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1.  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.
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.
Multiple ratings of simulated general practitioner (GP)–patient consultations by trained GP evaluators.
UK primary care.
21 GPs and six trained GP evaluators.
Outcome measures
GCRS score.
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.
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.
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.
PMCID: PMC3948635  PMID: 24604483
Statistics & Research Methods; Medical Education & Training
2.  The changing face of commissioning in England 
PMCID: PMC3046206  PMID: 21310783
3.  Accessing primary care: a simulated patient study 
The British Journal of General Practice  2013;63(608):e171-e176.
Simulated patient, or so-called ‘mystery-shopper’, studies are a controversial, but potentially useful, approach to take when conducting health services research.
To investigate the construct validity of survey questions relating to access to primary care included in the English GP Patient Survey.
Design and setting
Observational study in 41 general practices in rural, urban, and inner-city settings in the UK.
Between May 2010 and March 2011, researchers telephoned practices at monthly intervals, simulating patients requesting routine, but prompt, appointments. Seven measures of access and appointment availability, measured from the mystery-shopper contacts, were related to seven measures of practice performance from the GP Patient Survey.
Practices with lower access scores in the GP Patient Survey had poorer access and appointment availability for five out of seven items measured directly, when compared with practices that had higher scores. Scores on items from the national survey that related to appointment availability were significantly associated with direct measures of appointment availability. Patient-satisfaction levels and the likelihood that patients would recommend their practice were related to the availability of appointments. Patients’ reports of ease of telephone access in the national survey were unrelated to three out of four measures of practice call handling, but were related to the time taken to resolve an appointment request, suggesting responders’ possible confusion in answering this question.
Items relating to the accessibility of care in a the English GP patient survey have construct validity. Patients’ satisfaction with their practice is not related to practice call handling, but is related to appointment availability.
PMCID: PMC3582975  PMID: 23561783
access; family practice; patient simulation; survey; validity of results
4.  Challenges to the credibility of patient feedback in primary healthcare settings: a qualitative study 
The British Journal of General Practice  2013;63(608):e200-e208.
The UK government has encouraged NHS services to obtain patient feedback to support the further development of patient-centred care. In 2009, the English GP Patient Survey included a sample of 5.5 million, but little is known about its potential utility in informing developments aimed at improving the quality of patients’ experiences of primary care.
To investigate primary care providers’ response to feedback on patient experience from a national survey.
Design and setting
Qualitative interview study in 10 general practices from four primary care trusts in England.
Semi-structured interviews were conducted with GPs, practice nurses, and practice managers (n = 37). Transcripts were analysed thematically.
Although some participants reported making changes to their practice in response to the survey data, many expressed doubts about the credibility of the results. Key issues included: concerns about practical aspects of the survey, such as the response rate and representativeness of the sample; the view that it gave insufficient detail to facilitate change and failed to address some salient issues; and unease about the influence of political influences underpinning its introduction and use.
Although, in general, primary care professionals have positive attitudes towards patient feedback, this study suggests a mismatch between the conventional demonstration of the objectivity of a questionnaire survey and the attitudes and experiences of those receiving the data. This is likely to prevent doctors from engaging constructively with the survey. These concerns may well militate against the potential of the survey to act as a simple means of capturing, and effectively using, feedback from patients.
PMCID: PMC3582979  PMID: 23561787
primary healthcare; qualitative research; reliability and validity; surveys
5.  ACE Inhibitor and Angiotensin Receptor-II Antagonist Prescribing and Hospital Admissions with Acute Kidney Injury: A Longitudinal Ecological Study 
PLoS ONE  2013;8(11):e78465.
ACE Inhibitors (ACE-I) and Angiotensin-Receptor Antagonists (ARAs) are commonly prescribed but can cause acute kidney injury (AKI) during intercurrent illness. Rates of hospitalization with AKI are increasing. We aimed to determine whether hospital AKI admission rates are associated with increased ACE-I/ARA prescribing.
Methods and Findings
English NHS prescribing data for ACE-I/ARA prescriptions were matched at the level of the general practice to numbers of hospital admissions with a primary diagnosis of AKI. Numbers of prescriptions were weighted for the demographic characteristics of general practices by expressing prescribing as rates where the denominator is Age, Sex, and Temporary Resident Originated Prescribing Units (ASTRO-PUs). We performed a mixed-effect Poisson regression to model the number of admissions for AKI occurring in each practice for each of 4 years from 1/4/2007.
From 2007/8-2010/11, crude AKI admission rates increased from 0.38 to 0.57 per 1000 patients (51.6% increase), and national annual ACE-I/ARA prescribing rates increased by 0.032 from 0.202 to 0.234 (15.8% increase). There was strong evidence (p<0.001) that increases in practice-level prescribing of ACE-I/ARA over the study period were associated with an increase in AKI admission rates. The increase in prescribing seen in a typical practice corresponded to an increase in admissions of approximately 5.1% (rate ratio = 1.051 for a 0.03 per ASTRO-PU increase in annual prescribing rate, 95%CI 1.047-1.055). Using the regression model we predict that 1,636 (95%CI 1,540-1,780) AKI admissions would have been avoided if prescribing rates were at the 2007/8 level, equivalent to 14.8% of the total increase in AKI admissions.
In this ecological analysis, up to 15% of the increase in AKI admissions in England over a 4-year time period is potentially attributable to increased prescribing of ACE-I and ARAs. However, these findings are limited by the lack of patient level data such as indication for prescribing and patient characteristics.
PMCID: PMC3819379  PMID: 24223154
6.  Patterns of disease presentation and management in Egyptian primary care: findings from a survey of 2458 primary care patient consultations 
BMC Family Practice  2013;14:161.
The Egyptian government is considering embarking on a new wave of health sector reform. Although primary care is seen as central to the anticipated reforms, little is known about the current morbidity and utilization patterns in Egyptian publicly funded primary care. We conducted this survey study of patient encounters to describe the demographic characteristics of patients attending publicly-funded primary care practices, the relative frequency of conditions encountered in these practices, and the rates of drug prescription, investigation and referral.
Cross-sectional survey of twelve primary care practices and 2458 patient consultations. Additional secondary data were collected from five of the twelve practices for preventive services provided at these practices i.e. immunizations, family planning and ante-natal care.
54% of the attendances were for people below the age of twenty, of which 54% were females. In patients above the age of twenty, women accounted for 73% of consultations. Upper respiratory tract infection was the most common reason for encounter, accounting for 24% of the presentations, followed by gastroenteritis (10%), intestinal parasites (5%), and lower respiratory tract infections (5%). Over 97% of patients were prescribed at least one drug, whereas investigation and referral rates were low (15% and 5% respectively). When the analysis was repeated for practices where data on both curative and preventive services were available (5 practices and 2146 consultations), substantial proportions of patients were found to seek care for immunizations (25%), family planning (12%), and ante-natal care (11%).
Most patients utilizing primary care practices in Egypt seek care for minor and preventive services with relatively few consultations for more serious conditions. There is also a pattern of prescribing drugs to most primary care patients which may reflect over-prescribing by primary care doctors.
PMCID: PMC3840639  PMID: 24148873
Family practice; Primary health care; Egypt; Morbidity; Epidemiology; Demography; Physician’s practice patterns; Health care surveys; Health services research; Health facility administration
7.  GPAQ-R: development and psychometric properties of a version of the General Practice Assessment Questionnaire for use for revalidation by general practitioners in the UK 
BMC Family Practice  2013;14:160.
The General Practice Assessment Questionnaire (GPAQ) has been widely used to assess patient experience in general practice in the UK since 2004. In 2013, new regulations were introduced by the General Medical Council (GMC) requiring UK doctors to undertake periodic revalidation, which includes assessment of patient experience for individual doctors. We describe the development of a new version of GPAQ – GPAQ-R which addresses the GMC’s requirements for revalidation as well as additional NHS requirements for surveys that GPs may need to carry out in their own practices.
Questionnaires were given out by doctors or practice staff after routine consultations in line with the guidance given by the General Medical Council for surveys to be used for revalidation. Data analysis and practice reports were provided independently.
Data were analysed for questionnaires from 7258 patients relating to 164 GPs in 29 general practices. Levels of missing data were generally low (typically 4.5-6%). The number of returned questionnaires required to achieve reliability of 0.7 were around 35 for individual doctor communication items and 29 for a composite score based on doctor communication items. This suggests that the responses to GPAQ-R had similar reliability to the GMC’s own questionnaire and we recommend 30 completed GPAQ-R questionnaires are sufficient for revalidation purposes. However, where an initial screen raises concern, the survey might be repeated with 50 completed questionnaires in order to increase reliability.
GPAQ-R is a development of a well-established patient experience questionnaire used in general practice in the UK since 2004. This new version can be recommended for use in order to meet the UK General Medical Council’s requirements for surveys to be used in revalidation of doctors. It also meets the needs of GPs to ask about patient experience relating to aspects of practice care that are not specific to individual general practitioners (e.g. receptionists, telephone access) which meet other survey requirements of the National Health Service in England. Use of GPAQ-R has the potential to reduce the number of surveys that GPs need to carry out in their practices to meet the various regulatory requirements which they face.
PMCID: PMC3819733  PMID: 24138508
8.  Talking about smoking in primary care medical practice – Results of experimental studies from the US, UK and Germany 
To analyze effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences.
We conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice.
Female and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice.
Although all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited.
Practice implications
Findings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.
PMCID: PMC3444567  PMID: 22595655
primary care physicians; questions about smoking; cessation advice; comparative study
9.  Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis 
BMC Public Health  2013;13:756.
Governments can intervene to change health-related behaviours using various measures but are sensitive to public attitudes towards such interventions. This review describes public attitudes towards a range of policy interventions aimed at changing tobacco and alcohol use, diet, and physical activity, and the extent to which these attitudes vary with characteristics of (a) the targeted behaviour (b) the intervention and (c) the respondents.
We searched electronic databases and conducted a narrative synthesis of empirical studies that reported public attitudes in Europe, North America, Australia and New Zealand towards interventions relating to tobacco, alcohol, diet and physical activity. Two hundred studies met the inclusion criteria.
Over half the studies (105/200, 53%) were conducted in North America, with the most common interventions relating to tobacco control (110/200, 55%), followed by alcohol (42/200, 21%), diet-related interventions (18/200, 9%), interventions targeting both diet and physical activity (18/200, 9%), and physical activity alone (3/200, 2%). Most studies used survey-based methods (160/200, 80%), and only ten used experimental designs.
Acceptability varied as a function of: (a) the targeted behaviour, with more support observed for smoking-related interventions; (b) the type of intervention, with less intrusive interventions, those already implemented, and those targeting children and young people attracting most support; and (c) the characteristics of respondents, with support being highest in those not engaging in the targeted behaviour, and with women and older respondents being more likely to endorse more restrictive measures.
Public acceptability of government interventions to change behaviour is greatest for the least intrusive interventions, which are often the least effective, and for interventions targeting the behaviour of others, rather than the respondent him or herself. Experimental studies are needed to assess how the presentation of the problem and the benefits of intervention might increase acceptability for those interventions which are more effective but currently less acceptable.
PMCID: PMC3765153  PMID: 23947336
Health behaviour; Attitude; Public opinion; Policy
10.  Do English patients want continuity of care, and do they receive it? 
The British Journal of General Practice  2012;62(601):e567-e575.
Interpersonal continuity of care is valued by patients, but there is concern that it has declined in recent years.
To determine how often patients express preference for seeing a particular GP and the extent to which that preference is met.
Design of study
Analysis of data from the 2009/2010 English GP Patient Survey.
A stratified random sample of adult patients registered with 8362 general practices in England (response rate 39%, yielding 2?169?718 responses).
Weighted estimates were calculated of preference for and success in seeing a particular GP. Multilevel logistic regression was used to identify characteristics associated with these two outcomes.
Excluding practices with one GP, 62% of patients expressed a preference for seeing a particular GP. Of these patients, 72% were successful in seeing their preferred GP most of the time. Certain patient groups were associated with more preference for and success in seeing a particular GP. These were older patients (preference odds ratio [OR]?=?1.7, success OR?=?1.8), those with chronic medical conditions (preference OR?=?1.9, success OR?=?1.3), those with chronic psychological conditions (preference OR?=?1.6, success OR?=?1.3), and those recently requesting only non-urgent versus urgent appointments (preference OR?=?1.4, success OR?=?1.6). Patient groups that had more frequent preference but less success in seeing a preferred GP were females (preference OR?=?1.5, success OR?=?0.9), patients in larger practices (preference OR?=?1.3, success OR?=?0.5), and those belonging to non-white ethnic groups.
The majority of patients value interpersonal continuity, yet a large minority of patients and specific patient groups are not regularly able to see the GP they prefer.
PMCID: PMC3404335  PMID: 22867681
continuity of patient care; England; general practice; primary healthcare
11.  Changing practice as a quality indicator for primary care: analysis of data on voluntary disenrollment from the English GP Patient Survey 
BMC Family Practice  2013;14:89.
Changing family practice (voluntary disenrollment) without changing address may indicate dissatisfaction with care. We investigate the potential to use voluntary disenrollment as a quality indicator for primary care.
Data from the English national GP Patient Survey (2,169,718 respondents), the number of voluntary disenrollments without change of address, data relating to practice characteristics (ethnicity, deprivation, gender of patients, practice size and practice density) and doctor characteristics were obtained for all family practices in England (n = 8450). Poisson regression analyses examined associations between rates of voluntary disenrollment, patient experience, and practice and doctor characteristics.
Mean and median rates of annual voluntary disenrollment were 11.2 and 7.3 per 1000 patients respectively. Strongest associations with high rates of disenrollment were low practice scores for doctor-patient communication and confidence and trust in the doctor (rate ratios 4.63 and 4.85). In a fully adjusted model, overall satisfaction encompassed other measures of patient experience (rate ratio 3.46). Patients were more likely to move from small practices (single-handed doctors had 2.75 times the disenrollment rate of practices with 6–9 doctors) and where there were other local practices. After allowing for these, substantial unexplained variation remained in practice rates of voluntary disenrollment.
Family practices with low levels of patient satisfaction, especially for doctor patient communication, are more likely to experience high rates of disenrollment. However substantial variation in disenrollment rates remains among practices with similar levels of patient satisfaction, limiting the utility of voluntary disenrollment as a performance indicator for primary care in England.
PMCID: PMC3729545  PMID: 23800138
Medical care  2010;48(4):321-326.
This paper examines the diagnosis and management of type-2 diabetes when exactly the same “patient” is encountered by 192 randomly selected primary care doctors in three different health care systems - the US, UK and Germany.
We conducted a factorial experiment, employing two clinically authentic filmed scenarios, to examine country differences in the treatment of diabetes, while controlling for the effects of selected characteristics of patients and physicians. The “patient” in the first scenario presented with (undiagnosed) signs and symptoms strongly suggestive of diabetes, while the second scenario presented an already diagnosed “patient” with an emerging foot neuropathy. Physicians were asked how they would diagnose and manage the “patients” after watching the video vignettes using a questionnaire with standardised and open-ended questions.
Regarding the first (undiagnosed) case, US doctors would ask significantly more questions than physicians from the UK and Germany (p<.001). German physicians would give less advice but would want to see the patient again much sooner (p<.001). Regarding the diagnosed case with an emerging foot neuropathy, US physicians would be most active in terms of questioning, testing, prescribing and advice giving. Again, physicians from Germany would be less active in terms of therapeutic strategies but they would like to see the patient again sooner (p=.005).
Although physicians in the three countries encountered exactly the same “patient”, differences in diagnostic and management decisions were evident. The experimental design provides unconfounded estimates of health system differences while simultaneously controlling for the effects of selected patient attributes and physician characteristics.
PMCID: PMC3682768  PMID: 20355263
International differences in health care; clinical decision making; undiagnosed diabetes; emerging foot neuropathy
13.  Influences of organizational features of healthcare settings on clinical decision making: Qualitative results from a cross-national factorial experiment* 
A proliferating literature documents cross-national variation in medical practice and seeks to explain observed differences in terms of the presence of certain kinds of healthcare systems, economic, and cultural differences between countries. Less is known about how providers themselves understand these influences and perceive them as relevant to their clinical work. Using qualitative data from a cross-national factorial experiment in the United States and United Kingdom, we analyze 244 primary care physicians’ explanations of how organizational features of their respective healthcare settings influence the treatment decisions they made for a vignette patient, including affordability of care; within-system quality deficits; and constraints due to patient behavior. While many differences are attributed to financial constraints deriving from two very differently structured healthcare systems, in other ways they are reflections of cultural and historical expectations regarding medical care, or interactions between the two. Implications, including possible challenges to the implementation of universal care in the US, are discussed.
PMCID: PMC3682770  PMID: 21177712
health disparities; medical decision making; health policy; qualitative methods; US; UK
14.  Factors affecting patients’ trust and confidence in GPs: evidence from the English national GP patient survey 
BMJ Open  2013;3(5):e002762.
Patients’ trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients’ trust and their perceptions of communication within the consultation have been identified, but the influence of patients’ demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients’ ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor.
Secondary analysis of English national GP patient survey data (2009).
Primary Care, England, UK.
Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design.
Outcome measures
We used binary logistic regression analysis to investigate patients’ reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients’ sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors.
Among 1.5 million respondents (adjusted response rate 42%), the sense of ‘being taken seriously’ had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients.
Associations between patients’ ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients’ demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients’ confidence and trust in their doctor.
PMCID: PMC3657663  PMID: 23793686
Primary care; Health Services Administration & Management
15.  The accuracy of diagnostic coding for acute kidney injury in England – a single centre study 
BMC Nephrology  2013;14:58.
Acute kidney injury (AKI) is an independent risk factor for mortality and is responsible for a significant burden of healthcare expenditure, so accurate measurement of its incidence is important. Administrative coding data has been used for assessing AKI incidence, and shows an increasing proportion of hospital bed days attributable to AKI. However, the accuracy of coding for AKI and changes in coding over time have not been studied in England.
We studied a random sample of admissions from 2005 and 2010 where ICD-10 code N17 (acute renal failure) was recorded in the administrative coding data at one acute NHS Foundation Trust in England. Using the medical notes and computerised records we examined the demographic and clinical details of these admissions.
Against a 6.3% (95% CI 4.8-7.9%) increase in all non-elective admissions, we found a 64% increase in acute renal failure admissions (95% CI 41%-92%, p < 0.001) in 2010 compared to 2005. Median age was 78 years (IQR 72–87), 11-25% had a relevant pre-admission co-morbidity and 64% (55-73%) were taking drugs known to be associated with AKI. Over both years, 95% (91-99%) of cases examined met the Kidney Disease: Improving Global Outcomes criteria for AKI.
Patients with hospital admissions where AKI has been coded are elderly with multiple co-morbidities. Our results demonstrate a high positive predictive value of coding data for a clinical diagnosis of AKI, with no suggestion of marked changes in coding of AKI between 2005 and 2010.
PMCID: PMC3599863  PMID: 23496869
Acute kidney injury; Acute renal failure; ICD-10; Coding
16.  Does Higher Quality of Diabetes Management in Family Practice Reduce Unplanned Hospital Admissions? 
Health Services Research  2011;46(1 Pt 1):27-46.
To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes.
Study Setting
A total of 8,223 English family practices from 2001/2002 to 2006/2007.
Study Design
Multiple regression analyses of associations between admissions and proportions of practice diabetic patients with good (glycated hemoglobin [HbA1c] ≤7.4 percent) and moderate (7.4 percent
Practice quality measures extracted from practice records linked with practice-level hospital admissions data and practice-level covariates data.
Principal Findings
Practices with 1 percent more patients with moderate rather than poor glycemic control on average had 1.9 percent (95 percent CI: 1.1–2.6 percent) lower rates of emergency admissions for acute hyperglycemic complications. Having more patients with good rather than moderate control was not associated with lower admissions. There was no association of moderate or good control with hypoglycemic admissions.
Cross-sectionally, family practices with better quality of diabetes care had fewer emergency admissions for short-term complications of diabetes. Over time, after controlling for national trends in admissions, improvements in quality in a family practice were associated with a reduction in its admissions.
PMCID: PMC3034260  PMID: 20880046
Ambulatory care sensitive conditions; primary care; diabetes; quality indicators; hospital admissions
Care is better coordinated when doctors have personal responsibility for their patients. Continuity and a sense of personal responsibility are becoming more difficult to provide in hospitals, in part because of the European Working Time Directive. However, in many countries general practitioners are self-employed and able to organise their practices as they wish. In the UK, they increasingly do so in ways that make it difficult for patients to get continuity of care. This is despite most patients being clear that they want to see a regular doctor, and professional bodies in primary care consistently promoting continuity as a core value. General practitioners need to decide whether continuity of care matters. If it does, then they need to take a lead in ensuring that care is organised so that patients who want to see a regular doctor are able to do so. Suggestions are included for how contemporary practice can be organised to promote this traditional but still highly relevant value.
PMCID: PMC3601514  PMID: 23593056
continuity of care; integrated care; family practitioner
The Patient Assessment of Chronic Illness Care (PACIC) is a US measure of chronic illness quality of care, based on the influential Chronic Care Model (CCM). It measures a number of aspects of care, including patient activation; delivery system design and decision support; goal setting and tailoring; problem-solving and contextual counselling; follow-up and coordination. Although there is developing evidence of the utility of the scale, there is little evidence about its performance in the United Kingdom (UK). We present preliminary data on the psychometric performance of the PACIC in a large sample of UK patients with long-term conditions.
We collected PACIC, demographic, clinical and quality of care data from patients with long-term conditions across 38 general practices, as part of a wider longitudinal study. We assess rates of missing data, present descriptive and distributional data, assess internal consistency, and test validity through confirmatory factor analysis, and through associations between PACIC scores, patient characteristics and related measures.
There was evidence that rates of missing data were high on PACIC (9.6% - 15.9%), and higher than on other scales used in the same survey. Most PACIC sub-scales showed reasonable levels of internal consistency (alpha = 0.68 – 0.94), responses did not demonstrate high skewness levels, and floor effects were more frequent (up to 30.4% on the follow up and co-ordination subscale) than ceiling effects (generally <5%). PACIC demonstrated preliminary evidence of validity in terms of measures of long-term condition care. Confirmatory factor analysis suggested that the five factor PACIC structure proposed by the scale developers did not fit the data: reporting separate factor scores may not always be appropriate.
The importance of improving care for long-term conditions means that the development and validation of measures is a priority. The PACIC scale has demonstrated potential utility in this regard, but further assessment is required to assess low levels of completion of the scale, and to explore the performance of the scale in predicting outcomes and assessing the effects of interventions.
PMCID: PMC3526462  PMID: 22938193
Long term conditions; Chronic disease; Patient assessments; Primary care; Quality improvement
PMCID: PMC3145522
BMC Family Practice  2012;13:71.
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.
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.
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.
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.
PMCID: PMC3436749  PMID: 22831570
Aged; Chronic disease; Chronic illness; Patient care planning; Primary health care
Background: In 2008, the English Department of Health appointed 16 ‘Integrated Care Pilots’ which used a range of approaches to provide better integrated care. We report qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care.
Theory and methods: Data were analysed from transcripts of 213 in-depth staff interviews, and from semi-structured questionnaires (the ‘Living Document’) completed by staff in pilot sites at six points over a two-year period. Emerging findings were therefore built from ‘bottom up’ and grounded in the data. However, we were then interested in how these findings compared and contrasted with more generic analyses. Therefore after our analyses were complete we then systematically compared and contrasted the findings with the analysis of barriers and facilitators to quality improvement identified in a systematic review by Kaplan et al. (2010) and the analysis of more micro-level shapers of behaviour found in Normalisation Process Theory (May et al. 2007). Neither of these approaches claims to be full blown theories but both claim to provide mid-range theoretical arguments which may be used to structure existing data and which can be undercut or reinforced by new data.
Results and discussion: Many barriers and facilitators to integrating care are those of any large-scale organisational change. These include issues relating to leadership, organisational culture, information technology, physician involvement, and availability of resources. However, activities which appear particularly important for delivering integrated care include personal relationships between leaders in different organisations, the scale of planned activities, governance and finance arrangements, support for staff in new roles, and organisational and staff stability. We illustrate our analyses with a ‘routemap’ which identifies questions that providers may wish to consider when planning interventions to improve the integration of care.
PMCID: PMC3601528  PMID: 23593044
integrated care; facilitators; barriers; England
In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner’s Chronic Care Model.
Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation.
Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes.
Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients’ wishes, for example the ability to see a familiar doctor or nurse.
PMCID: PMC3601529  PMID: 23593045
integrated care; older people; case management; patient experience; staff experience; hospital utilization; risk stratification; England
BMJ quality & safety  2012;21(8):634-640.
Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care.
Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects.
Main outcome measures
Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services.
Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors.
While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would ‘cream-skim’ by not enrolling patients from vulnerable socio-demographic groups.
PMCID: PMC3402750  PMID: 22626735
General practice; family medicine; quality of care; healthcare quality improvement; primary care; health services research; quality measurement; patient satisfaction
The British Journal of General Practice  2010;60(578):e335-e344.
Small general practices are often perceived to provide worse care than larger practices.
To describe the comparative performance of small practices on the UK's pay-for-performance scheme, the Quality and Outcomes Framework.
Design of study
Longitudinal analysis (2004–2005 to 2006–2007) of quality scores for 48 clinical activities.
Family practices in England (n = 7502).
Comparison of performance of practices by list size, in terms of points scored in the pay-for-performance scheme, reported achievement rates, and population achievement rates (which allow for patients excluded from the scheme).
In the first year of the pay-for-performance scheme, the smallest practices (those with fewer than 2000 patients) had the lowest median reported achievement rates, achieving the clinical targets for 83.8% of eligible patients. Performance generally improved for practices of all sizes over time, but the smallest practices improved at the fastest rate, and by year 3 had the highest median reported achievement rates (91.5%). This improvement was not achieved by additional exception reporting. There was more variation in performance among small practices than larger ones: practices with fewer than 3000 patients (20.1% of all practices in year 3), represented 46.7% of the highest-achieving 5% of practices and 45.1% of the lowest-achieving 5% of practices.
Small practices were represented among both the best and the worst practices in terms of achievement of clinical quality targets. The effect of the pay-for-performance scheme appears to have been to reduce variation in performance, and to reduce the difference between large and small practices.
PMCID: PMC2930243  PMID: 20849683
incentives; quality; primary care
Objective To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme.
Design Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care.
Setting 148 general practices in England (653 500 patients).
Main outcome measures Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7).
Results Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends.
Conclusions There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.
PMCID: PMC3125475  PMID: 21712336

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