Patient safety events reported in general practice: a taxonomy.

OBJECTIVE: To develop a taxonomy describing patient safety events in general practice from reports submitted by a random representative sample of general practitioners (GPs), and to determine proportions of reported event types. DESIGN: 433 reports received by the Threats to Australian Patient Safety (TAPS) study were analysed by three investigating GPs, classifying event types contained. Agreement between investigators was recorded as the taxonomy developed. SETTING AND PARTICIPANTS: 84 volunteers from a random sample of 320 GPs, previously shown to be representative of 4666 GPs in New South Wales, Australia. MAIN OUTCOME MEASURES: Taxonomy, agreement of investigators coding, proportions of error types. RESULTS: A three-level taxonomy resulted. At the first level, errors relating to the processes of healthcare (type 1; n = 365 (69.5%)) were more common than those relating to deficiencies in the knowledge and skills of health professionals (type 2; n = 160 (30.5%)). At the second level, five type 1 themes were identified: healthcare systems (n = 112 (21.3%)); investigations (n = 65 (12.4%)); medications (n = 107 (20.4%)); other treatments (n = 13 (2.5%)); and communication (n = 68 (12.9%)). Two type 2 themes were identified: diagnosis (n = 62 (11.8%)) and management (n = 98 (18.7%)). The third level comprised 35 descriptors of the themes. Good inter-coder agreement was demonstrated with an overall kappa score of 0.66. A least two out of three investigators independently agreed on event classification in 92% of cases. CONCLUSIONS: The proposed taxonomy for reported events in general practice provides a comprehensible tool for clinicians describing threats to patient safety, and could be built into reporting systems to remove difficulties arising from coder interpretation of events.

Patients with dementia and their carers in general practice.

In 2004, 6.5% of Australians over 65 years of age were estimated to have dementia and the prevalence of dementia is rising as a result of our aging population. There is evidence to show that carer wellbeing is important for the wellbeing of the patient. Increasing burden of care may lead to depression, anxiety, and more frequent physical illness in the carer, and earlier institutionalisation of patients. The general practitioner's role includes recognising early dementia, undertaking assessments to confirm the diagnosis, managing the disease, health promotion and support for both patient and carer, and follow up. We initiated a project to explore the extent to which GPs currently fulfill this role for patients with dementia still living in the community (rather than in hostels or nursing homes).

The management of dementia in general practice. A field test of guidelines.

INTRODUCTION: Guidelines for the management of dementia in non-institutionalized patients living in the community were developed by a broadly representative group. We assessed their usefulness. METHOD: The draft guidelines included emphasis on psychosocial issues. They were field tested by 17 general practitioners with 119 dementia patients. RESULTS: There was a high prevalence of comorbidity in the patients and frequent psychosocial issues in their management that were often not addressed. The guidelines were rated as very helpful for at least one aspect of care for 50% of the patients. DISCUSSION: The guidelines were found to be useful to GPs.

Dementia care in general practice. What can the BEACH survey tell us?

BACKGROUND: Only a small amount of rather selective information about dementia care in general practice in Australia is available. AIM: To obtain a broader understanding of the prevalence and management of dementia in general practice. METHOD: An analysis of data from the Bettering the Evaluation And Care of Health (BEACH) study of general practice in 1998-2000 was undertaken. RESULTS: Only 21% of GPs reported any encounter with a patient at which dementia was treated within their reported 100 patient encounters. These encounters comprised only 0.43% of all encounters; 39% of these encounters were in a nursing home and 28% occurred in the GP's consulting rooms. For 7% of patients the diagnosis of dementia was new. Most patients with dementia were aged over 75 years, but dementia was treated in only 3% of all patients of this age. It was treated in 19% of patients seen in nursing homes. Nearly all patients (96%) with dementia had other conditions managed at the encounter. Medication was infrequently prescribed for dementia. DISCUSSION: More information is needed about dementia and its care in the community--its stage, extent of impairment and disability, social functioning, use of services, carers and their health, and progression over time.

General practitioners' views on patient care research.

BACKGROUND: Little research has been undertaken into the factors affecting recruitment by Australian general practitioners of patients for clinical trials. Understanding the differences between recruiters and non-recruiters will assist researchers in better supporting general practitioners involved in such research. METHOD: A survey of general practitioners involved in recruiting patients for clinical trials for the RACGP Research Program was undertaken. RESULTS: Recruiters were more likely to be interested in learning more about research, to perceive involvement as worthwhile, to desire a good relationship with Research Program staff and to feel the doctor-patient relationship assists recruitment. DISCUSSION: Recruiters in general are average general practitioners, male, middle-aged and work in group practices. Most felt some discomfort in recruiting patients, but believed the strong doctor-patient relationship assisted in the process. CONCLUSION: The Research Program needs to recruit general practitioners interested in research, choose topics of interest, keep recruitment protocols simple and stay in contact.

Cervical cytopathology reporting systems. Helping or hindering patient management?

OBJECTIVE: When a Pap smear is reported, the general practitioner needs to know whether it was technically satisfactory and, if abnormal, what kind of abnormality was found, in order to arrange appropriate management. A random survey of non hospital based cytology reporting laboratories in NSW was undertaken to determine the efficiency of this process. METHOD: This study examines the types of cytopathology reporting protocols used, the means provided by the laboratory to assist general practitioners in assessing the quality of their Pap smears and what, if any, management advice was given to general practitioners. RESULTS: Not only do different laboratories use different terminologies to report on Pap smears, but the majority use terms from at least two different reporting systems. Seven of the 10 laboratories provided feedback on the adequacy of the Pap smears while only 4 of the 10 laboratories provided management advice. CONCLUSIONS: If the 1993 National Health and Medical Research Council recommendations are followed, cytopathology reporting will be primarily Bethesda based with the pathology laboratories providing feedback on technical aspects of Pap smears taking as well as management advice.

Sampling techniques for cervical cancer prevention.

The principal goal of Pap smear screening is to detect those abnormalities of the cervix that require definitive diagnostic intervention. Any mainstream screening of the population should also seek to increase the participation of women belonging to groups with special needs, such as Aboriginal and Torres Strait Islander women, women of non English speaking background, women with disabilities and older unscreened women. As it is not always possible to obtain endocervical cells, the importance of a Pap smear for individual women is questioned. This article examines the various sampling techniques and choice of instruments. Though the literature is not entirely supportive of a particular cytological sampling technique, the overall evidence supports the use of the spatula/cytobrush combination.

Classification of severity of health problems in family/general practice: an international field trial.

BACKGROUND: A methodology is needed for classification of health problems by severity. OBJECTIVES: We aimed to test the Duke Severity of Illness Checklist (DUSOI) for feasibility and usefulness. METHOD: The DUSOI was field tested internationally by 22 family/general practitioners in 9 countries. RESULTS: The DUSOI was found to be feasible for rating severity of illness of health problems in family/general practice. The measure was shown to be clinically useful in older patients and those with chronic and more severe health problems. Variability of severity ratings was less within the same rater than between different raters (i.e. higher intrarater than interrater reliability). Clinical face validity was supported by the finding that DUSOI ratings classified patients with the same diagnosis and those with different diagnoses according to the severity differences that would be expected clinically. CONCLUSIONS: Although research is needed to improve reliability and to test validity further, the DUSOI was shown in the present study to be a methodology that is reasonable for consideration as an international classification of health problems by their severity in primary care patients.

Immunisation in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991.

Immunisation is the sixth most commonly managed problem in general practice in Australia. This paper provides an overview of its management in general practice.

Asthma management and morbidity in Australian general practice: the relationship between patient and doctor estimates.

The aims of this study were to describe asthma management and morbidity in patients attending general practitioners in Australia, and to assess the relationship between patient reports and those of their general practitioner (GP). The sample comprised consecutive patients attending 46 general practitioners chosen at random in five regions of New South Wales, Australia. A total of 4538 patients were screened, 607 (13.4%) reported ever having diagnosed asthma, and the 501 who reported asthma in the previous 12 months completed a detailed questionnaire. Three hundred and thirty-four patients also had information about their asthma management recorded by their GP. The patient questionnaire asked about asthma symptoms, therapy, lung function measurement, and asthma-related morbidity. The GP questionnaire asked the doctor to record similar information about the patients. Two-thirds of the patients used regular inhaled beta 2-agonist medication, and one-half reported using preventive therapy. Only 24% owned a peak flow meter and 9% had a written plan of action for asthma attacks. Although preventive therapy and airway function assessment were more common in those with frequent symptoms (> 2-3 times per week), this group were still sub-optimally managed. In the matched sample (n = 334), doctors reported prescribing bronchodilator and preventive medication, measuring airway function and recommending peak flow meter use more often than suggested by patient-reported data. The study concludes that many patients do not attend for regular review, and that management remains sub-optimal, particularly in young adults. Data from patient surveys may underestimate clinical practice, as assessed from doctors' records. This should lead to patient-derived estimates of management being interpreted with caution in epidemiological studies. Further attention to patient understanding and compliance with prescribed asthma management advice is needed in order to better manage asthma in the community.

A controlled trial of educational visiting to improve benzodiazepine prescribing in general practice.

A randomised controlled trial studied the effect of an educational visit on benzodiazepine prescribing. An approximately representative sample of 286 general practitioners was allocated to an intervention or a control group. Rates of benzodiazepine prescriptions were derived from two comprehensive self-report surveys seven months apart. Two months after the first survey the intervention group received an educational visit and supporting material from a doctor or pharmacist, ostensibly unconnected with the surveys. The overall benzodiazepine prescribing rate fell by 23.7 per cent from the first to the second surveys, from 4.93 to 3.76 prescriptions per 100 encounters (P < 0.001). Anxiety and insomnia diagnosis rates also declined from 4.68 to 3.76 per 100 encounters (19.7 per cent). After adjusting for confounders, there was a differential downward trend in prescriptions per diagnosis of insomnia but not to a statistical level. The same was true of initial prescriptions per insomnia diagnosis. In a subsidiary analysis selecting only new insomnia diagnoses, the intervention had a strong effect in reducing initial prescriptions (odds ratio 0.18, 95 per cent confidence interval 0.04 to 0.73). No effect was seen on prescribing for anxiety diagnoses. Educational practice visiting for benzodiazepine prescribing in anxiety, as we conducted it, is not justified in an unselected population of general practitioners. Specific education on prescribing for insomnia is probably useful. Our interpretation of the reduction in benzodiazepine prescribing is that probably there was an effect from self-monitoring alone which overwhelmed a main-analysis intervention effect. Retrospective diagnosis may also have obscured a real intervention effect.

Development of sample size models for national general practice surveys.

The most cost-effective method to measure the morbidity managed and treatments provided in general practice is from records of a cluster of consultations (encounters) from each general practitioner (GP) in a random sample. A cluster sampling method is proposed for future surveys for analysis of encounter-based general practice data. The sample sizes needed to measure the most common problems managed and drugs prescribed were estimated using ratio-estimator models for cluster sample surveys. Morbidity and treatment rates were estimated from the Australian Morbidity and Treatment Survey in General Practice 1990-1991 (AMTS). The 20 most common problems in the AMTS were managed at estimated rates of 1.5 to 9.5 per 100 encounters. The 20 most common drugs were prescribed at estimated rates of 0.7 to 3.6 per 100 problems. These rates were used to determine precision as a percentage of each true value for future surveys, that is, as relative precision. If we want to be 95 per cent confident that these rates will be within 5 per cent of each true rate, sample sizes of 552 to 5675 GPs are needed. If we fix the sample size at 1000 GPs, relative precision lies within 12 per cent of these rates. If the sample size is increased to 1500 GPs, relative precision improves only marginally. The differences in sample size for each of the most frequent morbidity and treatment data are largely due to their variable distributions and relatively infrequent occurrence in general practice. A sample size of 1000 GPs will enable measurement of the most common morbidity and treatments at 95 per cent confidence.

The management of asthma in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991.

Asthma is the third most commonly managed problem in general practice in Australia. This paper provides an overview of its management in general practice.

The management of sprains and strains in general practice. Results from the Australian Morbidity and Treatment Survey, 1990-1991.

Sprains and strains were the eighth most commonly managed problem in general practice in Australia. This paper provides an overview of their management in general practice.