Ovarian cancer suspicion, urgent referral and time to diagnosis in Danish general practice: a population-based study.

BACKGROUND: Ovarian cancer (OC) survival rates are lower in Denmark than in countries with similar health care. Prolonged time to diagnosis could be a contributing factor. The Danish cancer patient pathway (CPP) for OC was introduced in 2009. It provides GPs with fast access to diagnostic work-up. OBJECTIVE: To investigate cancer suspicion and pathway use among GPs and to explore the association between these factors and the diagnostic intervals (DIs). METHODS: We conducted a national population-based cohort study using questionnaires and national registers. RESULTS: Of the 313 women with participating GPs, 91% presented with symptoms within 1 year of diagnosis, 61% presented vague non-specific symptoms and 62% were diagnosed with late-stage disease. Cancer was suspected in 39%, and 36% were referred to a CPP. Comorbidity [prevalence ratio (PR): 0.53, 95% confidence interval (CI): 0.29-0.98] and no cancer suspicion (PR: 0.35, 95% CI: 0.20-0.60) were associated with no referral to a CPP. The median DI was 36 days. Long DIs were associated with no cancer suspicion (median DI: 59 versus 20 days) and no referral to a CPP (median DI: 42 versus 23 days). CONCLUSIONS: Nine in ten patients attended general practice with symptoms before diagnosis. Two-thirds initially presented with vague non-specific symptoms were less likely to be referred to a CPP and had longer DIs than women suspected of cancer. These findings underline the importance of supplementing the CPP with additional accelerated diagnostic routes.

General practitioners' experience and benefits from patient evaluations.

BACKGROUND: It has now for many years been recognised that patient evaluations should be undertaken as an integral part of the complex task of improving the quality of general practice care. Yet little is known about the general practitioners' (GPs') benefit from patient evaluations. Aim 1 was to study the impact on the GPs of a patient evaluation and subsequent feedback of results presented at a plenary session comprising a study guide for the results and group discussions. Aim 2 was to study possible facilitators and barriers to the implementations of the results raised by the patient evaluation process. METHODS: A patient evaluation survey of 597 voluntarily participating GPs was performed by means of the EUROPEP questionnaire. Evaluation results were fed back to the GPs as written reports at a single feedback meeting with group discussions of the results. Between 3 and 17 months after the feedback, the 597 GPs received a questionnaire with items addressing their experience with and perceived benefit from the evaluations. RESULTS: 79.4% of the GPs responded. 33% of the responding GPs reported that the patient evaluation had raised their attention to the patient perspective on the quality of general practice care. Job satisfaction had improved among 26%, and 21% had developed a more positive attitude to patient evaluations. 77% of the GPs reported having learnt from the evaluation. 54% had made changes to improve practice, 82% would recommend a patient evaluation to a colleague and 75% would do another patient evaluation if invited. 14% of the GPs had become less positive towards patient evaluations, and job satisfaction had decreased among 3%. CONCLUSIONS: We found a significant impact on the GPs regarding satisfaction with the process and attitude towards patient evaluations, GPs' attention to the patients' perspective on care quality and their job satisfaction. Being benchmarked against the average seemed to raise barriers to the concept of patient evaluations and difficulties interpreting the results may have formed a barrier to their implementation which was partly overcome by adding qualitative data to the quantitative results. The GPs' significant willingness to share and discuss the results with others may have served as a facilitator.

[Patients' assessment of their general practitioners--the significance of patient characteristics. General results from the DanPEP--part I]. / Patienternes vurdering af de praktiserende laeger. Overordnede resultater fra DanPEP-projektet--del I.

INTRODUCTION: Patients' experiences constitute a significant part of the quality assessment of general practice care. The aim of the present study was to examine the patients' assessment of their general practitioners (GPs) and to determine to which extent the assessments were associated with patient characteristics. MATERIAL AND METHODS: A survey among patients registered with the participating GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analyses of associations between the assessments and patient characteristics. RESULTS: The most positively assessed aspect was confidentiality in the GPs' record keeping followed by aspects of empathy and precision, while the poorest evaluations were given to GP and practice availability by phone and amount of waiting time in the waiting room. Elderly patients, frequent attenders, patients who had a long history with the GP and patients with a good self-rated health were those who were most satisfied in general. The significance of patient gender and educational level was more complex. Patients suffering from chronic heart, endocrine or cancer diseases were more satisfied than patients without a chronic condition. CONCLUSION: Our results may be used for ongoing adjustment of care to the needs of groups of patients - while keeping in mind the individual patient's needs.

[Patients' assessment of their general practitioners--the significance of physician gender and age]. / Patienternes vurdering af de praktiserende laeger--sammenhaeng med laegens køn og alder.

INTRODUCTION: The aim of the present study was to examine to which extent the patients' assessment of their general practitioner was associated which the gender and age of the physician. MATERIAL AND METHODS: A survey among patients registered with the GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analyses of associations between the assessments and the gender and age of the physicians. RESULTS: A total of 703 doctors participated in the study. Assessments from 56,652 patients were included in the analyses (response rate 73.1%). We found that patients perceived male physicians as more accessible than their female colleagues. The younger doctors were assessed more positively than their older colleagues on certain aspects, but the numeric differences between the groups were minor. CONCLUSION: Female general practitioners may benefit from paying more attention to the accessibility aspect. Older physicians may benefit from emphasizing their patients' need for participation, information and a sense of continuity.

[Patients' assessment of general practitioners. Association with type of practice]. / Patienternes vurdering af de praktiserende laeger: sammenhaeng med praksistype.

INTRODUCTION: This study aimed to examine if and how the patients' assessment of their general practitioner (GP) was associated with the organization of the practice, the number of listed patients and the number of staff members. MATERIAL AND METHODS: A survey among patients registered with the participating GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analysis of the associations between the assessments and practice characteristics was performed. RESULTS: A total of 703 GPs partook in the study. Assessments from 56,652 patients were included in the analyses (response rate 67.6%). Solo practicing GPs, GPs with a short list of patients and GPs with a large staff were assessed more positively than their colleagues in other types of practices, GPs with many listed patients and GPs with a small staff. CONCLUSION: The study showed a complex association between the patient-experienced accessibility of general practice care and the number of listed patients and practice staff. Patients experienced the best accessibility in practices with few listed patients and in practices with a large staff. GPs in single-handed practices had far more positive assessments of accessibility than did GPs in partnership practices, especially availability by phone and waiting time prior to an appointment. Differences in patient list and staff between practices could not explain this finding.

[Patient evaluation of health care]. / Patientevaluering af sundhedsvaesenet.

Quality improvement in health care should include patient evaluations. Patient evaluation is a relevant instrument for assessing those aspects of care which are significant for the patient's experience of quality and for assessing courses of treatment. The striving for 100% satisfaction should be balanced by the regard for quality viewed from a professional and an organizational perspective. Patient evaluations must be integrated in a learning process in order to produce quality improvement in the evaluated organization. Scientific development of instruments for evaluation by patients with specific diagnoses and evaluations of courses of treatment will contribute to future quality improvement of health care.

Association between patients' recommendation of their GP and their evaluation of the GP.

OBJECTIVE: Patient priorities and patient evaluations indicate that accessibility should receive more attention to increase quality in general practice. The definition of family medicine emphasizes the patient-centred approach, communication skills, continuity, and clinical skills. We aimed to explore the associations between the 23 items in the Europep questionnaire measuring patient evaluation of general practice and the patients' recommendation of their general practitioner (GP) to friends and to study the relationship of these items with the core competences of family medicine. DESIGN: Cross-sectional study where patients aged 18 years and over attending the practice were included. Patients completed the Danish version of the 23 item Europep questionnaire and an additional item about the degree to which they could recommend their GP to friends. SETTING: Danish general practice (the DanPEP study). SUBJECTS: A total of 50 191 patients and 690 GPs were included in the analyses. MAIN OUTCOME MEASURES: For each item, associations were calculated between a positive answer and the degree to which the patient could recommend the GP. Analyses were made at patient and GP levels. RESULTS: We found 12 items that covered the 10 most strongly associated items from both analyses: four of six items from the "doctor-patient relationship", two of five items from "medical care", and all items from "information and support" and "organization of services". No items from "accessibility" were among the 12 items. CONCLUSIONS: Recommending the GP to others was most strongly associated with the "emphatic", "patient-oriented", "informative and coordinating", and "competent/skilled" GP and to a lesser degree with accessibility to general practice.

Data quality and confirmatory factor analysis of the Danish EUROPEP questionnaire on patient evaluation of general practice.

OBJECTIVE: The Danish version of the 23-item EUROPEP questionnaire measuring patient evaluation of general practice has not been evaluated with regard to psychometric properties. This study aimed to assess data quality and internal consistency and to validate the proposed factorial structure. SETTING: General practice in Denmark. SUBJECTS: A total of 703 general practitioners (GPs). Some 83,480 questionnaires were distributed to consecutive patients aged 18 or more attending practice during the daytime. A total of 56,594 eligible patients responded (67.8%). MAIN OUTCOME MEASURES: Data quality (mean, median, item response, missing, floor and ceiling effects), internal consistency (Cronbach's alpha and average inter-item correlation), item-rest correlations. Model fit from confirmatory factor analysis (CFA). RESULTS: The distribution was skewed to the left for almost all items with a small floor effect (0.1-9.3%) and a ceiling effect larger than 15% (18.6-56.3%). Item response was high. For seven items "not applicable/relevant" represented more than 10% of the answers. Internal consistency was good. Item-rest correlations were below 0.60 for three items, and four items had lower correlations with their own domain than with other domains. CFA showed that four domains were highly correlated and that model fit was good for two indices (TLI and SRMR), acceptable for one index (CFI), and poor for three indices (chi-squared, RMSEA and WRMR). CONCLUSIONS: This study revealed high ceiling effects, a few items with low item-rest correlation and low item discriminant validity, and an uncertain model fit. There seems to be a need for developing response categories to bring down the ceiling effect and it is also unclear how to use the proposed domains. Future research should focus on evaluating the factorial structure when ceiling effect has been lowered, on whether items should be deleted, and on assessing the unidimensionality of each domain.

Doctor and practice characteristics associated with differences in patient evaluations of general practice.

BACKGROUND: Variation in patients' evaluation due to general practitioner (GP) and practice factors may provide information useful in a quality improvement context. However, the extent to which differences in patients' evaluation of the GPs are associated with differences in GP and practice characteristics must also be ascertained in order to facilitate comparison of adjusted patient evaluations between GPs. The aim of this study was to determine such associations in a setting where GPs serve a list of patients and act as gatekeepers. METHODS: We carried out a patient evaluation survey among voluntarily participating GPs using the EUROPEP questionnaire, which produced 28,260 patient evaluations (response rate 77.3%) of 365 GPs. In our analyses we compared the prevalence of positive evaluations in groups of GPs. RESULTS: Our principal finding was a negative association between the GP's age and the evaluation of all aspects, except accessibility. We also found an association between the way the practice was organised and the patients' evaluation of accessibility, with GPs in single-handed practices getting far the most positive evaluations. Long weekly working hours were associated with more positive evaluations of all dimensions except accessibility, whereas more than 0.5 full-time employees per GP, a higher number of listed patients per GP and working in a training practice were associated with negative evaluation of accessibility. CONCLUSION: GP characteristics are mainly associated with patients' experience of interpersonal aspects of care, while practice characteristics are associated with evaluation of accessibility. These differences need to be accounted for when comparing patient evaluations of different practices.

A cluster-randomized trial of the significance of a reminder procedure in a patient evaluation survey in general practice.

OBJECTIVE: . To determine whether adding a reminder procedure to the personal handing out of questionnaires to patients by general practitioners (GPs) in a patient evaluation survey added further information to the study and whether this influenced the results of the evaluations fed back to the GPs. DESIGN: Patient evaluation survey in general practice. STUDY PARTICIPANTS: 6822 patients consulting 60 GPs in a Danish county. GPs were voluntarily participating in a national patient evaluation project. INTERVENTION: We used the EUROPEP instrument for patient evaluation in general practice. It contains 23 items in five dimensions and two additional questions on general satisfaction. GPs were randomized into two groups with and without a reminder procedure. Main outcome measure. Scores in the six assessment dimensions and patient characteristics were compared for the primary and the reminder respondents and between the two randomization groups. In the analyses, we adjusted for the clustering of patients. RESULTS: We found that the use of a reminder procedure increased the response rate. Respondents to a reminder were younger than the primary responding patients and were more critical in their GP assessment. Patient evaluations of the individual GPs were statistically significantly more critical if these reminder responses were included. Absolute differences were too small to have any practical implications. CONCLUSIONS: Adding a reminder procedure to the face-to-face handing out of questionnaires to patients by the GPs increased the response rate significantly but produced no clinically significant differences in the assessment of the GPs.