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The quality of general dental care: public and users' perceptions. 普通牙科保健的质量:公众和使用者的看法。
Pub Date : 1999-09-01 DOI: 10.1136/qshc.8.3.149
M Calnan, M Dickinson, G Manley

Background: Systematic evidence about how the public and users perceive and experience the quality of general dental care is in short supply, particularly in light of the recent changes in the general dental service. The study reported here attempted to fill this gap.

Objectives: To identify the criteria the public and users adopt in evaluating the quality of general dental care, and to identify the extent and nature of perceived concerns with general dental care.

Design: Postal questionnaires were sent to random samples of adults living in an inner city area (I) and semi-rural area (R) in southern England. Fifty six per cent (1499) in area R and 48% (1388) in area I completed the questionnaire after four mailings. Follow up face-to-face interviews were done with a purposive subsample (n = 50) of responders from the postal survey.

Main measures: Public/user views about quality of dental care were measured through groups of questions about the importance of and satisfaction with different aspects of dental care (access/availability including cost; facilities; technical skills; and interpersonal care) and a scale (Dentsat) measuring general satisfaction was constructed from questions on different aspects of care.

Results: Evaluation of quality of general dental care from the users' point of view hinges on perceived technical skills, particularly pain management. Major dissatisfaction stems from concerns about costs of dental care and privatisation.

Conclusions: The criteria adopted by the public/users to assess general dental care are similar to other areas of health care, apart from the priority placed on technical skills and pain management. However, the major source of decline in satisfaction with the quality of general dental care is the barrier to access created by the rising cost of dental care and the increasing involvement of dentists in private practice. This evidence suggests that the public and users find the drift towards private practice and away from NHS practice a major source of concern.

背景:关于公众和使用者如何感知和体验普通牙科护理质量的系统证据缺乏,特别是考虑到最近普通牙科服务的变化。本文报道的研究试图填补这一空白。目的:确定公众和使用者在评估普通牙科保健质量时采用的标准,并确定对普通牙科保健的关注程度和性质。设计:邮寄调查问卷随机发送给居住在英格兰南部内城地区(I)和半农村地区(R)的成年人。区域R的56%(1499)和区域I的48%(1388)在四次邮寄后完成了问卷。后续面对面访谈是通过邮政调查中有目的的子样本(n = 50)进行的。主要措施:公众/使用者对牙科保健质量的看法通过对牙科保健不同方面的重要性和满意度的问题组来衡量(可及性/可获得性,包括费用;设施;技术技能;和人际关怀)和一个测量总体满意度的量表(Dentsat)是由护理的不同方面的问题构建的。结果:从用户的角度评价一般牙科保健的质量取决于感知的技术技能,特别是疼痛管理。主要的不满来自对牙科保健费用和私有化的担忧。结论:除了优先重视技术技能和疼痛管理之外,公众/用户评估普通牙科保健所采用的标准与其他保健领域类似。然而,对一般牙科护理质量满意度下降的主要原因是牙科护理费用上升和牙医越来越多地参与私人执业所造成的障碍。这一证据表明,公众和用户发现向私人执业和远离NHS实践的漂移是一个主要的担忧来源。
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引用次数: 30
A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. 有效管理临床实践变化的框架:临床实践指南的传播和实施。
Pub Date : 1999-09-01 DOI: 10.1136/qshc.8.3.177
N T Moulding, C A Silagy, D P Weller

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.

来自社会和行为科学的理论可以为开发一个概念框架的过程做出重要贡献,以改进临床实践指南的使用和临床医生的表现。基于创新扩散理论、行为改变跨理论模型、健康教育理论、社会影响理论和社会生态学的相关概念,以及对各种行为改变策略有效性的系统文献综述,提出了指导方针传播和实施的概念框架。该框架强调需要对以下方面进行实施前评估:(a)临床医生将指南付诸实践的准备情况,(b)临床医生所经历的改变障碍,以及(c)干预措施的目标水平。它还纳入了对多方面干预措施的需求,确定了每种策略将解决的障碍类型,并通过临床医生采用指南的各个阶段发展了进展概念,并使用了适当的有针对性的支持策略。该模型的潜在价值在于,它可以使参与指南传播和实施过程的人员更有效地指导目标群体的战略。显然,该模型在促进指南传播和实施方面的有效性和实用性需要进一步的实证研究来验证。在这样的研究出现之前,它提供了一个理论框架,可以帮助选择适当的指南传播和实施策略。
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引用次数: 273
What type of filling? Best practice in dental restorations. 什么类型的填充物?牙科修复的最佳实践。
Pub Date : 1999-09-01 DOI: 10.1136/qshc.8.3.202
B L Chadwick, P M Dummer, F D Dunstan, A S Gilmour, R J Jones, C J Phillips, J Rees, S Richmond, J Stevens, E T Treasure
Dental caries (tooth decay) is one of the most common diseases, with approximately 80% of the population in developed countries having experienced the condition. If decay has not been prevented cavities develop. To prevent considerable pain and tooth loss it may be necessary to remove the diseased tissues and restore the cavities (a filling). Restorations have a limited lifespan and, once a tooth is restored, the filling is likely to be replaced several times in the patient’s lifetime. Studies in the UK suggest that much of restorative dentistry is replacement of existing restorations, accounting for around 60% of all restorative work. Similar figures have been found in other parts of Europe, 4 and the USA. (Quality in Health Care 1999;8:202–207) There is a large choice of materials which can be used for fillings. Many are introduced into the market place and used on patients with limited evidence that they are more eVective or robust than existing materials. Consequently, one of the key questions is, all other things being equal, what type of filling is best? This paper summarises the results of a systematic review of the relative longevity and cost eVectiveness of routine intracoronal dental restorations, which formed the basis of a recent issue of EVective Health Care. The reasons for replacing a restoration are numerous and vary with tooth type and restorative material. Once inserted, restorations may fail at variable rates due to various “objective” factors aVecting both the failure of the filling material and further decay of the tooth around the filling. These factors include the characteristics of the filling material and eVect modifiers related to operator skill and technique, patients’ dental characteristics, and the environment around the tooth. The decision to replace a restoration is also influenced by more subjective factors such as dentists’ interpretation of the restoration’s condition and the health of the tooth, the criteria used to define failure, and patient demand. These decisions are subject to much variation. 10 A lack of standardisation exists, and no generally agreed criteria are used to decide when a restoration requires replacement. Types of restoration Tooth restorations may be classified as intracoronal, when they are placed within a cavity prepared in the crown of a tooth, or extracoronal, when they are placed around (outside) the tooth as in the case of a crown. Intracoronal restorations are usually placed directly into the tooth cavity and normally consist of a mouldable material that sets and becomes rigid; the material is retained by the surrounding walls of the remaining tooth tissue. An alternative intracoronal restoration uses an indirect technique; here an impression of the cavity is taken and a laboratory constructed inlay is produced and subsequently cemented into the prepared cavity. The materials currently used to restore intracoronal preparations are: dental amalgam, composite resins, glass ionomer cemen
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引用次数: 28
Influences on clinical practice: the case of glue ear. 对临床的影响:胶耳1例。
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.108
S Dopson, R Miller, S Dawson, K Sutherland

A case study of clinical practice in children with glue ear is presented. The case is part of a larger project, funded by the North Thames Research and Development Programme, that sought to explore the part played by clinicians in the implementation of research and development into practice in two areas: adult asthma and glue ear in children. What is striking about this case is the differences found in every area of the analysis. That is, diversity was found in views about diagnosis and treatment of glue ear; the organisation of related services; and in the reported practice of our interviewees, both between particular groupings of clinical staff and within these groupings. The challenge inherent in the case is to go beyond describing the complexity and differences that were found, and look for patterns in the accounts of practice and tease out why such patterns may occur.

本文报道一例儿童胶耳的临床实践。该病例是一个更大项目的一部分,该项目由北泰晤士研究与发展计划资助,旨在探索临床医生在将研究与开发应用于两个领域中的作用:成人哮喘和儿童胶耳。这个案例的惊人之处在于分析的每个方面都存在差异。即对胶耳的诊断和治疗存在不同的看法;组织相关服务;在我们的受访者报告的实践中,无论是在临床工作人员的特定分组之间还是在这些分组内。这个案例固有的挑战是超越描述所发现的复杂性和差异,在实践的描述中寻找模式,并梳理出为什么会出现这种模式。
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引用次数: 23
A new structure for quality improvement reports. 质量改进报告的新结构。
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.76
F Moss, R Thompson
Finding out about how others’ schemes to implement change succeed or why they fail can be extremely helpful. It can save time and eVort and may accelerate improvements in service delivery. One of the stated aims of this journal is to publish such quality improvement reports alongside papers that report the results of relevant research. The editorial team are aware through discussion with colleagues, from papers presented at meetings, and reading local reports that many people are involved in useful and informative quality improvement projects that could have valuable messages for others. And yet in the past seven and a half years we have only published 12 quality improvement reports—the most recent one in December 1995. We rely on submitted reports, and one of the reasons for this dearth of published quality improvement reports may be that people are simply too busy improving care to have time to write. But there may be other barriers. The standard form for writing papers in medical journals is the scientific IMRaD (introduction, methods, results, and discussion) structure. This is a convenient and helpful structure for writing about research. When writing a quality improvement report this structure does not quite fit, however. For example, there will be a first methods section—when the measurements are made—and a first results section—when the results are analysed. However, there follows a second methods section describing the implementation of change, perhaps followed by a third methods section when the measurements are repeated to assess progress, and then a second results section describing the improvements. Writing quality improvement reports in this way may not only be diYcult but may result in a paper that does not convey the lessons that others would find useful. The editorial team has therefore developed a new structure (box) for describing quality improvement work that we think will reflect this work more accurately and which we hope will encourage authors to write about their experience. The first quality improvement report using this structure is published in this issue of Quality in Health Care (page 119). There is also another fundamental diVerence between quality improvement reports and the reports of original research. Research seeks broadly to produce generalisable results. Thus, trials of thrombolytic treatment in acute myocardial infarction sought to determine whether trombolysis reduced subsequent mortality, such that the results could be generalised to coronary care units and medical wards treating such patients. On the other hand, a local audit or quality improvement project, which seeks to assess whether patients are appropriately treated with thrombolytic therapy does so to monitor and ensure the implementation of evidence based treatment in practice. The results of such a study are not generalisable to other coronary care units in the same way as the preceding research evidence, and for many this would suggest that the wo
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引用次数: 68
Improving the repeat prescribing process in a busy general practice. A study using continuous quality improvement methodology. 在繁忙的全科执业中改进重复处方流程。使用持续质量改进方法的研究。
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.119
S Cox, P Wilcock, J Young

Problem: A need to improve service to patients by reducing the time wasted by reception staff so that the 48 hour target for processing repeat prescription requests for patient collection could be achieved.

Design: An interprofessional team was established within the practice to tackle the area of repeat prescribing which had been identified as a priority by practice reception staff. The team met four times in three months and used continuous quality improvement (CQI) methodology (including the Plan-Do-Study-Act cycle) with the assistance of an external facilitator.

Background and setting: A seven partner practice serving the 14,000 patients on the northern outskirts of Bournemouth including a large council estate and a substantial student population from Bournemouth University. The repeat prescribing process is computerised.

Key measures for improvement: Reducing turn around times for repeat prescription requests. Reducing numbers of requests which need medical records to be checked to issue the script. Feedback to staff about the working of the process.

Strategies for change: Using a Plan-Do-Study-Act cycle for guidance, the team decided to (a) coincide repeat medications and to record on the computer drugs prescribed during visits; (b) give signing of prescriptions a higher priority and bring them to doctors' desks at an agreed time; and (c) move the site for printing prescriptions to the reception desk so as to facilitate face to face queries.

Effects of change: Prescription turnaround within 48 hours increased from 95% to 99% with reduced variability case to case and at a reduced cost. The number of prescriptions needing records to be looked at was reduced from 18% to 8.6%. This saved at least one working day of receptionist time each month. Feedback from all staff within the practice indicated greatly increased satisfaction with the newly designed process.

Lessons learnt: The team's experience suggests that a combination of audit and improvement methodology offers a powerful way to learn about, and improve, practice. The interventions used by the team not only produced measurable and sustainable improvements but also helped the team to learn about the cost of achieving the results and provided them with tools to accomplish the aims. The importance of feedback to all staff about CQI measures was also recognised.

问题:需要通过减少接待人员浪费的时间来改善对患者的服务,以便实现48小时处理重复处方请求以收集患者的目标。设计:在实践中建立了一个跨专业团队来解决重复处方的问题,这已经被实践接待人员确定为优先事项。该团队在三个月内召开了四次会议,并在外部促进者的协助下使用了持续质量改进(CQI)方法(包括计划-执行-研究-行动周期)。背景和环境:伯恩茅斯北郊有7个合作伙伴,为14000名患者提供服务,其中包括一个大型理事会地产和伯恩茅斯大学的大量学生。重复处方过程是计算机化的。改进的关键措施:减少重复处方请求的周转时间。减少需要检查医疗记录以发出脚本的请求数量。向员工反馈流程的工作情况。变革策略:采用计划-执行-研究-行动周期作为指导,研究小组决定(a)重复用药,并在电脑上记录就诊期间开具的药物;(b)把签署处方放在更优先的位置,并在约定的时间将处方送到医生的办公桌;(三)将打印处方的地点移至前台,方便面对面查询。变化的影响:48小时内的处方周转从95%增加到99%,减少了病例之间的差异,降低了成本。需要查看记录的处方数量从18%减少到8.6%。这样每月至少节省了一个工作日的前台接待时间。实践中所有员工的反馈表明,对新设计流程的满意度大大提高。经验教训:团队的经验表明,审计和改进方法的结合提供了学习和改进实践的有力途径。团队使用的干预措施不仅产生了可衡量的和可持续的改进,而且还帮助团队了解了实现结果的成本,并为他们提供了实现目标的工具。向全体员工反馈CQI措施的重要性也得到了认可。
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引用次数: 48
Deliberate self harm. 故意自残。
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.137
A House, D Owens, L Patchett
Self poisoning is the most common form ofdeliberate self harm. Most cases of deliberateself poisoning present to general hospitals; inthe UK there are more than 150 000 suchattendances annually. The most common sub-stances ingested are analgesics, particularlyparacetamol and paracetamol containingcompounds.
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引用次数: 21
Can small group education and peer review improve care for patients with asthma/chronic obstructive pulmonary disease? 小组教育和同行评议能否改善哮喘/慢性阻塞性肺疾病患者的护理?
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.92
I J Smeele, R P Grol, C P van Schayck, W J van den Bosch, H J van den Hoogen, J W Muris

Objective: To study the effectiveness of an intensive small group education and peer review programme aimed at implementing national guidelines on asthma/chronic obstructive pulmonary disease (COPD) on care provision by general practitioners (GPs) and on patient outcomes.

Design: A randomised experimental study with pre-measurement and post-measurement (after one year) in an experimental group and a control group in Dutch general practice.

Subjects and intervention: Two groups of GPs were formed and randomised. The education and peer review group (17 GPs with 210 patients) had an intervention consisting of an interactive group education and peer review programme (four sessions each lasting two hours). The control group consisted of 17 GPs with 223 patients (no intervention).

Main outcome measures: Knowledge, skills, opinion about asthma and COPD care, presence of equipment in practice; actual performance about peakflow measurement, non-pharmacological and pharmacological treatment; asthma symptoms (Dutch Medical Research Council), smoking habits, exacerbation ratio, and disease specific quality of life (QOL-RIQ). Data were collected by a written questionnaire for GPs, by self recording of consultations by GPs, and by a written self administered questionnaire for adult patients with asthma/COPD.

Results: Data from 34 GP questionnaires, 433 patient questionnaires, and recordings from 934 consultations/visits and 350 repeat prescriptions were available. Compared with the control group there were only significant changes for self estimated skills (+16%, 95% confidence interval 4% to 26%) and presence of peakflow meters in practice (+18%, p < 0.05). No significant changes were found for provided care and patient outcomes compared with the control group. In the subgroup of more severe patients, the group of older patients, and in the group of patients not using anti-inflammatory medication at baseline, no significant changes compared with the control group were seen in patient outcomes.

Conclusion: Except for two aspects, intensive small group education and peer review in asthma and COPD care do not seem to be effective in changing relevant aspects of the provided care by GPs in accordance with guidelines, nor in changing patients' health status.

目的:研究强化小组教育和同行评议项目的有效性,该项目旨在实施全科医生(gp)提供的哮喘/慢性阻塞性肺疾病(COPD)护理和患者预后的国家指南。设计:一项随机实验研究,在荷兰全科实践中,实验组和对照组进行前测量和后测量(一年后)。受试者和干预措施:随机分为两组全科医生。教育和同行评议组(17名全科医生,210名患者)的干预包括互动式小组教育和同行评议计划(4次,每次持续2小时)。对照组由17名全科医生223例患者组成(无干预)。主要结局指标:对哮喘和慢性阻塞性肺病护理的知识、技能、意见、实践中设备的存在;峰流量测量、非药物和药物治疗的实际表现;哮喘症状(荷兰医学研究委员会),吸烟习惯,恶化率和疾病特定生活质量(QOL-RIQ)。数据通过全科医生的书面问卷、全科医生的自我咨询记录和成人哮喘/慢性阻塞性肺病患者的书面自我管理问卷收集。结果:收集了34份全科医生问卷、433份患者问卷、934次会诊/就诊记录和350张重复处方记录。与对照组相比,只有自我评估技能(+16%,95%置信区间为4%至26%)和实际使用峰值流量计(+18%,p < 0.05)有显著变化。与对照组相比,提供的护理和患者预后没有明显变化。在较严重的患者亚组、老年患者组和基线时未使用抗炎药物的患者组中,患者的预后与对照组相比没有明显变化。结论:除两个方面外,强化小组教育和同行评议在改变全科医生按照指南提供的护理的相关方面,以及改变患者的健康状况方面似乎都没有效果。
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引用次数: 69
Case studies as a research tool. 案例研究作为研究工具。
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.75
L Fitzgerald
In many fields of knowledge, there is increasing recognition that a range of research methodologies can enrich and extend the available evidence and knowledge base. Understandably, in medical research and in clinical bench sciences, quantitative research methodologies have predominated. In the social sciences, however, qualitative methodologies such as case studies have long been accepted, and indeed developed as useful research tools. As with any methodology, case studies are best suited to particular forms of enquiry. Under what conditions therefore would one consider using a case study methodology? One appropriate use would be for conducting exploratory research, where the field of enquiry is novel and underresearched. If there is minimal or no foundation of previous research evidence, it is diYcult to formulate the critical research questions and useful hypotheses. In these circumstances, case studies can be used to explore and describe the issues within a given context. Appropriate research questions can then be formulated on a foundation of data. For example, there has been limited research on the problems of eYcient service delivery in primary care partnerships. We know from some previous research in the private sector that partnerships have unique problems of control and accountability. A case study approach to research, particularly using multiple or comparative case studies would be useful. Case studies are also useful as research tools in complex and dynamic contexts where it is diYcult to isolate variables or where there are multiple, influencing variables. Because many organisational contexts have these characteristics, this is one explanation for the use of case study methods in organisational research. Case studies are a fruitful method to answer the “why” questions in such contexts. For example, in the two cases published in this edition of Quality in Health Care (pages 99 and 108), the authors seek to explore and answer questions about why and under what conditions, clinical professionals decide to adopt an innovation or change their clinical practice. The argument has been posed that if there is strong scientific evidence to support an innovation, then professionals, once they know this evidence, will adopt the innovation. But do we know if this is why clinical professionals change their practice? If it is an influence, is it the only or even the major influence? Many of the critics of case study methods would simply see a case study as a loosely constructed “story”, selected at random (or worse because the researcher is connected to the case in some manner). In many respects this undervalues the approach and certainly underestimates the current stage of development of the case study approach. Yinn, provides a resource which helps researchers wishing to construct well rounded cases. The selection of the case or cases is a critical stage. Some of the issues of generalisation may be mitigated by a purposeful approach to case selec
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引用次数: 39
Implementing continuous quality improvement in general practice: the whole package or a series of projects? 在全科实践中实施持续质量改进:是整个项目还是一系列项目?
Pub Date : 1999-06-01 DOI: 10.1136/qshc.8.2.77
H Geboers
Continuous quality improvement is a complex approach to improvement that describes an all encompassing “package” of principles, methods, and techniques (box). For large organisations setting out to change working practices in line with the principles of continuous quality improvement, implementation of the complete package may be appropriate. But for much smaller organisations with fewer resources—such as general practices—such a task may seem overwhelming. Yet continuous quality improvement has been shown to work in general practice. 2 The evidence suggests, however, that implementing it gradually, starting with small scale projects, may be more successful in general practice, and a quality improvement report in this issue adds further support for this approach.
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引用次数: 9
期刊
Quality in health care : QHC
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