Can we rely on simulated patients' satisfaction with their consultation for assessing medical students' communication skills? A cross-sectional study.

BACKGROUND: In medical education, teaching methods offering intensive practice without high utilization of faculty resources are needed. We investigated whether simulated patients' (SPs') satisfaction with a consultation could predict professional observers' assessment of young doctors' communication skills. METHODS: This was a comparative cross-sectional study of 62 videotaped consultations in a general practice setting with young doctors who were finishing their internship. The SPs played a female patient who had observed blood when using the toilet, which had prompted a fear of cancer. Immediately afterwards, the SP rated her level of satisfaction with the consultation, and the scores were dichotomized into satisfaction or dissatisfaction. Professional observers viewed the videotapes and assessed the doctors' communication skills using the Arizona Communication Interview Rating Scale (ACIR). Their ratings of communication skills were dichotomized into acceptable versus unacceptable levels of competence. RESULTS: The SPs' satisfaction showed a predictive power of 0.74 for the observers' assessment of the young doctors and whether they reached an acceptable level of communication skills. The SPs' dissatisfaction had a predictive power of 0.71 for the observers' assessment of an unacceptable communication level. The two assessment methods differed in 26% of the consultations. When SPs felt relief about their cancer concern after the consultation, they assessed the doctors' skills as satisfactory independent of the observers' assessment. CONCLUSIONS: Accordance between the dichotomized SPs' satisfaction score and communication skills assessed by observers (using the ACIR) was in the acceptable range. These findings suggest that SPs' satisfaction scores may provide a reliable source for assessing communication skills in educational programs for medical trainees (students and young doctors). Awareness of the patient's concerns seems to be of vital importance to patient satisfaction.

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa.

OBJECTIVES: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity-particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. METHODS: A decision analytical model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon (1) a study of pregnant women in Botswana, (2) literature reviews and (3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. RESULTS: Azithromycin was less costly and more effective than erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 in a population of 100,000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. CONCLUSIONS: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does-and at acceptable costs-especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people's health and even reduce healthcare budgets.

Continuous and integrated health care services in rural areas. A literature study.

This article presents the result of a literature review examining possible ways to improve healthcare services in rural areas. While there is abundant literature on making healthcare programs integrated, interdisciplinary and managed in order to reduce fragmentation and improve continuity and coordination of care, only some part of this relates to rural issues. An added challenge is the lack of a generally accepted international definition of rurality, which makes it difficult to generalise from one region to another, and to develop an evidence-based understanding of rural health care. In evaluating the literature it was found that the development of new forms of interaction is particularly relevant in rural regions - such as interdisciplinary and team-based work with flexibility of roles and responsibilities, delegation of tasks and cultural adjustments. In addition, programs such as integrated and managed care pathways, outreach programs , shared care and telemedicine were relevant initiatives. These may be associated with greater equity in access to care, and more coherent services with greater continuity, but they are not necessarily linked to reduced costs; they may, in some cases, entail additional expenses. Such endeavours are, to a large degree, dependent on a well-functioning primary healthcare system as a base.

Trichomoniasis and bacterial vaginosis in pregnancy: inadequately managed with the syndromic approach.

OBJECTIVE: To measure the prevalence of Trichomonas vaginalis (TV) infection and bacterial vaginosis (BV) among pregnant women in Botswana, and to evaluate the syndromic approach and alternative management strategies for these conditions in pregnancy. METHODS: In a cross-sectional study, 703 antenatal care attendees were interviewed and examined, and specimens were collected to identify TV, BV, Candida species, Chlamydia trachomatis and Neisseria gonorrhoeae. Information on reproductive tract infections earlier in pregnancy was obtained from a structured interview and the antenatal record. FINDINGS: TV was found in 19% and BV in 38% of the attendees. Three-fourths of women with TV or BV were asymptomatic. Syndromic management according to the vaginal discharge algorithm would lead to substantial under-diagnosis and over-treatment of TV and BV. Signs of vaginal discharge were more predictive of the presence of these conditions than were symptoms. Among the 546 attendees on a repeat antenatal visit, 142 (26%) had been diagnosed with vaginal discharge earlier in their pregnancy--14 of them twice. In 143 cases, an attendee was diagnosed with vaginal discharge in the second or third trimester; however, metronidazole had been prescribed only 17 times (12%). CONCLUSION: Diagnosis and treatment of TV and BV among pregnant women in sub-Saharan Africa presents major challenges. Half the pregnant women in this study were diagnosed with TV or BV, but these conditions were not detected and treated during antenatal care with syndromic management. Also, health workers did not adhere to treatment guidelines. These results indicate that management guidelines for TV and BV in antenatal care should be revised.

Hospital quality improvement in context: a multilevel analysis of staff job evaluations.

OBJECTIVE: To investigate how much of the variance in data on nurse evaluation of different aspects of hospital work can be attributed to individual, ward, department and hospital levels, and to discuss the implication of the findings on quality improvement strategies. DESIGN AND METHOD: National survey data of work experiences were collected from hospital nurses working at 124 hospital wards in 36 departments in 15 hospitals across Norway during the autumn of 1998. The multilevel structure of the variation of nine indices of job satisfaction was explored by fitting four-level random intercept models (nurse, ward, department and hospital). RESULTS: A total of 2606 nurses (66%) responded. The indices showed varying clustering to organizational units. Intraclass correlations (ICCs) varied from 0.05 to 0.38, representing considerable higher level variation. The ward level was the dominating level for the clustering of nurses' job aspect evaluations. CONCLUSION: Multilevel modelling of staff work experiences may identify which improvement goals can be addressed at which organizational level. Improvement efforts should be directed specifically towards each aspect of work and at its most relevant organizational level. Strategies aimed at the micro-organizational level (ward management) rather than the individual level or the macro level (hospital top management) might prove worthwhile.

Chlamydia and gonorrhoea in pregnancy: effectiveness of diagnosis and treatment in Botswana.

BACKGROUND: Millions of patients are prescribed drugs for sexually transmitted infections (STIs) in developing countries each year, yet the treatment effect of these prescriptions is largely unknown. OBJECTIVES: To determine if the prescribing of erythromycin and ceftriaxone to pregnant women with STI symptoms leads to a reduction in the prevalence among these women of chlamydia and gonorrhoea, respectively. METHODS: We compared the prevalence of chlamydia among 116 pregnant women who had been prescribed erythromycin for a history of STI symptoms in their current pregnancy with the prevalence in a control group of 557 pregnant women who had not been prescribed this drug. Similarly we compared the prevalence of gonorrhoea among 110 pregnant women who had and 561 women who had not been prescribed ceftriaxone. RESULTS: There was no significant difference in the prevalence of chlamydia among the women who had and the women who had not been prescribed erythromycin four times daily for 10 days (7% v 8%). Contrarily, none of the women who had been prescribed a single dose of ceftriaxone had gonorrhoea, whereas 4% of the women who had not had this drug prescribed did have gonorrhoea. CONCLUSIONS: The prescribing of erythromycin seems to have had a limited effect on chlamydia in this population, whereas the prescribing of ceftriaxone led to the curing of gonorrhoea. Ceftriaxone is provided as a single dose injection at the point of care, and the differential effectiveness between the two drugs may reflect low compliance with the complex erythromycin regimen. Interventions to increase compliance could improve cure rates. The use of a simpler drug regimen should be considered when low compliance is likely.

Structuring prescribing data into traffic-light categories; a tool for evaluating treatment quality in primary care.

BACKGROUND: Prescribing feedback based on aggregated data alone does not give the information needed to improve treatment quality. OBJECTIVES: Our aim was to develop a new method, or tool, of presenting prescribing feedback which, combined with guideline recommendations, makes it possible for doctors to judge their own prescribing as good or bad. METHODS: Asthma was chosen as a disease model, as treatment recommendations are readily available published as national and international guidelines. Four mean daily dosage intervals of inhaled short-acting beta-agonists and four mean daily dosage intervals of inhaled steroids were combined into a 4 x 4 matrix. This matrix of 16 combined dosage boxes was presented to 68 Norwegian GPs participating in peer review groups. As a first step, the GPs in the groups reached consensus on what they considered to be appropriate and inappropriate combined dosage intervals of these drugs based on national guideline recommendations and their joint clinical experience. Accordingly, traffic-light colours, green and red, were assigned to the combined dosage boxes in the matrix. Treatments in boxes difficult to judge were coloured yellow. During a 1-year period prior to the consensus meetings, the dispensed inhaled short-acting beta-agonists and inhaled steroids of each of the doctors' patients were recorded at the local pharmacies. As a second step in developing the new method, the number of patients treated within each of the coloured boxes was presented to the GPs in the peer review groups. These combined presentations provided an overview to the whole group, and individually to each GP, of how many patients were actually given appropriate or inappropriate treatment according to their own agreed upon standard. RESULTS: The GPs categorized 34% of 1122 evaluated patients receiving inhaled short-acting beta-agonists or inhaled steroids as treated inappropriately during the 1-year registration period. Appropriate treatment was given to 47% of the patients, and in 19% of the cases the treatment was difficult to evaluate. CONCLUSIONS: A method has been developed enabling GPs to categorize prescribing information into good (green), bad (red) and difficult to judge (yellow) treatment qualities, based on guideline recommendations and clinical experience. The actual prescribing data for each GP were labelled according to the same colour scheme, thus revealing to each GP his or her own actual prescribing compared with their own treatment standard, yielding information and motivation for quality improvement efforts.

Bacteriological findings in nasopharynx specimens from patients with a clinical diagnosis of acute sinusitis.

OBJECTIVE: To study results from bacteriological specimens from nasopharynx in patients with a clinical diagnosis of acute sinusitis in relation to CT findings. DESIGN: Prospective study. SETTING: Patients from general practice in Vestfold county, Norway. PATIENTS: 427 patients 15 years and older from two studies with a clinical diagnosis of acute sinusitis, and who were examined with coronal CT scans of the paranasal sinuses. Fluid level or total opacification of any sinus was taken as a hallmark of sinusitis. MAIN OUTCOME MEASURES: Bacteriological findings in nasopharynx specimens and proportions of various sinus pathogens in patients with and without sinusitis confirmed by CT. RESULTS: In the study, 252 patients had acute sinusitis and 175 patients did not. In the sinusitis groups, 27% of the patients had Streptococcus pneumonia, 12% had Staphylococcus aureus and 10% had Haemophilus influenzae in their nasopharynx specimens. Forty-five percent of the patients had normal nasal flora or no growth. The strains of Streptococcus pneumonia and Haemophilus influenzae showed high sensitivity to PcV, while the Moraxella strains were resistant to it. CONCLUSION: Streptococcus pneumoniae and Haemophilus influenzae were the most frequent sinus pathogens found in the nasopharynx specimens, and they were significantly more frequent in the group with confirmed sinusitis. The proportion of specimens with normal nasal flora or no growth was significantly higher in the non-sinusitis group.

[Local groups as a tool for quality assurance of community health services]. / Lokale grupper som verktøy for kvalitetssikring i kommunehelsetjenesten.

BACKGROUND: The aim of this study was to assess the use of local interprofessional or audit groups as a tool of quality enhancement. MATERIAL AND METHODS: Fifty-six doctors, physiotherapists and nurses attended nine local interprofessional groups. The aim was to improve the quality of each professional's practice and to improve communication between the professions. RESULTS: The groups had a total of 62 meetings with each professional attending on average 5.7 meetings. All groups initiated quality enhancement projects. Initially the groups were very active and showed great initiative, but there were few final results. However, many groups reported improved communication and cooperation between the participating professionals. INTERPRETATION: The experience from this project may be summarised as follows: The professionals within one and the same group should have more or less the same background and specialty. We recommend caution with organising interprofessional groups unless their participants work in the same practice. Interprofessional groups should spend adequate time for the members to get to know each other, and they should be guided by an experienced leader.

Self-efficacy and health status in rheumatoid arthritis: a two-year longitudinal observational study.

OBJECTIVE: To investigate the relationship between baseline level of self-efficacy for pain and other symptoms and changes in measures for similar dimensions of health status over a period of 2 yr in patients with rheumatoid arthritis (RA). METHODS: Data collected from patients with RA enrolled in a county-based disease register in Oslo, Norway were analysed: 815 patients were examined by mail questionnaire in 1994 and again in 1996. Relationships of the baseline level of self-efficacy and demographic variables with 2-yr changes in health status measures were examined by bivariate and multiple regression analysis. The following health status measures were included: pain and fatigue on a visual analogue scale; the patient's global assessment of disease activity; the symptom and affect scales of the Arthritis Impact Measurement Scales (AIMS2); and the bodily pain, mental health, general health and vitality scales of the Short Form-36 (SF-36). RESULTS: For all health status measures, there was a significant correlation between the change over a 2-yr span and baseline self-efficacy, even after adjustment for demographic variables and for the baseline level of the health status measure. Favourable changes were associated with high self-efficacy scores. CONCLUSIONS: In patients with RA, the baseline levels of self-efficacy for pain and other symptoms seem to influence 2-yr changes in health status measures regarding these aspects.

Involvement and satisfaction: a Norwegian study of health care among 1,024 patients with rheumatoid arthritis and 1,509 patients with chronic noninflammatory musculoskeletal pain.

OBJECTIVE: To investigate involvement in and satisfaction with health care among patients with rheumatoid arthritis (RA) and persons with chronic noninflammatory musculoskeletal pain, to identify target areas for improvement. METHODS: Data were collected from postal surveys carried out in 1994 in Oslo, Norway, with 1,542 patients with RA and 10,000 randomly selected adults. Patients with RA and persons with noninflammatory musculoskeletal pain were asked 3 questions about their involvement with treatment and 1 question about their satisfaction with health care. Levels of involvement and of satisfaction were related to demographic measures, health status measures, use of health services, and, for patients with RA, self-efficacy. RESULTS: Of the respondents with RA (n = 1,024), 40% scored low on at least 1 question on involvement and 11% reported global dissatisfaction. Being young, well educated, physically disabled, in good mental health, and self-efficient and having visited a rheumatologist in the last 12 months were associated with a high level of involvement; being female and having a low pain level, good mental health, and high self-efficacy were associated with satisfaction with health care. Of persons with noninflammatory musculoskeletal pain of more than 5 years duration (n = 1,509), 57% scored low on at least 1 question on involvement and 27% reported global dissatisfaction. Being well educated, having visited a general practitioner in the last 12 months, and having ever visited a rheumatologist were associated with a high level of involvement. Being older and having a low pain level and good mental health were associated with satisfaction. A low score on involvement was a strong independent predictor of global dissatisfaction in both groups. CONCLUSION: High education level and health service provided by rheumatologists were consistently associated with a high level of involvement. Good mental health and high involvement were associated with satisfaction with the care received. Efforts to achieve a higher level of patient involvement should especially be directed toward patients with low education, emotional distress, and a chronic physical disorder.

[Practice patterns, physicians' characteristics and patient-evaluated quality of general practice in Norway]. / Praksisform, legekarakteristika og pasientvurdert kvalitet i norsk allmennpraksis.

BACKGROUND: Norwegian general practice is a conglomerate of organisational forms. Studies of quality differences between types of practice have not been published. There is scant knowledge of how physician characteristics may influence patients' experience of the quality of care. MATERIALS AND METHODS: In this study of patient experiences with quality in primary care, we received answers to a questionnaire from more than 1,600 patients who had made office visits to 61 GPs working in 44 different practices. The patients expressed their opinion of the quality of medical-technical performance, doctor-patient relationship, information and support, accessibility and the organisation of general practice. Using multilevel analysis we compared solo-practices with group practices, and conventional types of practices with list-patient practices. RESULTS: No significant differences in patient experienced quality were found for different practices with traditional organisation. List-patient practices scored lower on quality than conventional practices, especially on accessibility and organisation. There were no significant differences in patient evaluation related to the doctor's gender. GPs with more than ten years in a practice were rated lower on quality than GPs with ten or fewer years of experience. INTERPRETATION: The way general practice is organised and the number of years the GP has worked in the same practice appear to influence how patients experience the quality of primary health care.

[Quality of general practice as experienced by patients]. / Pasientopplevd kvalitet i allmennpraksis.

BACKGROUND: The aim of the study was to explore the impact of feedback to general practitioners regarding patient evaluation of the quality of services rendered. MATERIAL AND METHODS: 1,614 patients in 41 general practices assessed the quality of care they had received during the last 12 months. The results for each practice were compared to the mean quality level of all the practices, and returned to the practice. This report was followed by a questionnaire to the GPs asking for their opinion of such feedback. Six of the GPs were also interviewed by telephone. RESULTS: The GPs welcomed patient quality evaluations and comparisons. However, they doubted that the feedback would lead to any action taken, as they had neither the time nor the energy to make changes in clinical performance or organisational structure. They questioned quality assessment by patients being an objective measure of quality. The GPs were willing to discuss the results in peer groups, but were reluctant to share the information with staff or patients. INTERPRETATION: The present study does not indicate that feedback given in the form of reports at practice level regarding patient assessed quality is an effective method for quality improvement.

[Guidelines for diagnosis and treatment of sore throat]. / Retningslinjer for diagnostikk og behandling av sår hals.

BACKGROUND: Available guidelines for the diagnosis and treatment of sore throat give conflicting recommendations. Our aim was to develop evidence-based guidelines. MATERIAL AND METHODS: We searched The Cochrane Library, Medline and other sources for systematic reviews and other evidence that met explicit inclusion criteria for all of the relevant options and outcomes we identified. The validity of included studies was assessed. Draft recommendations based on assessment of this evidence were widely circulated and discussed in focus groups with patients and physician assistants. RESULTS: Throat infections are self-limiting and complications rare. Penicillin shortens the duration of symptoms in tonsillitis caused by beta-haemolytic streptococci and reduces the risk of complications. Penicillin has adverse effects and increases the risk of reinfections. Patients with sore throat should usually be treated without antibiotics. Visiting a physician is normally unnecessary. Antibiotics should be considered in serious cases or if the patient prefers this, but should only be prescribed for throat infections caused by beta-haemolytic streptococci. The diagnosis should be based on clinical criteria and a rapid antigen test in cases of doubt. INTERPRETATION: Benefits of antibiotics must be weighed against harms. Patients should be given good information and involved in decision/making if they want antibiotics.

Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study.

BACKGROUND: It is difficult to put research findings into clinical practice by either guidelines or prescription feedback. AIM: To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups. METHODS: 199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments. MAIN OUTCOME MEASURE: Difference in the prescribing behaviour between the year before and the year after the intervention. RESULTS: Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group. CONCLUSIONS: Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.