The incidence and notification of measles in Australia

The incidence of measles in Australia in 1986 was estimated as 43 per 100,000 population, high by the standards of countries where immunization levels are high, low by the standards of countries where immunization levels are low. It is estimated that only 5 per cent of cases are notified in New South Wales, one of only 2 States which require notification. The reasons for this, its significance and a possible remedy are discussed.

Patients with dementia and their carers in general practice

In 2004, 6.5% of Australians over 65 years of age were estimated to have dementia and the prevalence of dementia is rising as a result of our aging population. There is evidence to show that carer wellbeing is important for the wellbeing of the patient. Increasing burden of care may lead to depression, anxiety, and more frequent physical illness in the carer, and earlier institutionalisation of patients. The general practitioner's role includes recognising early dementia, undertaking assessments to confirm the diagnosis, managing the disease, health promotion and support for both patient and carer, and follow up. We initiated a project to explore the extent to which GPs currently fulfill this role for patients with dementia still living in the community (rather than in hostels or nursing homes).

The management of dementia in general practice. A field test of guidelines

INTRODUCTION

Guidelines for the management of dementia in non-institutionalized patients living in the community were developed by a broadly representative group. We assessed their usefulness.

METHOD

The draft guidelines included emphasis on psychosocial issues. They were field tested by 17 general practitioners with 119 dementia patients.

RESULTS

There was a high prevalence of comorbidity in the patients and frequent psychosocial issues in their management that were often not addressed. The guidelines were rated as very helpful for at least one aspect of care for 50% of the patients.

DISCUSSION

The guidelines were found to be useful to GPs.

Dementia care in general practice. What can the BEACH survey tell us?

BACKGROUND

Only a small amount of rather selective information about dementia care in general practice in Australia is available.

AIM

To obtain a broader understanding of the prevalence and management of dementia in general practice.

METHOD

An analysis of data from the Bettering the Evaluation And Care of Health (BEACH) study of general practice in 1998-2000 was undertaken.

RESULTS

Only 21% of GPs reported any encounter with a patient at which dementia was treated within their reported 100 patient encounters. These encounters comprised only 0.43% of all encounters; 39% of these encounters were in a nursing home and 28% occurred in the GP's consulting rooms. For 7% of patients the diagnosis of dementia was new. Most patients with dementia were aged over 75 years, but dementia was treated in only 3% of all patients of this age. It was treated in 19% of patients seen in nursing homes. Nearly all patients (96%) with dementia had other conditions managed at the encounter. Medication was infrequently prescribed for dementia.

DISCUSSION

More information is needed about dementia and its care in the community--its stage, extent of impairment and disability, social functioning, use of services, carers and their health, and progression over time.

General practitioners' views on patient care research

BACKGROUND

Little research has been undertaken into the factors affecting recruitment by Australian general practitioners of patients for clinical trials. Understanding the differences between recruiters and non-recruiters will assist researchers in better supporting general practitioners involved in such research.

METHOD

A survey of general practitioners involved in recruiting patients for clinical trials for the RACGP Research Program was undertaken.

RESULTS

Recruiters were more likely to be interested in learning more about research, to perceive involvement as worthwhile, to desire a good relationship with Research Program staff and to feel the doctor-patient relationship assists recruitment.

DISCUSSION

Recruiters in general are average general practitioners, male, middle-aged and work in group practices. Most felt some discomfort in recruiting patients, but believed the strong doctor-patient relationship assisted in the process.

CONCLUSION

The Research Program needs to recruit general practitioners interested in research, choose topics of interest, keep recruitment protocols simple and stay in contact.

Cervical cytopathology reporting systems. Helping or hindering patient management?

OBJECTIVE

When a Pap smear is reported, the general practitioner needs to know whether it was technically satisfactory and, if abnormal, what kind of abnormality was found, in order to arrange appropriate management. A random survey of non hospital based cytology reporting laboratories in NSW was undertaken to determine the efficiency of this process.

METHOD

This study examines the types of cytopathology reporting protocols used, the means provided by the laboratory to assist general practitioners in assessing the quality of their Pap smears and what, if any, management advice was given to general practitioners.

RESULTS

Not only do different laboratories use different terminologies to report on Pap smears, but the majority use terms from at least two different reporting systems. Seven of the 10 laboratories provided feedback on the adequacy of the Pap smears while only 4 of the 10 laboratories provided management advice.

CONCLUSIONS

If the 1993 National Health and Medical Research Council recommendations are followed, cytopathology reporting will be primarily Bethesda based with the pathology laboratories providing feedback on technical aspects of Pap smears taking as well as management advice.

Sampling techniques for cervical cancer prevention

The principal goal of Pap smear screening is to detect those abnormalities of the cervix that require definitive diagnostic intervention. Any mainstream screening of the population should also seek to increase the participation of women belonging to groups with special needs, such as Aboriginal and Torres Strait Islander women, women of non English speaking background, women with disabilities and older unscreened women. As it is not always possible to obtain endocervical cells, the importance of a Pap smear for individual women is questioned. This article examines the various sampling techniques and choice of instruments. Though the literature is not entirely supportive of a particular cytological sampling technique, the overall evidence supports the use of the spatula/cytobrush combination.

Classification of severity of health problems in family/general practice: an international field trial

BACKGROUND

A methodology is needed for classification of health problems by severity.

OBJECTIVES

We aimed to test the Duke Severity of Illness Checklist (DUSOI) for feasibility and usefulness.

METHOD

The DUSOI was field tested internationally by 22 family/general practitioners in 9 countries.

RESULTS

The DUSOI was found to be feasible for rating severity of illness of health problems in family/general practice. The measure was shown to be clinically useful in older patients and those with chronic and more severe health problems. Variability of severity ratings was less within the same rater than between different raters (i.e. higher intrarater than interrater reliability). Clinical face validity was supported by the finding that DUSOI ratings classified patients with the same diagnosis and those with different diagnoses according to the severity differences that would be expected clinically.

CONCLUSIONS

Although research is needed to improve reliability and to test validity further, the DUSOI was shown in the present study to be a methodology that is reasonable for consideration as an international classification of health problems by their severity in primary care patients.

Immunisation in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991

Immunisation is the sixth most commonly managed problem in general practice in Australia. This paper provides an overview of its management in general practice.

Asthma management and morbidity in Australian general practice: the relationship between patient and doctor estimates

The aims of this study were to describe asthma management and morbidity in patients attending general practitioners in Australia, and to assess the relationship between patient reports and those of their general practitioner (GP). The sample comprised consecutive patients attending 46 general practitioners chosen at random in five regions of New South Wales, Australia. A total of 4538 patients were screened, 607 (13.4%) reported ever having diagnosed asthma, and the 501 who reported asthma in the previous 12 months completed a detailed questionnaire. Three hundred and thirty-four patients also had information about their asthma management recorded by their GP. The patient questionnaire asked about asthma symptoms, therapy, lung function measurement, and asthma-related morbidity. The GP questionnaire asked the doctor to record similar information about the patients. Two-thirds of the patients used regular inhaled beta 2-agonist medication, and one-half reported using preventive therapy. Only 24% owned a peak flow meter and 9% had a written plan of action for asthma attacks. Although preventive therapy and airway function assessment were more common in those with frequent symptoms (> 2-3 times per week), this group were still sub-optimally managed. In the matched sample (n = 334), doctors reported prescribing bronchodilator and preventive medication, measuring airway function and recommending peak flow meter use more often than suggested by patient-reported data. The study concludes that many patients do not attend for regular review, and that management remains sub-optimal, particularly in young adults. Data from patient surveys may underestimate clinical practice, as assessed from doctors' records. This should lead to patient-derived estimates of management being interpreted with caution in epidemiological studies. Further attention to patient understanding and compliance with prescribed asthma management advice is needed in order to better manage asthma in the community.

A controlled trial of educational visiting to improve benzodiazepine prescribing in general practice

A randomised controlled trial studied the effect of an educational visit on benzodiazepine prescribing. An approximately representative sample of 286 general practitioners was allocated to an intervention or a control group. Rates of benzodiazepine prescriptions were derived from two comprehensive self-report surveys seven months apart. Two months after the first survey the intervention group received an educational visit and supporting material from a doctor or pharmacist, ostensibly unconnected with the surveys. The overall benzodiazepine prescribing rate fell by 23.7 per cent from the first to the second surveys, from 4.93 to 3.76 prescriptions per 100 encounters (P < 0.001). Anxiety and insomnia diagnosis rates also declined from 4.68 to 3.76 per 100 encounters (19.7 per cent). After adjusting for confounders, there was a differential downward trend in prescriptions per diagnosis of insomnia but not to a statistical level. The same was true of initial prescriptions per insomnia diagnosis. In a subsidiary analysis selecting only new insomnia diagnoses, the intervention had a strong effect in reducing initial prescriptions (odds ratio 0.18, 95 per cent confidence interval 0.04 to 0.73). No effect was seen on prescribing for anxiety diagnoses. Educational practice visiting for benzodiazepine prescribing in anxiety, as we conducted it, is not justified in an unselected population of general practitioners. Specific education on prescribing for insomnia is probably useful. Our interpretation of the reduction in benzodiazepine prescribing is that probably there was an effect from self-monitoring alone which overwhelmed a main-analysis intervention effect. Retrospective diagnosis may also have obscured a real intervention effect.

Development of sample size models for national general practice surveys

The most cost-effective method to measure the morbidity managed and treatments provided in general practice is from records of a cluster of consultations (encounters) from each general practitioner (GP) in a random sample. A cluster sampling method is proposed for future surveys for analysis of encounter-based general practice data. The sample sizes needed to measure the most common problems managed and drugs prescribed were estimated using ratio-estimator models for cluster sample surveys. Morbidity and treatment rates were estimated from the Australian Morbidity and Treatment Survey in General Practice 1990-1991 (AMTS). The 20 most common problems in the AMTS were managed at estimated rates of 1.5 to 9.5 per 100 encounters. The 20 most common drugs were prescribed at estimated rates of 0.7 to 3.6 per 100 problems. These rates were used to determine precision as a percentage of each true value for future surveys, that is, as relative precision. If we want to be 95 per cent confident that these rates will be within 5 per cent of each true rate, sample sizes of 552 to 5675 GPs are needed. If we fix the sample size at 1000 GPs, relative precision lies within 12 per cent of these rates. If the sample size is increased to 1500 GPs, relative precision improves only marginally. The differences in sample size for each of the most frequent morbidity and treatment data are largely due to their variable distributions and relatively infrequent occurrence in general practice. A sample size of 1000 GPs will enable measurement of the most common morbidity and treatments at 95 per cent confidence.

The management of asthma in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991

Asthma is the third most commonly managed problem in general practice in Australia. This paper provides an overview of its management in general practice.

The management of sprains and strains in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991

Sprains and strains were the eighth most commonly managed problem in general practice in Australia. This paper provides an overview of their management in general practice.

The management of acute bronchitis in general practice: results from the Australian Morbidity and Treatment Survey, 1990-1991

Acute bronchitis is the fifth most commonly managed problem in general practice in Australia. This paper provides an overview of its management in general practice and compares the results with those of an earlier study.

A comparison of country and metropolitan general practice

This paper is a summary of a report of a comparison of country and metropolitan general practice undertaken by the Family Medicine Research Unit, University of Sydney, and published as a supplement to the Medical Journal of Australia. The identified differences were not consistent across small medium and large country towns. The morbidity patterns were similar between all areas, but country GPs were generally busier and undertook more hospital and procedural work.

Educational visiting and hypnosedative prescribing in general practice

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

The diagnostic difficulties of abdominal pain

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

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

A comparison of country and metropolitan general practice

OBJECTIVE

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

METHOD

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

SAMPLE

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

DATA COLLECTION

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

RESULTS

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

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

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

Childhood immunisation in general practice

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Asthma management in general practice

OBJECTIVE

To provide guidelines for management of asthma in general practice.

DATA SOURCES

Selected articles, particularly those relating to general practice.

CONCLUSION

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

Antibiotics in acute respiratory infections

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

Recruiting general practitioners for survey research

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

Asthma in general practice. Opportunities for recognition and management

OBJECTIVE

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

SETTING

Sydney.

DESIGN

Cross-sectional survey by written questionnaire.

SAMPLE

1933 patients of 21 general practitioners.

RESULTS

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

CONCLUSION

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

Morbidity and treatment in general practice in Australia

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

Quality assurance in general practice

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

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

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

Using general practitioners to measure community morbidity

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

How representative are patients in general practice morbidity surveys?

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