Quality in primary care最新文献

Background: The ordering of thyroid function tests (TFTs) is increasing but there is not a similar increase in thyroid disorders in the general population, leading some to query whether inappropriate testing is taking place. Inconsistent clinical practice is thought to be a cause of this, but there is little evidence of the views of general practitioners, practice nurses or practice managers on the reasons for variation in the ordering of TFTs.

Aim: To find out the reasons for variation in ordering of TFTs from the perspective of primary healthcare professionals Methods: Fifteen semi-structured interviews were carried out with primary healthcare professionals (general practitioners, practice nurses, practice managers) that used one laboratory of a general hospital in South West England for TFTs. Framework Analysis was used to analyse views on test ordering variation at the societal, practice, individual practitioner and patient level.

Results: A number of reasons for variation in ordering across practices were suggested. These related to: primary healthcare professionals awareness of and adherence to national policy changes; practices having different protocols on TFTs ordering; the set-up and use of computer systems in practices; the range of practice healthcare professionals able to order TFTs; greater risk-aversion amongst general practitioners and changes in their training and finally how primary healthcare staff responded to patients who were perceived to seek help more readily than in the past.

Conclusion: The reasons for variation in TFTs ordering are complex and interdependent. Interventions to reduce variation in TFTs ordering need to consider multiple behavioural and contextual factors to be most effective.

The systems-based management of laboratory test ordering and results handling is a significant patient safety concern in primary care internationally. In this pilot study, we describe the testing of a method to systematically measure and monitor compliance with basic safe performance in this area in different European primary care settings. The findings show high overall compliance with the safe system measures developed although the data indicates performance variation within and between the different systems audited, which suggests that aspects of the reliability (and safety) of these systems could be improved by care teams. However, the overall utility of the method is still to be determined and this will require testing on a greater scale in more diverse practices with larger samples of patients and blood tests, and using different technology support systems.

Background: Clinical commissioning is the centrepiece of government health reforms. Engagement with the reforms is important if they are to bring about improvements in the quality of healthcare. This is important in any healthcare system, not just the UK National Health Service (NHS). This study draws on data from a specially commissioned survey, exploring the extent to which general practitioners (GPs) in East Lancashire are engaged with clinical commissioning. Aim The aim of this study was to assess levels of engagement with clinical commissioning using a Clinical Commissioning Engagement Scale (CCES).

Methods: A six-point Likert scale CCES was distributed to all GPs within the boundary of East Lancashire Clinical Commissioning Group (CCG). The GPs are distributed across five localities that vary in terms of geography, demography and previous commissioning experience. The CCES aimed to capture comparative levels of engagement across twelve items, three for each of four dimensions of engagement: (1) personal attitude, (2) perceived capacity, (3) perceived capability and (4) opportunity. Eighty-five returns were received, representing a response rate of 35.3%. A full analysis of the data was conducted using SPSS v. 19.

Results: The results demonstrate concern for capacity and capability across the localities, where mean scores are universally well below the midpoint of the scale. However, attitude and opportunity were relatively positive indicators with mean scores above midpoint for all localities.

Conclusion: The findings highlight the potential challenges for CCGs in engaging GPs and in particular responding to perceived problems of capability and capacity. Further research is required to shed light on whether East Lancashire is typical of other CCGs.

Background: Community pharmacists (CPs) have been changing their role to focus on patient-centred services to improve the quality of chronic disease management (CDM) in primary care. However, CPs have not been readily included in collaborative CDM with other primary care professionals such as physicians. There is little understanding of the CP role change and whether it affects the utilisation of CPs in primary care collaborative CDM.

Aim: To explore physician and CP perceptions of the CP's role in Australian primary care and how these perceptions may influence the quality of physician/CP CDM programmes.

Methods: Data were collected from physicians and CPs using semi-structured interviews. A qualitative methodology utilising thematic analysis was employed during data analysis. Qualitative methodology trustworthiness techniques, negative case analysis and member checking were utilised to substantiate the resultant themes.

Results: A total of 22 physicians and 22 CPs were interviewed. Strong themes emerged regarding the participant perceptions of the CP's CDM role in primary care. The majority of interviewed physicians perceived that CPs did not have the appropriate CDM knowledge to complement physician knowledge to provide improved CDM compared with what they could provide on their own. Most of the interviewed CPs expressed a willingness and capability to undertake CDM; however, they were struggling to provide sustainable CDM in the business setting within which they function in the primary care environment.

Conclusions: Role theory was selected as it provided the optimum explanation of the resultant themes. First, physician lack of confidence in the appropriateness of CP CDM knowledge causes physicians to be confused about the role CPs would undertake in a collaborative CDM that would benefit the physicians and their patients. Thus, by increasing physician awareness of CP CDM knowledge, physicians may see CPs as suitable CDM collaborators. Second, CPs are experiencing role conflict and stress in trying to change their role. Strengthening the service business model may reduce these CP role issues and allow CPs to reach their full potential in CDM and improve the quality of collaborative CDM in Australian primary care.

This is the fourth in a series of articles about the science of quality improvement. We examine what to measure, how to measure and some important measurement techniques, such as run charts, control charts and funnel plots. These help us to understand healthcare processes, to assess whether they are stable or improving and to determine how they can be improved further.

This discussion paper describes a new and comprehensive model for diagnosing the causes of individual medical performance problems: SKIPE (skills, knowledge, internal, past and external factors). This builds on a previous paper describing a unifying theory of clinical practice, the RDM-p model, which captures the primary skill sets required for effective medical performance (relationship, diagnostics and management), and the professionalism that needs to underpin them. The SKIPE model is currently being used, in conjunction with the RDM-p model, for the in-depth assessment and management of doctors whose performance is a cause for concern.

Background: Quality improvement investigators working in field settings, who typically are not trained in epidemiological methods, may not consider all three elements of the epidemiologic triad (person, place and time) when planning their projects.

Aim: To demonstrate how the epidemiological triad can guide analysis for quality assessment. Predictors of antibiotic use in primary care were analysed to illustrate the approach.

Methods: This study was a secondary analysis of data previously collected from medical records and a provider survey. A convenience sample of 467 family medicine patients treated in two clinic sites for acute respiratory tract infections was analysed by locating quality variation in person, place and time. Independent variables included patient age, date of clinic visit, and clinic site. The outcome measure was antibiotic prescription (yes or no).

Results: Antibiotics were prescribed for 69.2% of patients in the sample. Age group was not related to antibiotic prescribing. Prescription was related to time (P = 0.0344) and clinic site (P = 0.0001) in univariate tests. However, only site was independently related to antibiotic prescription (odds ratio = 0.47, confidence interval = 0.30 to 0.73, P = 0.0008).

Conclusion: The epidemiological triad assisted in guiding further post hoc analysis of predictors of antibiotic prescriptions. Further investigations of this quality indicator can be directed at exploring site differences and testing interventions. Studies of other quality indicators in primary care can employ the triad to guide the analysis.

This is the second in a series of articles about the science of quality improvement. Many quality improvement initiatives are aimed at improving the process of care and ensuring that high-quality care is delivered reliably. In this article, we explain why it is important to understand healthcare processes in order to improve them and how this can be achieved. We explain the use of logic models to determine what information to collect (from surveys, interviews, direct observations and other sources) and how to analyse this information (using techniques such as process maps, critical-to-quality trees, driver diagrams and cause-and-effect diagrams) to design more reliable and higher quality healthcare processes.