Predictors of the quality of care for asthma in general practice: an observational study.

BACKGROUND: Asthma is a common and important health condition in the UK, predominantly managed in primary care. Little is known about how characteristics of practices and patients are associated with achievement of quality indicators (QIs) for asthma. OBJECTIVE: To measure the recorded quality of primary care for asthma and to assess whether quality of care differed by patient and practice characteristics. METHODS: Medical records were examined for 253 randomly selected asthma patients from 18 general practices in England. Quality of care was assessed against seven predetermined QIs. Logistic regression models were used to test variations in quality of care by age, gender, patient postcode deprivation rank, practice size and time point. RESULTS: There was substantial variation in achievement of individual QIs (range 39-97%). Participants whose postcodes were in the most deprived areas were more likely to be asked about difficulties sleeping [odds ratios (ORs) 1.7, 95% confidence interval (CI) 1.2-2.5] or whether asthma interfered with daily activities (OR 1.8, CI 1.2-2.7) than those from middle or least deprived postcode areas. QIs were more likely to be achieved in 2005 than 2003 (ORs 4.4, 2.4, 3.0). There were no significant differences by other characteristics. CONCLUSIONS: Great variations exist in the quality of primary care for asthma and considerable scope for improvement. Asthma care improved over time. The preliminary findings that quality of asthma care varied with deprivation support the idea that primary care may be targeting care to those in most need. However, variations were small and only significant for two QIs.

Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study.

OBJECTIVE: To gain understanding of general practitioners' and patients' opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. DESIGN: Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. PARTICIPANTS: 34 general practitioners and 24 patients. SETTING: 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. RESULTS: Patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment ("phronesis") to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. CONCLUSIONS: Despite general practitioners' caution about measures of severity for depression, these may benefit primary care consultations by increasing patients' confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires.

Management of depression in UK general practice in relation to scores on depression severity questionnaires: analysis of medical record data.

OBJECTIVE: To determine if general practitioner rates of antidepressant drug prescribing and referrals to specialist services for depression vary in line with patients' scores on depression severity questionnaires. DESIGN: Analysis of anonymised medical record data. SETTING: 38 general practices in three sites-Southampton, Liverpool, and Norfolk. Data reviewed Records for 2294 patients assessed with severity questionnaires for depression between April 2006 and March 2007 inclusive. MAIN OUTCOME MEASURES: Rates of prescribing of antidepressants and referrals to specialist mental health or social services. RESULTS: 1658 patients were assessed with the 9 item patient health questionnaire (PHQ-9), 584 with the depression subscale of the hospital anxiety and depression scale (HADS), and 52 with the Beck depression inventory, 2nd edition (BDI-II). Overall, 79.1% of patients assessed with either PHQ-9 or HADS received a prescription for an antidepressant, and 22.8% were referred to specialist services. Prescriptions and referrals were significantly associated with higher severity scores. However, overall rates of treatment and referral were similar for patients assessed with either measure despite the fact that, with PHQ-9, 83.5% of patients were classified as moderately to severely depressed and in need of treatment, whereas only 55.6% of patients were so classified with HADS. Rates of treatment were lower for older patients and for patients with comorbid physical illness (including coronary heart disease and diabetes) despite the fact that screening for depression among such patients is encouraged in the quality and outcomes framework. Conclusions General practitioners do not decide on drug treatment or referral for depression on the basis of questionnaire scores alone, but also take account of other factors such as age and physical illness. The two most widely used severity questionnaires perform inconsistently in practice, suggesting that changing the recommended threshold scores for intervention might make the measures more valid, more consistent with practitioners' clinical judgment, and more acceptable to practitioners as a way of classifying patients.