The epidemiology of serious adverse drug reactions among the elderly.

Although the incidence and prevalence of serious adverse drug reactions (ADRs) in the elderly cannot be accurately stated, published estimates appear to be unchanged since the earliest reports in the 1960s. Whereas heightened awareness of the problem may weigh in favour of a reduction in ADR frequency, the dramatic increase in the number and availability of therapeutic agents has undoubtedly contributed to the observed high proportion of drug-induced morbidity among acute geriatric hospital admissions. No single drug or drug class is of particular concern since none appears to cause serious morbidity out of proportion with its use. Although numerous studies have sought to identify risk factors for ADRs, the only truly independent predictor is the absolute number of concurrently used medications. However, other studies indicate that there is poor doctor-patient agreement regarding a patient's drug regimen, and interventions that aim to reduce the incidence of ADRs have failed to demonstrate a positive effect. Thus at present the most rational approach would appear to be to establish an accurate knowledge of the patients drug regimens: once this is known one can attempt to rationally minimise the number of medications without compromising therapeutic goals.

Improving educational needs assessment for general practitioners.

OBJECTIVE: To improve the quality of educational needs analysis for groups of general practitioners through the development of a range of simple, inexpensive practice based performance measures of general practice. METHOD: Members of one volunteer semi rural division of general practice were allocated randomly to groups that collected or provided data on: local referral patterns; consulting, prescribing and ordering, as collected by the Health Insurance Commission; and age, gender, reasons for encounter and management of a sample of patients. Other information was provided by a recent division community needs analysis, a consumer survey, national health targets and local health professionals. These data were combined to develop a list of educational topics that deserved attention. RESULTS: A total of 56% of GPs agreed to participate, providing Health Insurance Commission data for seven GPs, referral patterns for 11 GPs and BEACH surveys for five GPs. Much of the data collected for other purposes proved to be of little value in determining specific educational needs and the more time consuming methods attracted poor participation rates. The most useful data were those collected locally by the division. CONCLUSION: Educational needs analyses for groups of GPs should consider the perspectives of the profession, funders and patients, in addition to those of individual GPs. Practice based measures of GP performance need to be made more relevant to current practice, while remaining inexpensive and not intruding too much into GPs' time. A range of potential measures is provided.

A comparison of a hospital outpatients department and general practice in remote Queensland.

A survey of all ambulant patients attending the hospital outpatients' department and the private general practice in a remote town in Queensland sought information on patients' reasons for attending. Patients handed the completed questionnaires to their practitioner, who indicated the type of visit and the focus of the encounter. There was little difference between the facilities in terms of patient demographics, except that males accounted for a higher proportion of encounters at the Outpatients' Department (OPD), mainly as emergency encounters. Excluding emergency encounters, patients appeared to perceive the facilities as alternative practices. The practitioners' reports suggested some differences in practice and/or experience between the two facilities, which were in line with commonly held perceptions about OPD and private general practice. The data suggest that the similarities between the two facilities may outweigh the differences. Moreover, the differences between rural hospital practice and rural general practice should be seen as providing the opportunity for more rounded training, rather than mutually exclusive forms of practice.

Methodological issues in medical workforce analysis: implications for regional Australia.

Medical workforce data have a profound impact on health policy formulation, but derived doctor population ratios (DPR) are often more relevant to plotting national trends than providing a detailed regional or local workforce perspective. Regional workforce data may be more useful if national approaches are augmented by local information. In developing a detailed workforce analysis for one region of Australia, the authors encountered several challenging methodological issues, including the accuracy of medical workforce databases, clarity of definition of community boundaries, interpretation of workforce definitions and the difficulty accounting for local community needs. This paper discusses the implications for regional workforce research.

Why doctors leave rural practice.

Retention of rural doctors remains difficult because of complex factors that influence decisions of medical families. This study explores the reasons why Queensland rural doctors left their communities during 1995. Semi-structured interviews were conducted with contactable former rural doctors who claimed that they had entered rural practice with the intention to stay for a substantial period of time. The interviews were audiotaped, transcribed and analysed using NUD.IST software. Participants appeared to be subject to a dynamic balance between opposing pressures to stay and pressures to leave. In time, they became susceptible to 'triggers' to leave. These triggers were sometimes locality-specific and could be difficult to address, particularly without early intervention. We believe that it should be possible to develop strategies that address specific concerns of rural doctors, particularly if they are identified early. The optimum period of stay in rural practice should be reconsidered, such that moderate stays should be rewarded in a way that retains the doctors in some form of rural, or near-rural practice.

Barriers to the use of urban medical services by rural and remote area households.

People from rural and remote areas commonly need to attend provincial and metropolitan cities for specialist care. There decisions to make such trips 'away' involve a number of non-medical considerations that include economic, emotional and social factors. This paper reports the results of two surveys that sought information about the types and importance of non-medical considerations taken into account by rural and remote Queensland householders when faced with a trip away. In addition, the problems encountered by respondents on their last trip away are reported and discussed. The data revealed that important considerations taken into account when planning the trip were predominantly related to urgency, household organisation and the costs likely to be incurred where away. A number of avoidable problems occurring at destination were also described. Generally, remote area respondents saw these impediments as more serious barriers to seeking care than did rural area respondents. When respondents were further asked to identify major problems associated with their last trip to an urban facility, problems at the destination figured more prominently, particularly problems directly related to the lack of understanding of the transport and distance needs of rural people. With one exception, these problems were reported by similar proportions of rural and remote area respondents. These are matters that merit high priority attention in any programs to enhance access to specialist medical services by people in rural and remote areas.

A comparison of patient-reported reasons for encounter and provider-reported diagnoses.

People attending the general practices and hospital OPDs in two rural Queensland towns were asked, before receiving care, to indicate why they were seeking care. The consulting providers reported the outcome of the encounter. Using ICPC Components and Chapters patient and provider reports were compared to assess the level of agreement between same, in order to determine the nexus between patient perceptions and provider diagnoses. Patients tended to report signs and symptoms in preference to specific diagnoses, for both first and follow-up visits. Good concurrence between patient and provider reports were recorded in those Chapters in which conditions commonly had obvious signs and symptoms and relatively high follow-up rates. 'Psychological' conditions were an exception in this regard, suggesting that patient reports are unreliable for such conditions. Patient and provider reports should be seen as different aspects of health care, and therefore should not be used as corollaries of each other. Researchers need to be clear about which perspective is required--that of the patient or the provider--in exploring the content of clinical encounters. Provider reports do not reflect the triggers (perceptions) which persuade patients to seek care.

The development of a method for measuring anticipated illness behaviour in three common injuries.

This note outlines the rationale, development and validation of three injury scenarios as objective measures of anticipated illness behaviour. The measures were originally developed to consider differences in illness behaviour with distance from medical services in rural and remote areas of Queensland, Australia. However, the measures have a more universal applicability than the purpose for which they were developed. Unlike other measures of illness behaviour, the scenarios each incorporate a number of progressively worsening stages which permit the mapping of changes in individual or group behaviour. By working through conditions stage by stage, the likelihood of individual variations in interpretation of condition severity is greatly reduced and so a better understanding of people's responses to these conditions is obtained. In a survey of 800 rural households, each scenario met the proposed criteria of: (i) increasing urgency of action with increasing condition severity; and (ii) increasing agreement about urgency of action with increasing severity. The fractured limb scenario was perceived by respondents (in terms of urgency and agreement about type of action) as the most serious condition. There was little difference in perceived seriousness for the other two conditions.

Anticipated response to three common injuries by rural and remote area residents.

Three progressively worsening injury scenarios were used to determine the influence of distance from medical services on the anticipated illness behaviour of rural and remote area residents. A total of 801 householders were interviewed in two rural areas of Queensland, Australia (320 in a coastal area and 481 in an inland area). There was a consistent trend with distance of decreasing willingness to seek immediate care at each injury stage. As the severity of each scenario increased, there was a convergence in anticipated action. Inland area respondents were less likely to seek medical care at each stage of the injuries than coastal area respondents. Distant respondents were more likely to telephone for medical advice before seeking care. When this was taken into account, there was less difference in anticipated action by distance, although those further from medical services still indicated a propensity to delay action in the less serious injuries.

General practice procedural skills.

In 1988 a self reported competency survey of Queensland interns was undertaken in the final months of their pre-registration year. The survey revealed that 24 of 46 essential procedural skills for general practice had been performed alone by 80 per cent or more of interns. Eleven of the remaining 22 procedures had been performed under supervision by at least 80 per cent of the respondents. There were four procedures that had been performed by fewer than half the respondents.

Competency of medical students in general practice procedural skills.

A self-reported competency survey of 1988 sixth year medical students in Queensland revealed that only 2 of 47 procedural skills considered essential for general practice had been performed alone by 80 per cent or more of students. Six of the essential skills had not been performed by more than 80 per cent of students. Consideration needs to be given to the content and effectiveness of undergraduate general practice procedural skills training.

Analysis of the RACGP Fellowship examination results.

The FRACGP examination assesses a candidate's performance in five behavioural attributes--knowledge, interpretation, problem solving, affective behaviour and psychomotor skills. These attributes were used as the basis for comparing the performance of various groups of candidates in the examination.

How do patients identify their drugs?

This survey conducted by FMP trainees in Queensland describes how general practice patients on long term, self administered medications identify their drugs. Trade names are by far the most common means of identification. Generic names and identification by action, colour, and shape and common usage names are less frequently used. Knowledge of alternative trade and generic names is sparse, emphasising the need to inform patients fully of any changes to the brand names of their drugs.