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1.  Research in general practice. 
PMCID: PMC1372464  PMID: 8398254
2.  Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice. 
BACKGROUND: Various methods are available for implementing change in the clinical behaviour of general practitioners (GPs). Although passive dissemination of information is generally ineffective, other methods can be variably effective. Few studies have investigated the impact of tailored methods. AIM: To determine whether methods tailored to overcome obstacles to change using psychological theories are more effective than dissemination alone in the implementation of guidelines for depression among GPs. DESIGN OF STUDY: Randomised controlled trial. SETTING: Sixty general practices in England; 30 GPs in the control group, 34 in the intervention group. METHOD: Practitioners identified patients presenting with depression before and after the implementation of guidelines (control group n = 192 in the first data collection, n = 181 in the second; intervention group n = 210 in the first data collection and n = 197 in the second). The main outcome measures were: record of adherence to guideline recommendations in clinical records; proportion of patients with Beck Depression Inventory (BDI) score less than 11 at 16 weeks after diagnosis. RESULTS: In comparison with the control group, in the group of GPs receiving tailored implementation, there were increases in the proportions of patients assessed for suicide risk. In the intervention group, the proportion of patients with BDI scores of less than 11 at 16 weeks increased. CONCLUSION: Obstacles to implementation can be identified and strategies tailored to address them. The findings indicate a new approach for research to understand and develop methods of implementation.
PMCID: PMC1314102  PMID: 11593835
3.  Diagnosis of heart failure in primary care: an assessment of international guidelines. 
An appraisal of published, peer-reviewed guidelines, in terms of their development methodologies and clinical effectiveness, was undertaken using a published and validated appraisal tool. Electronic databases revealed 13 guidelines on heart failure but only seven of these referred to diagnosis. The quality of the published guidelines was variable but there was consensus over the main symptoms and diagnostic tests, although only two symptoms were mentioned in all guidelines. Only two guidelines scored greater than 50% for rigour of development.
PMCID: PMC1314004  PMID: 11360704
4.  Features of primary care associated with variations in process and outcome of care of people with diabetes. 
BACKGROUND: There is now clear evidence that tight control of blood glucose and blood pressure significantly lowers the risk of complications in both type I and type II diabetes. Although there is evidence that primary care can be as effective as secondary care in delivering care for people with diabetes, standards in primary care are variable. Previous studies have shown that practice, patient or organisational factors may influence the level of care of patients with diabetes. However, these studies have been conducted in single geographical areas and involved only small numbers of practices. AIM: To determine the standard of diabetes care in general practice and to determine which features of practices are associated with delivering good quality care. DESIGN OF STUDY: A questionnaire survey and analysis of multi-practice audit data. SETTING: Three health authorities in England, comprising 169 general practices. METHOD: This study was conducted with a total population of 1,182,872 patients and 18,642 people with diabetes. Linkage analysis was carried out on data collected by a questionnaire, routinely collected health authority data, and multi-practice audit data collected by primary care audit groups. Practice annual compliance was measured with process and outcome measures of care, including the proportion of patients who had an examination of their fundi, feet, blood pressure, urine, glycated haemoglobin, and the proportion who had a normal glycated haemoglobin. RESULTS: Median compliance with process and outcome measures of care varied widely between practices: fundi were checked for 64.6% of patients (interquartile range [IQR] = 45.3-77.8%), urine was checked for 71.4% (IQR = 49.7-84.3%), feet were checked for 70.4% (IQR = 51.0-84.4%), blood pressure for 83.6% (IQR = 66.7-91.5%), and glycated haemoglobin was checked for 83.0% of patients (IQR = 69.4-92.0%). The glycated haemoglobin was normal in 42.9% of patients (IQR = 33.0-51.2%). In multiple regression analysis, compliance with measures of process of care were significantly associated with smaller practices, fundholding practices, and practices with a recall system. Practices with more socioeconomically deprived patients were associated with lower compliance with most process measures. Practices with a greater proportion of patients attending hospital clinics had lower compliance with process and outcome measures. Being a training practice, having a diabetes mini-clinic, having more nurses, personal care, and general practitioner or nurse interest in diabetes were not associated with compliance of process or outcome of care. CONCLUSIONS: Despite recent evidence that complications of diabetes may be delayed or prevented, this study has highlighted a number of deficiencies in the provision of diabetes care and variations in care between general practices. Provision of high quality diabetes care in the United Kingdom will present an organisational challenge to primary care groups and trusts, especially those in deprived areas.
PMCID: PMC1313998  PMID: 11360698
7.  What proportion of patients refuse consent to data collection from their records for research purposes? 
In a randomised trial of the implementation of guidelines for asthma and angina, we sent questionnaires that included a request for consent to collect data from the patient's clinical records to 5069 patients in 81 general practices. Of these 3429 (67.6%) responded, of whom 335 (9.8% [95%, CI = 8.8%-10.8%]) refused consent. We conclude that consent should always be sought unless a research ethics committee has waived this requirement for pressing reasons.
PMCID: PMC1313779  PMID: 11042920
8.  Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations. 
Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available, a patient with suspected heart failure must have objective tests to confirm the diagnosis. These should include an electrocardiogram and, ideally, an echocardiogram. Further research is also needed on the usefulness of signs and symptoms in primary care, as most studies of heart failure have been conducted in secondary care.
PMCID: PMC1313613  PMID: 10695070
9.  Collation and comparison of multi-practice audit data: prevalence and treatment of known diabetes mellitus. 
BACKGROUND: Different methods have been used to determine the prevalence and treatment of diabetes. Despite the large number of studies, previous estimations of prevalence and treatment have been carried out on relatively small numbers of patients, and then in only a few practices in single geographical regions. AIM: To investigate the feasibility of collating data from multi-practice audits organized by primary care audit groups in order to estimate the prevalence and treatment of patients with known diabetes, and to discuss the methodological issues and reasons for variation. METHOD: A postal questionnaire survey of all primary care audit groups in England and Wales that had conducted a multi-practice audit of diabetes between 1993-1995. Prevalence rates and patterns of diabetic care were compared with other community-based surveys of known diabetes from 1986-1996 identified on MEDLINE. RESULTS: Twenty-five (43%) audit groups supplied data from multi-practice audits of diabetes. Seven (28%) multi-practice audits involving 259 practices fulfilled the inclusion criteria for prevalence estimation. The overall prevalence of diabetes based on a population of 1,475,512 patients was 1.46% (range between audit groups = 1.18% to 1.66%; chi 2 = 308; df = 6; P < 0.0001). Male to female ratio was 1.15:1. Treatment of diabetes could be ascertained for 10 (40%) audit groups comprising 319 practices. Of these, 23.4% (range = 16.5%-27.4%) were controlled by diet, 48.5% (range = 43.6%-55.8%) were prescribed oral hypoglycaemic drugs, and 28.2% (range = 25.0%-32.4%) were treated with insulin. There were significant variations between audit groups in treatment pattern (chi 2 = 250; df = 18; P < 0.0001). CONCLUSION: Prevalence and treatment rates of diabetes and other chronic diseases can be assessed and compared using data from multi-practice audits. Collation of audit data could improve the precision of quantitative estimates of health status in populations. A standard method of data recording and collection may provide a new approach that could considerably improve our ability to monitor disease and its management.
PMCID: PMC1313423  PMID: 10736888
10.  Learners' experience of continuing medical education events: a qualitative study of GP principals in Dorset. 
The British Journal of General Practice  1998;48(434):1590-1593.
BACKGROUND: General practitioners' (GPs') attendance at continuing medical education (CME) events has increased since the introduction of the Post Graduate Educational Allowance (PGEA) in 1990. However, few studies have examined doctors' perceptions about their continuing education, and explored their views in depth. AIM: To investigate general practitioners' experience of CME events, what personal impact they had, and how the GPs perceived the influence of CME in their professional practice and patient care. METHOD: A qualitative study, with in-depth semi-structured interviews, of a purposive sample of 25 general practitioners in Dorset was conducted. Content analysis was used to identify major themes from the transcripts. RESULTS: GPs perceived CME events as beneficial. Confidence levels rose, and the events provided a break from practice that refreshed and relaxed, thus indirectly benefiting patients. The opportunities provided by formal events for informal learning and exchange of ideas, with both peers in general practice and consultant colleagues, were highly valued. The relevance of the subject to general practice, and the appropriateness of the educational format, were considered of paramount importance. Few responders identified major changes in their practice as a result of formal CME events, and information was seldom disseminated among practice colleagues. CONCLUSION: The results of this study challenge GP educators to provide CME that is relevant, to recognize the value of peer contact, and to facilitate the incorporation of new information into practice.
PMCID: PMC1313223  PMID: 9830185
11.  Evaluation of a primary care counselling service in Dorset. 
The British Journal of General Practice  1998;48(428):1049-1053.
BACKGROUND: Research into the effectiveness of counselling in primary care is rare. This study attempts to provide a thorough evaluation of the effects of a new counselling service introduced throughout Dorset. AIM: To evaluate the impact of counselling on client symptomatology, self-esteem, and quality of life. The effect of counselling on drug prescribing, referrals to other mental health professionals, and client and general practitioner (GP) satisfaction were also assessed. METHOD: All new clients referred for counselling were asked to complete and return questionnaires before and after counselling. A total of 385 clients took part in the study. The first and second assessments were compared statistically. Clients were ascribed a psychiatric diagnosis using a simplified version of DSM-IIIR (Diagnostic and Statistical Manual of the American Psychiatric Association). GPs' views of the service were determined using a specially designed questionnaire. Drug data were obtained from the Prescription Pricing Authority and referral statistics from Dorset HealthCare National Health Service (NHS) Trust. RESULTS: The number of psychiatric symptoms and their severity were significantly reduced by counselling. There were no significant differences in the prescription of anxiolytic/hypnotic and anti-depressant medication between matched practices with and without counsellors. The presence of a counsellor did not affect the rate of referral to other mental health professionals. Clients and GPs valued the service highly. CONCLUSIONS: The Psychology Managed Counselling Service is an effective method of running a counselling service and is well received by both clients and GPs. Counselled clients improved significantly on several measures.
PMCID: PMC1410018  PMID: 9624745
12.  A survey of audit activity in general practice. 
BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care.
PMCID: PMC1409969  PMID: 9624769
13.  Will the future GP remain a personal doctor? 
During the past three decades, general practice has evolved into a form of primary health care that provides a wide range of reactive, anticipatory, and preventive services, and now also purchases secondary care. As a result, practices now have more staff and more complex patterns of organization. However, most patients prefer smaller practices and personal list systems. There is a danger that a core feature of general practice--personal care--is gradually being eroded. If this trend is to be halted, the organization of general practices and the support available to them must be revised so that they can continue to provide personal care, yet also offer a wide range of effective services in the community.
PMCID: PMC1410072  PMID: 9463989
14.  Effective audit in general practice: a method for systematically developing audit protocols containing evidence-based review criteria. 
Though many general practitioners (GPs) now take part in audit, there is still concern about the extent to which participation in audit leads to improvements in practice. Improved methods are needed for the incorporation of research evidence into criteria for use in audit. In this paper, a six-stage systematic method is described for developing audit protocols containing prioritized evidence-based criteria. The stages are: selection of a topic, identification of key elements of care, focused literature reviews, prioritization of the criteria on the strength of the evidence and impact on outcome, preparation of full documentation, and peer review.
PMCID: PMC1409940  PMID: 9519525
15.  Characteristics of practices, general practitioners and patients related to levels of patients' satisfaction with consultations. 
BACKGROUND: Despite interest in the relationship between patient satisfaction and consultation performance, there is little information about how other characteristics of general practitioners, practices and patients influence satisfaction with consultations. AIM: To identify characteristics of patients, practices and general practitioners that influence satisfaction with consultations. METHOD: In 1991-92, a consultation satisfaction questionnaire (CSQ) was administered to 75 patients attending each of the 126 general practitioners in 39 practices. Further questionnaires were used to collect information about the practice (such as total list size, training status, fundholding status and presence of a personal list system) and about the general practitioners (age, sex, whether vocationally trained, a trainer or a trainee, and the number of patients booked in the appointment system per hour). Stepwise multiple regression was undertaken to identify characteristics of patients, practices or general practitioners that influenced satisfaction. RESULTS: The mean of the response rates to the patient questionnaire for each general practitioner was 76.6%, with a standard deviation (SD) of 17.8. Practice characteristics associated with falls in satisfaction were an increasing total list size, the absence of a personal list system and its being a training practice. If more patients were booked in the appointment system per hour, satisfaction with the perceived length of consultations fell. Patient characteristics associated with falls in satisfaction were increased age and an increased proportion of male patients. The only characteristic of general practitioners associated with lower levels of satisfaction was increasing age. The sex of general practitioners did not influence satisfaction. CONCLUSIONS: The findings of this study give further support to the importance of a personal service in determining patient satisfaction in general practice. General Practitioners need to review the organization of practices to ensure an acceptable balance between the requirements of modern clinical care and the wishes of patients. Future studies should take account of the many variables that can influence patient satisfaction.
PMCID: PMC1239785  PMID: 8945798
16.  What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. 
BACKGROUND: General practice is currently experiencing a large number of developments. Studies of patient satisfaction are required to guide the changes that many general practitioners are introducing. AIM: A study set out to examine the characteristics of general practices that influence patient satisfaction. METHOD: In 1991-92, a surgery satisfaction questionnaire of demonstrated reliability and validity was administered to 220 patients in each of 89 general practices. A further questionnaire completed by a member of practice staff collected information about practice characteristics including total list size, number, age and sex of practice partners, training status, fundholding status, presence of a practice manager and whether there was a personal list system. Stepwise multiple regression analyses were undertaken to identify those practice characteristics that influenced patient satisfaction. RESULTS: The mean of the response rates of patients completing questionnaires in each practice was 82%. An increasing total list size of patients registered with practices was associated with decreasing levels of general satisfaction and decreased satisfaction with accessibility, availability, continuity of care, medical care and premises. The presence of a personal list system was associated with increased levels of general satisfaction and increased satisfaction with accessibility, availability, continuity of care and medical care. Training practices were associated with decreased levels of general satisfaction and decreased satisfaction with availability and continuity of care. CONCLUSION: The patients of practices in this study preferred smaller practices, non-training practices and practices that had personal list systems. Practice organization should be reviewed in order to ensure that the trend towards larger practices that provide a wider range of services does not lead to a decline in patient satisfaction. General practitioners should have personal list systems and consider the creation of several personal teams within the practice consisting of small numbers of doctors, receptionists and practice nurses.
PMCID: PMC1239467  PMID: 8745863
17.  Innovation in general practice: is the gap between training and non-training practices getting wider? 
BACKGROUND. Training practices are more developed than non-training practices in terms of a wide range of educational and clinical activities, facilities and staff. If training practices are also adopting new innovations at a faster rate than non-training practices the gap between them will increase. AIM. The aim of this study was to determine whether, between 1982 and 1990, training practices did develop at a faster rate than non-training practices. METHOD. In 1982 a questionnaire was sent to 153 practices in Gloucestershire, Avon and Somerset which all had one or more partners who were members of the Royal College of General Practitioners. A second questionnaire was sent to the same practices in 1990. Information was sought about practice features including organization, size, facilities, staff and clinical and educational activities. A total of 124 practices (62 training and non-training) completed questionnaires on both occasions. RESULTS. There were substantial changes in the cohort between the surveys in 1982 and 1990, with many practices gaining, for example, a practice manager, practice nurse and purpose built premises, and introducing audits, screening activities and specific clinics. For each feature of practice a logistic regression was undertaken with training used as an explanatory variable. Training practices were more likely to develop than non-training practices for a number of features including personnel, aspects of practice organization, educational activities, clinical activities and equipment. CONCLUSION. Training practices are not only more developed than non-training practices but are also more innovative. The gap between training and non-training practices did grow wider between 1982 and 1990. This may be because the members of training practices are inherently more innovative, face fewer obstacles to innovation or that the scheme for approval of practices for training has encouraged specific innovations. Any future accreditation scheme for general practices must be organized to encourage accelerated development in less developed practices rather than only stimulate innovation in already advanced practices.
PMCID: PMC1239263  PMID: 7619584
18.  General practice in Gloucestershire, Avon and Somerset: explaining variations in standards. 
Variations in standards are found in all health services. The method and amount of funding are thought to be important reasons for these variations. A cross sectional survey of all general practices in three counties in south west England was undertaken in order to explain variations in the level of development. A development score for each practice was calculated. There was wide variation in standards as described by the level of development. Multiple regression analysis showed that being a training practice, having a practice manager, the partners having a younger mean age, a larger total number of patients registered with the practice and a lower Jarman underprivileged area score were all independently related to a higher level of practice development. In addition, the responsible family health services authority was also related to the level of development. A combination of professional factors such as the decision to become a training practice, environmental factors such as the family health services authority or the underprivileged area score and economic factors reflected in the total list size determine the level of practice development. The most easily corrected factor is the employment of a practice manager. It is suggested that differences in standards in general practice may be increased rather than decreased by the fundholding scheme.
PMCID: PMC1372231  PMID: 1466919
19.  Development of a questionnaire to assess patients' satisfaction with consultations in general practice. 
The assessment of patient satisfaction has become an important concern in the evaluation of health services. Measures of satisfaction must be valid and reliable if they are to be used widely. This paper reports the development of a new questionnaire to assess patients' satisfaction with consultations together with initial tests of the questionnaire's reliability and validity. Principal components analysis of the patients' assessments of care revealed three factors of satisfaction: the professional aspects of the consultation, the depth of the patient's relationship with the doctor, and the perceived length of the consultation. The consultation satisfaction questionnaire is reliable under the conditions of this study and may have a role in research, medical education and audit.
PMCID: PMC1371443  PMID: 2282225

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