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.

Running effective meetings: a primer for doctors.

This paper uses a series of exercises and practical examples to assist individuals and groups of doctors in training to gain skills in a critical area of management: conducting and participating in effective meetings. Through this paper, readers will be shown how to recognise and manage situations as they occur in meetings to work towards appropriate outcomes. By understanding the elements of conducting a meeting from preparation through to follow up, doctors will be able to conduct and participate more effectively in meetings that arise in their workplaces.

Conflict management: a primer for doctors in training.

Conflict in the health arena is a growing concern and is well recognised for doctors in training. Its most extreme expression, workplace violence is on the increase. There is evidence that many conflicts remain unsatisfactorily resolved or unresolved, and result in ongoing issues for staff morale. This paper describes the nature of conflict in the health care system and identifies the difference between conflict and disagreement. Using a conflict resolution model, strategies for dealing with conflict as it arises are explored and tips are provided on how to effectively manage conflict to a satisfactory resolution for all parties.

Co-morbidity in general practice.

BACKGROUND: Co-morbidity, or the presence of more than one clinical condition, is gaining increased attention in epidemiological and health services research. However, the clinical relevance of co-morbidity has yet to be defined. In general practice, few studies have been conducted into co-morbidity, either at a single health care encounter, an episode of care, or for a defined time period. AIMS: To describe the major co-morbidity cluster profiles recorded by general practitioners. Another aim of this study is to describe the common clusters of co-prescribing. METHODS AND RESULTS: Twelve month data from patients attending 156 GPs from 95 practices around a six month period of January to June 2003 were analysed. This represented 840,961 encounters from about 200,000 individual patients at these participating practices. Co-morbidity and co-prescribing cluster profiles are represented by problems managed and reasons for prescribing for the top 10 presentations and top 10 prescribed drugs in the study period. CONCLUSIONS: By analysing the 10 most prevalent problems and 10 most prevalent drugs prescribed in consultations in a community sample, other co-morbidities that are particular to general practice, for example hypertension and lipid disorders, can be uncovered. Whether these clusters are causally related or occur by chance requires further analysis.

The relationship between physician cost and functional status in the elderly.

OBJECTIVE: To explore the relationship between functional status and physician cost (general practitioner/specialist) in an elderly population. DESIGN, SETTING AND PARTICIPANTS: A longitudinal study involving 328 patients aged 65 years or over admitted to medical and surgical wards of a Sydney metropolitan hospital over a 10-month period. MAIN OUTCOME MEASURES: Two predictive cost models were developed using multiple linear regression analyses. Nine predictors were modelled including functional status (Short Form 36; SF-36) and major diagnostic categories. These models were then applied to the Australian SF-36 norms to produce a profile of cost by level of functioning. RESULTS: After adjusting for potential confounders, five variables were found to be predictive of general practitioner cost at a 5% significance level. Females and age were positively associated, whereas case note mention of post-discharge services and high SF-36 vitality and role emotional scores were negatively predictive. For specialist cost, five variables were statistically significant. The SF-36 domains of physical functioning and mental health were positively associated. Higher vitality, role emotional scores and case note mention of post-discharge services were negatively associated. CONCLUSIONS: Cost models can be used to highlight the differences between general practitioner and specialist attendances, guide future physician care of the aged, and facilitate informed decision making.

Functional status and health service planning.

Functional status indicators have been proposed as instruments to aid health service planning for patients. This study examines functional status at three points surrounding an acute health episode: admission, discharge and 3 months post discharge from a community hospital. The aim of the study is to determine the most appropriate time to measure functional status to assist health service planning. A longitudinal cohort study was conducted at Manly Hospital, Australia. Four hundred patients aged 65 years and over representing a 10% random sample of all hospital admissions in a 10-month period were interviewed on admission, discharge and 3 months post discharge. Repeated measure multiple analysis of variance identified a decline in functional status between admission and discharge. At 3 months post discharge functional status had improved to levels higher than admission. Functional status assessment at discharge can assist consumers, clinicians, health planners and health insurers to make effective decisions to maximize health outcomes.

Standardising health outcome measurements in general practice.

BACKGROUND: Outcome measures are gaining importance especially in areas such as divisions of general practice. The plethora of outcome measurements and the rhetoric surrounding this may make it difficult for doctors to decide the place of such measures in daily practice. An understanding of outcomes and their indicators is emerging as an essential requirement for good practice. OBJECTIVE: The aim of this paper is to propose a practical framework for describing health outcome measurements that may be applied to general practice. METHODS: This paper outlines the key features of outcomes measurements and proposes a model for understanding health outcome indicators using a set of indicators relevant to clinical practice. RESULTS: Pertinent to developing outcome terminology for use with patients in general practice are the four key features: a clear description of the indicator utility in practice comparability between practices endurance over time. CONCLUSION: To have reliability and validity and be able to deliver outcomes with practical and clinical significance, we need to be sure that the instruments we use are precisely defined. It is also important that the meaning is universally understood by all who might want to use the instruments. The product should also have cultural applicability beyond English. In clinical practice, the definition of the instrument aims not only to give the general practitioner a clear understanding of what is being measured but how it is used and the implications for its future use.

Guidelines for every person.

Guidelines, it is assumed in health care circles, have worth. In the ideal health care system they may offer everything from medical certainty to legal protection. They have the potential to save practitioners from the trauma of indecision and at the same time protect them from the consequences of wrong decisions. In this paper, I discuss the impact of guidelines on general practitioners and consumers. Both groups are at the effector end where guidelines should have maximal impact. It is primarily medical practitioners and their constituents in the long run that have to make guidelines work. Theoretical questions about the essential worth of guidelines for consumers and general practitioners are explored, as well as the more practical issues of utility of guidelines. My hypothesis is that guidelines may be conceptually worthwhile, but as yet are of unproven utility. This argument is traced through the literature surrounding the involvement of general practitioners and consumers in guideline development, implementation, review and relevance. From this information a new role for guidelines which is cogniscent of the needs and circumstances of the end users is postulated. Guidelines can become the basis for the principles of sound clinical practice which allow for the unique individual circumstances of clinical practice whilst also providing a consolidated basis for this practice.

The reliability and validity of work measurement in Australian general practice consultations.

OBJECTIVES: To examine the reliability of relative work value assessment in general practice consultations and to determine whether different methods of assessing work produce consistent rankings. DESIGN: Cross-sectional observational assessment of general practice consulations. SETTING: General practices in Victoria between October 1991 and October 1992. PARTICIPANTS: 686 patients attending one of 58 general practitioners (GPs) drawn from a random, stratified sample. METHODS: Each participating GP had one day of consultations videotaped. They rated the work value of each consultation by using a magnitude estimation scale relative to a reference vignette. Three GP observers independently applied the same scale to the videotaped consultations. After three months, the observers applied a second measurement of work value, a compensation scale (also relative to the reference vignette), to the videotaped consultations. Duration of consultation was the third rating method. MAIN OUTCOME MEASURES: The reliability of work value assessment for each scale. Consultation rank order correlation coefficients among all rating methods. RESULTS: Observer reliability was high for both scales. Practising GPs showed lower levels of reliability in assessing the work value of their consultations. Strong positive correlations were found for consultation rankings among the observer scales and duration of the consultation. The duration of the consultation emerged as an important predictor of consultation work value. CONCLUSIONS: Scaling methods appear to be of little value to the practising GP in reliably assessing the relative work value of their consultations; training in the use of these scales may improve their reliability. However, the duration of consultation may be a reasonable proxy for relative work value assessment in general practice consultations.

Consumer use of multiple general practitioners: an Australian epidemiological study.

The aim of this Australian study was to explore the reasons for peoples' choice of general practitioner (GP) in an environment where they have freedom of choice of doctor on every occasion of attendance. A questionnaire was administered by trained research assistants to 555 people during an hour-long interview. Utilization of more than one general practitioner was examined in terms of sociodemographic factors, health status and satisfaction with the last general practice visit. Respondents were more likely to see more than one general practitioner if they had more visits; were dissatisfied with their last consultation with a general practitioner; were younger; were female; and were highly qualified. Further, respondents who described good communication as the rationale for their satisfaction rating for their last general practitioner visit were less likely to have seen more than one general practitioner.

Community Health and Medical Practitioners Scheme: providers evaluate a pilot program of integration of services.

OBJECTIVE: To set up and evaluate a pilot scheme integrating salaried community health centre staff and fee-for-service medical practitioner services (CHAMPS). DESIGN: Preliminary interviews with both groups established the aims, logistics and financial arrangements of the project. The community health centre provided staff and the general practitioners provided premises and administrative services. Follow-up interviews evaluated the scheme and made recommendations. SETTING: A New South Wales country town, population 24,000, with 25 general practitioners and 23 community health centre professionals. RESULTS: Six general practitioners and 23 community health professionals determined the aims to be: improved access for patients to community health services; improved liaison between the two groups of providers; and a broadening of services offered at general practice locations. Two dietitians and three mental health workers were rostered for half a day per week in four general practices for six months. The dietitians continued after the project finished, but the mental health workers did not. The five community health staff, five of the general practitioners originally interviewed and six other general practitioner participants cited the major benefits as increased communication between providers and improved access for patients, and the major difficulties as lack of appropriate equipment and organisational logistics. CONCLUSIONS: The providers believe that the project succeeded in improving access to community health services and liaison between professionals. For future projects they recommended better communication, firmer role delineation and better planning for space and equipment.

General practitioner databases in Australia.

OBJECTIVE: General practitioner-based research has been hampered by the poorly defined database and the cost of continuous updating of lists of practitioners. Little is known about the general practitioner workforce. Fresh awareness by health planners of the serious maldistribution of general practitioners has heightened the need for workforce planning. Integral to this is the availability of an accurate listing of general practitioners. DATA SOURCES: A CD-ROM Medline review of all surveys involving general practitioners which were conducted in Australia in the period 1983-1990 was performed. All general practitioner listings still existing at the end of the decade were identified. STUDY SELECTION: Nine listings considered for use as general practitioner databases. DATA EXTRACTION: Each listing was assessed in six ways--quality of information provided, availability for research purposes, cost, potential to provide the correct postal address, ability to identify general practitioners in active practice and comparative advantage over other lists. DATA SYNTHESIS: Each listing has limitations and advantages, with individual peculiarities and variable information relating to identifying characteristics of general practitioners. None was specifically created for research or workforce planning purposes. The Medical Provider File (formerly called the Central Register of Medical Practitioners) was the most used list. CONCLUSIONS: We propose a framework for the ideal database and avenues for its development.

Older persons' definitions of good health: implications for general practitioners.

General practitioners are the major providers of health-care services for the older population in Australia. Care that is provided for older persons within the general-practice setting remains crisis-orientated. Nevertheless, many of the disabling health problems of older persons neither can be "solved" nor cured. Therefore, the older population is a unique population in which to study what constitutes good health and ways in which good health can be maintained. This article describes the perceptions of a group of older persons about their health. They define good health in a remarkably non-medical way. General practitioners need to take into account this knowledge when considering ways to improve the health of these patients.