Quality in health care : QHC最新文献

Objectives: To test the feasibility of deriving comparative indicators in all the practices within a primary care group.

Design: A retrospective audit using practice computer systems and random note review.

Setting: A primary care group in southern England.

Subjects: All 18 general practices in a primary care group.

Main outcome measures: Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators.

Results: It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds.

Conclusion: Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.

Objective: To clarify the usefulness, acceptability, sensitivity, and validity of version 4 of the Health of the Nation Outcome Scale (HoNOS), a scale developed to meet the requirement for a clinically acceptable outcome scale for routine use in mental illness services.

Design: Patients with a range of mental illnesses were rated on the HoNOS at the beginning and end of an episode by interviews with mental health professionals.

Subjects: 934 patients from eight diagnostic categories were rated by 129 mental health professionals at 17 sites; 250 were also rated on a range of comparison scales.

Outcome measures: Comparison of patients' scores at the beginning and end of an episode using individual item scores, dimensional subscores, and the total score.

Results: HoNOS scores decreased by almost 50% between the beginning and end of episodes. They varied with the severity of the setting and discriminant analysis showed that the HoNOS had a moderate level of discriminatory power. Correlation analysis showed acceptable levels of agreement with independent scales, although the accuracy of ratings of some items at the beginning of an episode was affected by information deficits.

Conclusion: The findings indicate that HoNOS is sensitive to change across time and to differences in illness type and severity, and has a sufficient degree of both construct and criterion related validity to fulfil the requirements of a mental health outcome scale for routine use in clinical settings.

Objective: To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.

Design: Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.

Setting: General practices and midwifery practices in the Netherlands.

Subjects: 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.

Main measures: Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.

Results: In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.

Conclusions: The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.

Problem: Interviews with parents and children attending a hospital paediatric neurology clinic indicated they had difficulties in asking questions during consultations.

Aim: To set up a process to enable parents and children to get the information they wanted.

Background and setting: Two paediatric neurology clinics in separate hospitals in Greater Manchester, UK with a similar client group run by one consultant.

Design: Various styles of question sheets were evaluated. The one that was chosen asked patients to write down questions and hand these to the doctor at the beginning of the consultation. Question sheets were given to all patients attending one clinic over a 13 week period.

Strategies for change: Use of sheets: number of patients taking or refusing a sheet, with reasons for refusal, were recorded. Doctors noted those who handed questions sheets to them Satisfaction with sheets: patients completed a short feedback form after the consultation Effect on consultations: evaluated through interviews with the doctors.

Effects of change: In total, 66 (41%) of the 162 patients offered the sheet declined: 14 had already prepared questions; eight being seen for the first time felt they did not know what to ask. Seventeen had used the sheet on a previous visit and did not need it again; 19 gave no reason; the rest said they had no questions. Seventy six (47%) patients produced a sheet in the consultation. Of those using the sheet, 64 (84%) liked it and 61 (80%) found it useful. Fifty two (68%) wished to use it at future consultations. The doctors reported that through questions articulated on the sheets many issues, fears, and misunderstandings emerged which otherwise would not have been identified. Concerns about increasing consultation time and clinical disruption did not materialize. In contrast, doctors reported patients to be taking more initiative and control, particularly on subsequent visits. None of these changes was noted in the comparison clinic.

Lessons learnt: An attractive, clear question sheet proved a simple but effective intervention in the consultation. Parents felt empowered to take control. The approach may have wider applicability, but implementation requires staff training and support to ensure its continuing use; this ensures medical staff adjust to a new consultation format, and that clinic nurses see the value of the sheets and continue to provide them.