relevant. The pattern of discrepancy, falsely high BPs below the heart level and a higher pulse pressure in the supine position, is uniform in both sexes at all adult ages.

General practitioners in partnership with management: an organisational model for debate

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community.

Audit of compliance with antenatal protocols

OBJECTIVE

To assess the implementation of action protocols dictated by antenatal risk factors noted at the initial (booking) antenatal visit.

DESIGN

Retrospective study of 2000 women delivered between 1 March 1990 and 29 March 1991.

SETTING

Maternity department of a district general hospital supporting a multiethnic population in inner London.

MAIN OUTCOME MEASURES

Comparison of clinical actions performed against those dictated by the department's protocols. Analysis according to clinical importance, gestation at booking, maternal age, parity, birth order, ethnic origin, and certainty of gestational age.

RESULTS

Interobserver agreement between the two auditors was good (kappa statistic for risk factors detected, 0.78; for actions generated, 0.80). Of the 15,658 actions dictated by department protocols, 3673 (23.5%) were actually performed by the clinicians. The 63 combinations of risk factors and actions believed by consultants to be of particular clinical importance had an action rate of 28.3% compared with 18.6% for those considered less important (p < 0.001). Mothers who first visited the hospital antenatal clinic at or before 24 weeks' gestation had 25.2% of relevant protocols fulfilled (p < 0.001). Compliance was significantly improved in women aged 36 or over (32.4%), black women (24.9%), and cases of uncertain gestation (24.5%). Parity and birth order were not associated with an altered action rate. Ethnic origin deemed as "other" (than white, black, Asian, or oriental) or "unknown" was associated with poor compliance (19.3%).

CONCLUSIONS

Compliance to a set of agreed protocols was poor even though a computer system was available and a protocol manual had been distributed. Protocols were more likely to be implemented in women who booked early and in some groups of women deemed at high risk including older mothers, black women, and those denoted as having uncertain gestational age.

[Should general practitioners consider the costs of their prescriptions? Reflections stemming from the "White Paper" and an opinion survey]

The British government proposal to introduce drug budgets will compel general practitioners to consider the financial consequences of prescribing. In our country, the practitioner neither in the past nor now has an incentive to consider the cost of his prescription, and few efforts have been made to influence it, if we exclude the pharmacy industry. In the present article, the situation of both countries is analyzed and the answers of the general practitioners of Girona and Scotland to questions that examine their predisposition towards considering costs when prescribing are compared. The reduction of the prescription costs must be formulated as a part of a rational prescription and should employ a combination of approaches: education, feedback, administrative changes, and incentives. The procedures to encourage a more efficient use of medicines require an active participation of the practitioners in managing the resources of their practices.

Set menus and clinical freedom

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