How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care

2002 ◽  
Vol 7 (4) ◽  
pp. 202-208 ◽  
Author(s):  
Peter Davis ◽  
Barry Gribben ◽  
Roy Lay-Yee ◽  
Alastair Scott
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
General Practitioners ◽  
Office Visit ◽  
Clinical Activity ◽  
Upper Respiratory Tract ◽  
Components Of Variance ◽  
Multi Level ◽  
Level Analysis

Objectives: There is considerable policy interest in medical practice variation (MPV). Although the extent of MPV has been quantified for secondary care, this has not been investigated adequately in general practice. Technical obstacles to such analyses have been presented by the reliance on ecological small area variation (SAV) data, the binary nature of many clinical outcomes in primary care and by diagnostic variability. The study seeks to quantify the extent of variation in clinical activity between general practitioners by addressing these problems. Methods: A survey of nearly 10 000 encounters drawn from a representative sample of general practitioners in the Waikato region of New Zealand was carried out in the period 1991-1992. Participating doctors recorded all details of clinical activity for a sample of encounters. Measures used in this analysis are the issuing of a prescription, the ordering of a laboratory test or radiology examination, and the recommendation of a future follow-up office visit at a specified date. An innovative statistical technique is adopted to assess the allocation of variance for binary outcomes within a multi-level analysis of decision-making. Results: As expected, there was considerable variability between doctors in levels of prescribing, ordering of investigations and requests for follow up. These differences persisted after controlling for case-mix and patient and practitioner attributes. However, analysis of the components of variance suggested that less than 10% of remaining variability occurred at the practitioner level for any of the measures of clinical activity. Further analysis of a single diagnostic group - upper respiratory tract infection - marginally increased the practitioner contribution. Conclusions: The amount of variability in clinical activity that can definitively be linked to the practitioner in primary care is similar to that recorded in studies of the secondary sector. With primary care doctors increasingly being grouped into larger professional organisations, we can expect application of multi-level techniques to the analysis of clinical activity in primary care at different levels of organisational complexity.

Work Stress and Quality of Work Performance in Australian General Practitioners

2002 ◽  
Vol 8 (2) ◽  
pp. 59 ◽  
Author(s):  
Helen R. Winefield ◽  
Bronwyn M. Veale
Keyword(s):  
Primary Care ◽  
General Practitioners ◽  
Work Stress ◽  
Work Performance ◽  
Stress Indicators ◽  
Response Biases ◽  
Work Supports ◽  
The Relationship ◽  
Level Analysis

The relationship between work stress and work performance has received little empirical attention in professional areas such as health care where measurement of work quality is difficult. In health sciences there is growing concern about work errors, although little is known about the determinants and prevention of these in primary care. This study aimed to explore connections between workload, work stress in terms of burnout, job satisfaction and retirement age intentions, and reported mistakes at work, in general practice. A randomly-selected sample of mid-career General Practitioners (aged 35-45 years) was approached and 86% agreed to participate (N = 30). Satisfaction with work supports was a better predictor of work stress indicators than was workload. There was no evidence of the hypothesised association between work stress and severity of mistakes. Although response biases are a likely threat to the validity of mistakes as a quality indicator, results can be seen as supporting the need for a systems-level analysis of primary care work performance.

scholarly journals General practitioners referring patients to specialists in tertiary healthcare: a qualitative study

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Konstantinos Tzartzas ◽  
Pierre-Nicolas Oberhauser ◽  
Régis Marion-Veyron ◽  
Céline Bourquin ◽  
Nicolas Senn ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
General Practitioners ◽  
Care Center ◽  
Decision Making Process ◽  
Primary Care Center ◽  
Feedback Group ◽  
Clear Cut ◽  
Tertiary Healthcare ◽  
Complex Cases

Abstract Background There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners’ perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center. Methods Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results. Results Participating general practitioners distinguished two kinds of situations regarding referral: a) “clear-cut situations”, in which the decision to refer or not seems obvious and b) “complex cases”, in which they hesitate to refer or not. Regarding the “complex cases”, they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients’ emotions, earning specialists’ esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress. Conclusions General practitioners’ referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

Interactive Media for Diabetes Self-Management: Issues in Maximizing Public Health Impact

2010 ◽  
Vol 30 (6) ◽  
pp. 745-758 ◽  
Author(s):  
Russell E. Glasgow
Keyword(s):  
Public Health ◽  
Primary Care ◽  
Decision Making ◽  
Shared Decision Making ◽  
Interactive Media ◽  
Health Impact ◽  
Self Management ◽  
Public Health Impact ◽  
Shared Decision

Background . Diabetes self-management presents a series of challenging tasks, and primary care, where the majority of cases of adult diabetes are treated, is hard-pressed to address these issues given competing demands. This article discusses how interactive media (IM) can be used to support diabetes self-management. Methods . Following a brief review of the literature, the 5 As framework for enhancing the effectiveness of health behavior counseling and the RE-AIM model for estimating and enhancing public health impact are used to frame discussion of the strengths and limitations of IM for diabetes shared decision making and self-management support. Results . Data and lessons learned from a series of randomized trials of IM for diabetes self-management education are summarized around 2 key issues. The first is enhancing patient engagement in decision making and includes enhancing user experience and engagement, improving quality of care, and promoting collaborative action planning and follow-up. The second is getting such resources into place and sustaining them in real-world primary care settings and involves enhancing participation at patient, clinician, and health care system levels and enhancing the generalizability of results. Conclusions . Key opportunities for IM to support diabetes self-management include assessment of information for shared decision making, assistance with problem-solving self-management challenges, and provision of follow-up support. A key current challenge is the linkage of IM supports to the rest of the patient’s care, and collection of cost-effectiveness data is a key need for future research.

A survey of Australian general practitioners’ hepatitis C knowledge and management 2 years after subsidised direct-acting antiviral therapy became available

Sexual Health ◽  
2020 ◽  
Vol 17 (4) ◽  
pp. 387
Author(s):  
Michelle Gooey ◽  
Evelyn Wong ◽  
Alisa Pedrana ◽  
Nicole Allard ◽  
Joseph Doyle ◽  
...  
Keyword(s):  
Primary Care ◽  
Hepatitis C ◽  
General Practitioners ◽  
People Who Inject Drugs ◽  
Knowledge Score ◽  
Direct Acting Antivirals ◽  
Direct Acting Antiviral ◽  
Additional Support ◽  
Direct Acting

In 2016, hepatitis C direct-acting antivirals (DAAs) became available in Australia. A group of general practitioners (GPs) were surveyed twice to assess hepatitis C knowledge and management; 191/1000 (19.1%) responded at baseline, 164/938 (17.5%) at follow up. Participants’ mean Knowledge score increased: baseline 5.75 (95% CI 5.61–5.91), follow up 6.09 (95% CI 5.95–6.22; P <0.01). At follow up, 36/163 (22%) had prescribed DAAs compared with 23/187 (12%) at baseline (χ2(1) = 5.95, P = 0.02); however, 67/150 (45%) were unsure of treatment eligibility for people who inject drugs. Additional support for GPs is warranted to ensure optimal hepatitis C management in primary care.

Development of a New Encounter Decision Aid for Smoking Cessation (Preprint)

2021 ◽  
Author(s):  
Herul Holland Da Sa Neto ◽  
Ines Habfast-Robertson ◽  
Christina Hempel-Bruder ◽  
Marie-Anne Durand ◽  
Isabelle Jacot-Sadowski ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Smoking Cessation ◽  
Shared Decision Making ◽  
General Practitioners ◽  
Decision Aid ◽  
Tobacco Cessation ◽  
Decision Aids ◽  
Therapeutic Education ◽  
Shared Decision

BACKGROUND Smoking cessation is an essential part of preventing and reducing risk of smoking associated morbidity and mortality. However, there is often little time to discuss smoking cessation in primary care. Encounter decision aids, short, patient-facing decision aids used during clinic visits, optimize therapeutic education and increase interaction and the therapeutic alliance. Such a decision aid for smoking cessation could potentially improve counselling and increase the use of pharmacological treatments. OBJECTIVE We aimed to develop and test an electronic encounter decision aid (DA) that facilitates physician-patient interaction and shared decision making for smoking cessation in primary care. METHODS We developed a DA (howtoquit.ch) adapted from a paper version developed by our team in 2017 following user-centered design principles. The DA is a one page interactive website presenting and comparing medications for tobacco cessation and electronic cigarettes. Each smoking cessation medication has a drop down menu that presents additional information, a video demonstration, and prescribing information for physicians. To test the DA, a questionnaire was submitted to general practitioner residents of an academic general medicine department, five general practitioners, and five experts in the field of smoking cessation. The questionnaire consisted of 4 multiple-choice and 2 free text questions assessing the usability/acceptability of the DA, the acquisition of new knowledge for practitioners, the perceived utility in supporting shared decision making and patients' choices, perceived strengths and weaknesses and if they would recommend the tool to other clinicians. RESULTS Six residents, 3 general practitioners in private practice, and 2 tobacco cessation experts completed the questionnaire (n=11), and 4 additional experts provided open-text feedback. On the 11 questionnaires, the DA was rated as practical and intuitive (mean 4.6/5) and supported shared decision making (mean 4.4/5), as comparisons were readily possible. Inclusion of explanatory videos was seen as a bonus. Several changes were suggested like grouping together similar medications and adding a landing page to briefly explain the site. Changes were implemented according to the end users comments. CONCLUSIONS The overall assessment of the DA by a group of physicians and experts was positive. The ultimate objective is to have the tool deployed and easily accessible for all to use.

‘Unilateral’ decision making and patient participation in primary care

2012 ◽  
Vol 8 (2) ◽  
pp. 145-155 ◽  
Author(s):  
Taru Ijäs-Kallio ◽  
Johanna Ruusuvuori ◽  
Anssi Peräkylä
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Tract Infection ◽  
Respiratory Tract ◽  
Conversation Analysis ◽  
Treatment Decision ◽  
Decision Making Process ◽  
Upper Respiratory Tract ◽  
Upper Respiratory ◽  
Patients Acceptance

Using conversation analysis as a method, we examine patients’ responses to doctors’ treatment decision deliveries in Finnish primary care consultations for upper respiratory tract infection. We investigate decision-making sequences that are initiated by doctors’ ‘unilateral’ decision delivery (Collins et al. 2005). In line with Collins et al., we see the doctors’ decision deliveries as unilateral when they are offered as suggestions, recommendations or conclusions that make relevant patients’ acceptance of the decision rather than their further contributions to the decision. In contrast, more ‘bilateral’ decision making encourages and is dependent in part on patient’s contributions, too (Collins et al. 2005). We examine how patients respond to unilaterally made decisions and how they participate in and contribute to the outcome of the decision-making process. Within minimal responses patients approve the doctor’s unilateral agency in decision making whereas within two types of extended responses patients voice their own perspectives. 1) In positive responses they appraise the doctor’s decision as appropriate; 2) in other instances, patients may challenge the decision with an extended response that initiates a negotiation on the decision. We suggest that, firstly, unilateral decision making may be collaboratively maintained in consultations and that, secondly, patients have means for challenging it.

scholarly journals Much to do with nothing: microsimulation study on time management in primary care

BMJ ◽  
2018 ◽  
pp. k4983 ◽  
Author(s):  
Tanner J Caverly ◽  
Rodney A Hayward ◽  
James F Burke
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Shared Decision Making ◽  
General Practitioners ◽  
Preventive Care ◽  
Time Management ◽  
Clinic Visit ◽  
Shared Decision ◽  
Personal Time ◽  
Time Space

Abstract Objective To investigate the credibility of claims that general practitioners lack time for shared decision making and preventive care. Design Monte Carlo microsimulation study. Setting Primary care, United States. Participants Sample of general practitioners (n=1000) representative of annual work hours and patient panel size (n=2000 patients) in the US, derived from the National Health and Nutrition Examination Survey. Main outcome measures The primary outcome was the time needed to deliver shared decision making for highly recommended preventive interventions in relation to time available for preventive care—the prevention-time-space-deficit (ie, time-space needed by doctor exceeding the time-space available). Results On average, general practitioners have 29 minutes each workday to discuss preventive care services (just over two minutes for each clinic visit) with patients, but they need about 6.1 hours to complete shared decision making for preventive care. 100% of the study sample experienced a prevention-time-space-deficit (mean deficit 5.6 h/day) even given conservative (ie, absurdly wishful) time estimates for shared decision making. However, this time deficit could be easily overcome by reducing personal time and shifting gains to work tasks. For example, general practitioners could reduce the frequency of bathroom breaks to every other day and skip time with older children who don’t like them much anyway. Conclusions This study confirms a widely held suspicion that general practitioners waste valuable time on “personal care” activities. Primary care overlords, once informed about the extent of this vast reservoir of personal time, can start testing methods to “persuade” general practitioners to reallocate more personal time toward bulging clinical demands.

Association of teledermatology workflows with standardising co-management of rashes by primary care physicians and dermatologists

2020 ◽  
pp. 1357633X2093045
Author(s):  
Jennifer R Dusendang ◽  
Sangeeta Marwaha ◽  
Stacey E Alexeeff ◽  
Eileen Crowley ◽  
Michael Haiman ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Primary Care Physicians ◽  
Multivariable Analysis ◽  
Office Visit ◽  
Primary Care Visit ◽  
Kaiser Permanente ◽  
Care Visit ◽  
High Level

Introduction For patients with a rash, the effect of teledermatology workflow on utilization has not been defined. We compared utilization across four teledermatology workflows in patients with a rash. Methods The observational longitudinal cohort study included 28,857 Kaiser Permanente Northern California members with a new rash diagnosis seen in primary care and with dermatology advice obtained using teledermatology. The workflows differed in camera and image quality; who took the picture; how the image was forwarded; and synchronicity and convenience. Results On average, 23% of patients had a follow-up office visit in dermatology within 90 days of their primary care visit. In multivariable analysis, the four technologies differed substantially in the likelihood of a follow-up dermatology office visit. In contrast, the likelihood was only negligibly related to medical centre or primary care provider. Discussion Technologies and workflows that offer the mobility of a smartphone with a high level of synchronicity in communication were associated with standardised co-management of rashes.

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