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1.  Order effects in high stakes undergraduate examinations: an analysis of 5 years of administrative data in one UK medical school 
BMJ Open  2016;6(10):e012541.
Objective
To investigate the association between student performance in undergraduate objective structured clinical examinations (OSCEs) and the examination schedule to which they were assigned to undertake these examinations.
Design
Analysis of routinely collected data.
Setting
One UK medical school.
Participants
2331 OSCEs of 3 different types (obstetrics OSCE, paediatrics OSCE and simulated clinical encounter examination OSCE) between 2009 and 2013. Students were not quarantined between examinations.
Outcomes
(1) Pass rates by day examination started, (2) pass rates by day station undertaken and (3) mean scores by day examination started.
Results
We found no evidence that pass rates differed according to the day on which the examination was started by a candidate in any of the examinations considered (p>0.1 for all). There was evidence (p=0.013) that students were more likely to pass individual stations on the second day of the paediatrics OSCE (OR 1.27, 95% CI 1.05 to 1.54). In the cases of the simulated clinical encounter examination and the obstetrics and gynaecology OSCEs, there was no (p=0.42) or very weak evidence (p=0.099), respectively, of any such variation in the probability of passing individual stations according to the day they were attempted. There was no evidence that mean scores varied by day apart from the paediatric OSCE, where slightly higher scores were achieved on the second day of the examination.
Conclusions
There is little evidence that different examination schedules have a consistent effect on pass rates or mean scores: students starting the examinations later were not consistently more or less likely to pass or score more highly than those starting earlier. The practice of quarantining students to prevent communication with (and subsequent unfair advantage for) subsequent examination cohorts is unlikely to be required.
doi:10.1136/bmjopen-2016-012541
PMCID: PMC5073653  PMID: 27729351
MEDICAL EDUCATION & TRAINING; Educational Measurement; Clinical Competence
2.  Understanding negative feedback from South Asian patients: an experimental vignette study 
BMJ Open  2016;6(9):e011256.
Objectives
In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care.
Design
Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP–patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16.
Setting
Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling.
Participants
564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach.
Main outcome measure
Mean differences in communication score (on a scale of 0–100) between White British and Pakistani participants, estimated from linear regression.
Results
Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p<0.001) when viewing the same consultations. When adjusted for age, gender, deprivation, self-rated health and video, the difference increased to 11.0 points (95% CI 8.5 to 13.6, p<0.001). The largest differences were seen when participants were older (>55) and where communication was scripted to be poor.
Conclusions
Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.
doi:10.1136/bmjopen-2016-011256
PMCID: PMC5020840  PMID: 27609844
communication; healthcare disparities; minority groups; physician-patient relations; PRIMARY CARE
3.  Following the mixed methods trail: some travel advice 
doi:10.3399/bjgp15X685045
PMCID: PMC4408519  PMID: 25918329
4.  Language spoken at home and the association between ethnicity and doctor–patient communication in primary care: analysis of survey data for South Asian and White British patients 
BMJ Open  2016;6(3):e010042.
Objectives
To investigate if language spoken at home mediates the relationship between ethnicity and doctor–patient communication for South Asian and White British patients.
Methods
We conducted secondary analysis of patient experience survey data collected from 5870 patients across 25 English general practices. Mixed effect linear regression estimated the difference in composite general practitioner–patient communication scores between White British and South Asian patients, controlling for practice, patient demographics and patient language.
Results
There was strong evidence of an association between doctor–patient communication scores and ethnicity. South Asian patients reported scores averaging 3.0 percentage points lower (scale of 0–100) than White British patients (95% CI −4.9 to −1.1, p=0.002). This difference reduced to 1.4 points (95% CI −3.1 to 0.4) after accounting for speaking a non-English language at home; respondents who spoke a non-English language at home reported lower scores than English-speakers (adjusted difference 3.3 points, 95% CI −6.4 to −0.2).
Conclusions
South Asian patients rate communication lower than White British patients within the same practices and with similar demographics. Our analysis further shows that this disparity is largely mediated by language.
doi:10.1136/bmjopen-2015-010042
PMCID: PMC4785310  PMID: 26940108
MEDICAL EDUCATION & TRAINING; PRIMARY CARE
5.  Variations in GP–patient communication by ethnicity, age, and gender: evidence from a national primary care patient survey 
Background
Doctor–patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor–patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups.
Aim
To determine how reported GP–patient communication varies between patients from different ethnic groups, stratified by age and gender.
Design and setting
Analysis of data from the English GP Patient Survey from 2012–2013 and 2013–2014, including 1 599 801 responders.
Method
A composite score was created for doctor–patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group.
Results
There was strong evidence (P<0.001 for age by gender by ethnicity three-way interaction term) that the effect of ethnicity on reported GP–patient communication varied by both age and gender. The difference in scores between white British and other responders on doctor–patient communication items was largest for older, female Pakistani and Bangladeshi responders, and for younger responders who described their ethnicity as ‘Any other white’.
Conclusion
The identification of groups with particularly marked differences in experience of GP–patient communication — older, female, Asian patients and younger ‘Any other white’ patients — underlines the need for a renewed focus on quality of care for these groups.
doi:10.3399/bjgp15X687637
PMCID: PMC4684035  PMID: 26541182
communication; healthcare disparities; minority groups; physician–patient relations; primary health care
6.  Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study 
The British Journal of General Practice  2014;64(626):e568-e575.
Background
In the UK, the use of care planning and written care plans has been proposed to improve the management of long-term conditions, yet there is limited evidence concerning their uptake and benefits.
Aim
To explore the implementation of care plans and care planning in the UK and associations with the process and outcome of care.
Design and setting
A controlled prospective cohort study among two groups of patients with long-term conditions who were similar in demographic and clinical characteristics, but who were registered with general practices varying in their implementation of care plans and care planning.
Method
Implementation of care plans and care planning in general practice was assessed using the 2009–2010 GP Patient Survey, and relationships with patient outcomes (self-management and vitality) were examined using multilevel, mixed effects linear regression modelling.
Results
The study recruited 38 practices and 2439 patients. Practices in the two groups (high and low users of written documents) were similar in structural and population characteristics. Patients in the two groups of practices were similar in demographics and baseline health. Patients did demonstrate significant differences in reported experiences of care planning, although the differences were modest. Very few patients in the cohort reported a written plan that could be confirmed. Analysis of outcomes suggested that most patients show limited change over time in vitality and self-management. Variation in the use of care plans at the practice level was very limited and not related to patient outcomes over time.
Conclusion
The use of written care plans in patients with long-term conditions is uncommon and unlikely to explain a substantive amount of variation in the process and outcome of care. More proactive efforts at implementation may be required to provide a rigorous test of the potential of care plans and care planning.
doi:10.3399/bjgp14X681385
PMCID: PMC4141614  PMID: 25179071
care plans; care planning; general practice; long-term conditions; UK
7.  Web-Based Textual Analysis of Free-Text Patient Experience Comments From a Survey in Primary Care 
JMIR Medical Informatics  2015;3(2):e20.
Background
Open-ended questions eliciting free-text comments have been widely adopted in surveys of patient experience. Analysis of free text comments can provide deeper or new insight, identify areas for action, and initiate further investigation. Also, they may be a promising way to progress from documentation of patient experience to achieving quality improvement. The usual methods of analyzing free-text comments are known to be time and resource intensive. To efficiently deal with a large amount of free-text, new methods of rapidly summarizing and characterizing the text are being explored.
Objective
The aim of this study was to investigate the feasibility of using freely available Web-based text processing tools (text clouds, distinctive word extraction, key words in context) for extracting useful information from large amounts of free-text commentary about patient experience, as an alternative to more resource intensive analytic methods.
Methods
We collected free-text responses to a broad, open-ended question on patients’ experience of primary care in a cross-sectional postal survey of patients recently consulting doctors in 25 English general practices. We encoded the responses to text files which were then uploaded to three Web-based textual processing tools. The tools we used were two text cloud creators: TagCrowd for unigrams, and Many Eyes for bigrams; and Voyant Tools, a Web-based reading tool that can extract distinctive words and perform Keyword in Context (KWIC) analysis. The association of patients’ experience scores with the occurrence of certain words was tested with logistic regression analysis. KWIC analysis was also performed to gain insight into the use of a significant word.
Results
In total, 3426 free-text responses were received from 7721 patients (comment rate: 44.4%). The five most frequent words in the patients’ comments were “doctor”, “appointment”, “surgery”, “practice”, and “time”. The three most frequent two-word combinations were “reception staff”, “excellent service”, and “two weeks”. The regression analysis showed that the occurrence of the word “excellent” in the comments was significantly associated with a better patient experience (OR=1.96, 95%CI=1.63-2.34), while “rude” was significantly associated with a worse experience (OR=0.53, 95%CI=0.46-0.60). The KWIC results revealed that 49 of the 78 (63%) occurrences of the word “rude” in the comments were related to receptionists and 17(22%) were related to doctors.
Conclusions
Web-based text processing tools can extract useful information from free-text comments and the output may serve as a springboard for further investigation. Text clouds, distinctive words extraction and KWIC analysis show promise in quick evaluation of unstructured patient feedback. The results are easily understandable, but may require further probing such as KWIC analysis to establish the context. Future research should explore whether more sophisticated methods of textual analysis (eg, sentiment analysis, natural language processing) could add additional levels of understanding.
doi:10.2196/medinform.3783
PMCID: PMC4439523  PMID: 25947632
patient experience; patient feedback; free-text comments; quantitative content analysis; textual analysis
8.  Does the availability of a South Asian language in practices improve reports of doctor-patient communication from South Asian patients? Cross sectional analysis of a national patient survey in English general practices 
BMC Family Practice  2015;16:55.
Background
Ethnic minorities report poorer evaluations of primary health care compared to White British patients. Emerging evidence suggests that when a doctor and patient share ethnicity and/or language this is associated with more positive reports of patient experience. Whether this is true for adults in English general practices remains to be explored.
Methods
We analysed data from the 2010/2011 English General Practice Patient Survey, which were linked to data from the NHS Choices website to identify languages which were available at the practice. Our analysis was restricted to single-handed practices and included 190,582 patients across 1,068 practices. Including only single-handed practices enabled us to attribute, more accurately, reported patient experience to the languages that were listed as being available. We also carried out sensitivity analyses in multi-doctor practices.
We created a composite score on a 0-100 scale from seven survey items assessing doctor-patient communication. Mixed-effect linear regression models were used to examine how differences in reported experience of doctor communication between patients of different self-reported ethnicities varied according to whether a South Asian language concordant with their ethnicity was available in their practice. Models were adjusted for patient characteristics and a random effect for practice.
Results
Availability of a concordant language had the largest effect on communication ratings for Bangladeshis and the least for Indian respondents (p < 0.01). Bangladeshi, Pakistani and Indian respondents on average reported poorer communication than White British respondents [-2.9 (95%CI -4.2, -1.6), -1.9 (95%CI -2.6, -1.2) and -1.9 (95%CI -2.5, -1.4), respectively]. However, in practices where a concordant language was offered, the experience reported by Pakistani patients was not substantially worse than that reported by White British patients (-0.2, 95%CI -1.5,+1.0), and in the case of Bangladeshi patients was potentially much better (+4.5, 95%CI -1.0,+10.1). This contrasts with a worse experience reported among Bangladeshi (-3.3, 95%CI -4.6, -2.0) and Pakistani (-2.7, 95%CI -3.6, -1.9) respondents when a concordant language was not offered.
Conclusions
Substantial differences in reported patient experience exist between ethnic groups. Our results suggest that patient experience among Bangladeshis and Pakistanis is improved where the practice offers a language that is concordant with the patient’s ethnicity.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0270-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0270-5
PMCID: PMC4494805  PMID: 25943553
Doctor-patient communication; Ethnic minority; South Asians; Doctor–patient relationship; Ethnicity; Inequities
9.  Understanding high and low patient experience scores in primary care: analysis of patients’ survey data for general practices and individual doctors 
The BMJ  2014;349:g6034.
Objectives To determine the extent to which practice level scores mask variation in individual performance between doctors within a practice.
Design Analysis of postal survey of patients’ experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices.
Setting Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey.
Participants 7721 of 15 172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013.
Main outcome measure Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models.
Results After control for differences in patients’ age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores.
Conclusions Aggregating patients’ ratings of doctors’ communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to “screen” for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners.
doi:10.1136/bmj.g6034
PMCID: PMC4230029  PMID: 25389136
10.  Assessing communication quality of consultations in primary care: initial reliability of the Global Consultation Rating Scale, based on the Calgary-Cambridge Guide to the Medical Interview 
BMJ Open  2014;4(3):e004339.
Objectives
To investigate initial reliability of the Global Consultation Rating Scale (GCRS: an instrument to assess the effectiveness of communication across an entire doctor–patient consultation, based on the Calgary-Cambridge guide to the medical interview), in simulated patient consultations.
Design
Multiple ratings of simulated general practitioner (GP)–patient consultations by trained GP evaluators.
Setting
UK primary care.
Participants
21 GPs and six trained GP evaluators.
Outcome measures
GCRS score.
Methods
6 GP raters used GCRS to rate randomly assigned video recordings of GP consultations with simulated patients. Each of the 42 consultations was rated separately by four raters. We considered whether a fixed difference between scores had the same meaning at all levels of performance. We then examined the reliability of GCRS using mixed linear regression models. We augmented our regression model to also examine whether there were systematic biases between the scores given by different raters and to look for possible order effects.
Results
Assessing the communication quality of individual consultations, GCRS achieved a reliability of 0.73 (95% CI 0.44 to 0.79) for two raters, 0.80 (0.54 to 0.85) for three and 0.85 (0.61 to 0.88) for four. We found an average difference of 1.65 (on a 0–10 scale) in the scores given by the least and most generous raters: adjusting for this evaluator bias increased reliability to 0.78 (0.53 to 0.83) for two raters; 0.85 (0.63 to 0.88) for three and 0.88 (0.69 to 0.91) for four. There were considerable order effects, with later consultations (after 15–20 ratings) receiving, on average, scores more than one point higher on a 0–10 scale.
Conclusions
GCRS shows good reliability with three raters assessing each consultation. We are currently developing the scale further by assessing a large sample of real-world consultations.
doi:10.1136/bmjopen-2013-004339
PMCID: PMC3948635  PMID: 24604483
Statistics & Research Methods; Medical Education & Training
11.  Experiences of care planning in England: interviews with patients with long term conditions 
BMC Family Practice  2012;13:71.
Background
The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England.
Methods
We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes.
Results
No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term ‘care planning’. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term”reactive” care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described.
Conclusions
Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.
doi:10.1186/1471-2296-13-71
PMCID: PMC3436749  PMID: 22831570
Aged; Chronic disease; Chronic illness; Patient care planning; Primary health care
12.  Understanding high and low patient experience scores in primary care: analysis of patients’ survey data for general practices and individual doctors 
Objectives To determine the extent to which practice level scores mask variation in individual performance between doctors within a practice.
Design Analysis of postal survey of patients’ experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices.
Setting Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey.
Participants 7721 of 15 172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013.
Main outcome measure Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models.
Results After control for differences in patients’ age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores.
Conclusions Aggregating patients’ ratings of doctors’ communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to “screen” for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners.
doi:10.1136/bmj.g6034
PMCID: PMC4230029  PMID: 25389136

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