Quality in primary care最新文献

Background: The NHS Health Checks is a cardiovascular disease (CVD) risk assessment and management programme for individuals in England aged between 40 and 74 with the aim of identifying previously unassessed individuals that are at high risk of CVD. Little research to date has explored patient perceptions and opinions of Health Checks.

Objective: This paper aims to investigate the perceptions and opinions of patients who had attended a Health Check appointment within a cohort of 83 General Practices in Gloucestershire.

Methods: A cross sectional survey of patients who had completed a Health Check appointment during the period May to June 2012 within a single county in England. Quantitative and qualitative data were acquired from 1,011 standardised and anonymised patient surveys sent out by a Health Check Commissioner and GPs. Data gathered included perceptions concerning all aspects of the Health Checks process and actual appointment. Descriptive analysis was used to interrogate the quantitative data. Inductive content analysis was used to analyse qualitative data.

Results: Concerns about health were a principal driver of attendance. Reassurance, access to health information and guidance, and the identification of CVD risk and CVD diagnosis were perceived as key benefits of attending the appointment. Principal disadvantages included inconsistencies in the Health Check process, administration of appointments and a lack of appropriate follow up advice.

Conclusion: Health Checks are popular with patients and provide useful outcomes but greater consistency is needed in engaging patients and describing its purpose.

Background: The quality system in Estonia is a payfor-performance scheme, rewarding family doctors for the quality of care they provide. This study examines the impact of the quality system on the workload of family doctors in Estonia.

Aim: The aim of this study was to explore differences in the workload of family doctors participating in the clinical quality system and those not participating.

Methods: The study was conducted using a database from the Estonian Health Insurance Fund, which consists of health-related data for 96% of the Estonian population. The study compared the workload of Estonian family physicians in two groups: those participating in the quality system and those not.

Results: During the observation period 2005-2011, the proportion of family doctors participating in the clinical quality system increased from 48.2% to 69.2%. The total number of visits in primary care increased also and there was a difference in workload between the two groups. Doctors participating in the quality system performed more primary (initial) and secondary (follow-up) visits. The number of visits per doctor was also higher for those participating in the quality system. There was a shift to visits carried out by nurses, which showed an increased workload for nurses in the quality system during the observation period compared with a stable workload for those outside the system. The number of home visits decreased in both groups.

Conclusion: Pay-for-performance had a notable impact on the workload of the primary care team and its members. Paying more attention to detecting chronic diseases in their early stages, recalling patients for general health check-ups and immunising children may have an effect on health status, but also requires increased staff levels.

Background: Treatment fidelity has previously been defined as the degree to which a treatment or intervention is delivered to participants as intended. Underreporting of fidelity in primary care randomised controlled trials (RCTs) of complex interventions reduces our confidence that findings are due to the treatment or intervention being investigated, rather than unknown confounders.

Aim: We aimed to investigate treatment fidelity (for the purpose of this paper, hereafter referred to as intervention fidelity), of an educational intervention delivered to general practice teams and designed to improve the primary care management of insomnia.

Method: We conducted telephone interviews with patients and practitioners participating in the intervention arm of the trial to explore trial fidelity. Qualitative analysis was undertaken using constant comparison and a priori themes (categories): 'adherence to the delivery of the intervention', 'patients received and understood intervention' and 'patient enactment'.

Results: If the intervention protocol was not adhered to by the practitioner then patient receipt, understanding and enactment levels were reduced. Recruitment difficulties in terms of the gap between initially being recruited into the study and attending an intervention consultation also reduced the effectiveness of the intervention. Patient attributes such as motivation to learn and engage contributed to the success of the uptake of the intervention.

Conclusion: Qualitative methods using brief telephone interviews are an effective way of collecting the depth of data required to assess intervention fidelity. Intervention fidelity monitoring should be an important element of definitive trial design.

Trial registration: ClinicalTrials. gov id isrctn 55001433 - www.controlled-trials.com/isrctn55001433.

Individual practice needs to be developed to improve effectiveness, safety and patient experience. Although good systems can support better individual performance, without personal development, individual practice can be a source of error. This, the final article in our series on the science of quality improvement, describes models of competence and practice and the causes of good or poor practice. We show how quality improvement techniques can be used to improve individual practice and how this can be incorporated into the appraisal process for doctors, nurses and other healthcare professionals.

Background: NHS policy documents continue to make a wide-ranging commitment to patient involvement. The Patient Participation Direct Enhanced Service (PP-DES), launched in 2011, aimed to ensure patients are involved in decisions about the range and quality of services provided and commissioned by their practice through patient reference groups (PRGs). The aim of this exploratory study is to review the impact of the PP-DES (2011-13) on a sample of PRGs and assess how far it has facilitated their involvement in decisions about the services of their general practices.

Methods: A qualitative methods design, using semi- structured interviews and focus groups, was employed to explore the experiences and views of GP practice staff (n = 24), PRG members (n = 80) at 12 GP practices, and other stakeholders (n = 4).

Results: Wide variation in the role and remit of the participating PRGs was found, which broadly ranged from activities to improve practice resources to supporting health promotion activities. The majority of PRG members were unfamiliar with the PP-DES scheme and its aims and purpose. Stakeholders and practice staff felt strongly that the main success of the PP-DES was that it had led to an increase in the number of PRGs being established in the locality.

Conclusion: The PP-DES scheme has been a catalyst to establish PRGs. However, the picture was mixed in terms of the PRGs involvement in decisions about the services provided at their general practice as there was wide variation in the PRGs role and remit. The financial incentive alone, provided via the DES scheme, did not secure greater depth of PRG activity and power, however, as social factors were identified as playing an important role in PRGs' level of participation in decision making. Many PRGs have to become more firmly established before they are involved as partners in commissioning decisions at their practice.

Background: Doctors' opinions about quality improvement tools likely influence their uptake and eventual impact on patient care. Little is known about physicians' perception of the comparative utility of various quality improvement tools.

Methods: We conducted a mail survey of doctors in Geneva, Switzerland (2745 physicians, of whom 56% participated), to measure the perceived usefulness of 9 quality improvement tools.

Results: In decreasing order of perceived utility these tools were regular continuous education (rated as very or extremely useful by 75% of respondents), mortality and morbidity conferences (65%), quality circles (60%), patient satisfaction measurement (42%), assessment of the fulfillment of therapeutic objectives (41%), assessment of compliance with guidelines (36%), periodic evaluation of doctors' skills (14%), onsite visits with peer-review of medical records (11%), and certification of office practices (8%).

Conclusion: Quality improvement tools seen as most useful by physicians are traditional methods such as continuous education and mortality and morbidity conferences. Methods that rely on the measurement of indicators or that have a judgmental component received less support.