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PubMed1993

Geriatric education and practice of family practice graduates: an alumni survey.

BACKGROUND: The goal of this research was to study the relationship between family practice residency training in geriatrics and subsequent postresidency geriatric practice patterns. METHODS: We surveyed all graduates of the University of Maryland Family Practice Residency Program through 1990 to determine their attitudes toward their geriatric training and the extent of their geriatric practice. Logistic regression analysis was used to identify factors associated with 1) making house calls, 2) making weekly nursing home visits, and 3) having a practice in which more than 25% of patients were older than age 65. RESULTS: The responses of 143 graduates were analyzed. Most respondents (58.8%) made house calls, and the majority (51%) saw nursing home patients weekly. Older respondents and those possessing Certificates of Added Qualifications in Geriatric Medicine (CAQGMs) were more likely to treat patients older than age 65. Respondents with larger nursing home practices rated their geriatric training more favorably. Multivariate logistic regression analysis found that the following factors were associated with making house calls: working in a group family practice (odds ratio [OR] = 3.88, 95% confidence interval [CI] = 2.58-5.84) and a rural practice location (OR = 2.71, 95% CI = 1.77-4.17). Physicians who had additional training after residency (OR = 0.16, 95% CI = 0.10-0.25) were less likely to make house calls. Factors associated with making weekly nursing home visits were: additional training after residency (OR = 0.31, 95% CI = 0.19-0.50) and working in a group family practice (OR = 2.43, 95% CI = 1.63-3.65). Attainment of a CAQGM was the only factor associated with having more than 25% geriatric patients in the office practice (OR = 6.00, 95% CI = 2.72-13.24). CONCLUSIONS: Most graduates of the University of Maryland Family Practice Residency Program maintain significant geriatric practices and value geriatric training, but whether favorable training experiences influence graduates' practices is unknown. Prospective studies of family practice residents are needed to clarify the influence of geriatric curricula on residents' future clinical practices.

Family Practice↗
PubMed1996

Uptake of cervical screening in general practice: effect of practice organisation, structure, and deprivation.

OBJECTIVES - To investigate associations between uptake for cervical screening in general practice and the organisation of screening, features of practice structure, and deprivation. SETTING - Greater Glasgow Health Board area in the west of Scotland, which covers a socioeconomically varied population. METHODS - General practice questionnaire survey and interview based study. The main outcome measure was the uptake rate for each participating practice over the five and a half years ending 31 December 1993. This was used to determine whether practices achieved 80% uptake to trigger maximum payment for cervical screening services. RESULTS - Forty seven percent (n = 92) of all practices in the Greater Glasgow Health Board area agreed to take part in the research, with complete data collected for 87 practices. Participation varied according to number of partners in the practice and the average deprivation score of the practice. Uptake rates ranged from 48-2% to 92-9% (median 77.5%, interquartile range 69.8% to 83.4%). Thirty seven practices (43%) achieved the 80% target. None of the recommended features of good organisation of cervical screening showed any statistically significant association with uptake rates. In stepwise multiple regression four variables were shown to have independent associations with uptake. These were the number of partners in the practice, the average deprivation of the practice, the presence of a female general practitioner, and using a practice's own lists for sending out letters of invitation. In stepwise logistic regression just two of these variables contributed to the prediction of achieving 80% uptake namely, average deprivation and number of partners. There were no significant interactions between deprivation and the organisation of screening in relation to uptake. CONCLUSIONS - Organising cervical screening in general practice according to accepted standards is less important in predicting uptake than more intractable features of the practice such as the size of the partnership, its average deprivation level, the presence of a female general practitioner, and using their own (presumed more accurate) register of addresses to call women. A flexible incentive scheme may more fairly reward the efforts of those general practitioners who achieve high uptake rates but who do not trigger remuneration at the 80% level.

Family Practice↗
PubMed2000

[Practice patterns, physicians' characteristics and patient-evaluated quality of general practice in Norway].

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.

Family Practice↗
PubMedDate not supplied

Family practice residents' decision making regarding future practice of obstetrics.

BACKGROUND: This study assesses the attitudes of family practice residents toward their future practice of obstetrics. The decline of family practice obstetrics has resulted in problems of access to care for many areas. METHODS: Questionnaires were sent to 30 family practice residency programs and were distributed to 353 2nd- and 3rd-year residents; the overall response rate was 85 percent. Respondents were asked to describe factors contributing to their decision whether to practice obstetrics. RESULTS: Seventy-two percent of the respondents indicated plans for future obstetrics practice. Reasons for choosing to practice obstetrics included personal interest, believing that obstetrics is an important part of family health care, and desire for diversity in practice. Primary concerns included interference with personal life, fear of lawsuits, and insurance premiums. Those deciding not to practice obstetrics cited interference with personal or professional life and desire for limited practice as deterrents. Important demographic variables predicting future practice included female sex, geographic location, and type of practice desired. CONCLUSION: This study portrays a resurgence in the percentage of family practice residents planning to practice obstetrics and discusses aspects of the training system that merit support to increase the number of family physicians providing obstetric care.

Attitude of Health Personnel↗
PubMed1996

Clinical practice arrangements of physician faculty in family practice residency programs.

BACKGROUND AND OBJECTIVES: This descriptive study sought information on the types of clinical practice arrangements and the nature of clinical responsibilities of full-time physician faculty in family practice residency programs. METHODS: A four-page, 37-item, self-administered questionnaire was sent to a 20% proportionate, systematic randomly sampled group of family practice faculty. Simple descriptive statistics were used for demographic and clinical practice data. Clinical practice characteristics were compared by the three most frequent clinical practice arrangements (private practice, on-site practice, and off-site practice) to determine differences. RESULTS: The majority of respondents were white, board-certified males. Most faculty saw patients two (26.9%) or three (27.7%) half days per week and between 6-10 (47.5%) and 11-15 (41.1%) patients per session. The most frequent clinical practice arrangements were having faculty see patients in their own private practice (5.3%), as part of the faculty practice in the residency program's health center (72.9%), and as part of the faculty practice remote from the residency program's health center (11.7%). There were no differences among the three arrangements with respect to clinical sessions per week, taking call at night to back up the resident on call, seeing patients outside of regularly scheduled office hours, making house calls, following patients in the nursing home, or offering pregnancy care. CONCLUSIONS: Further research is needed to determine the advantages and disadvantages of different clinical practice arrangements for the clinical skills and role-modeling ability of family physician faculty.

Adult↗
PubMed1996

Catchment areas in general practice and their relation to size and quality of practice and deprivation: a descriptive study in one London borough.

OBJECTIVE: To relate the sizes of general practice catchment areas in one London borough to list size, deprivation payments, medical staffing, and locally and nationally recognised measures of quality. DESIGN: Study of general practice catchment area maps. SETTING: London borough of Lambeth. SUBJECTS: 60 out of the 71 general practices in Lambeth. MAIN OUTCOME MEASURES: Practice catchment area size with corrections for numbers of doctors and patients. RESULTS: Catchment area size varied greatly between practices, showing an almost 150-fold difference between the largest and smallest practices. This size differential was even more marked when the size of the catchment area was corrected for the number of general practitioners in the practice, where a 300-fold difference was found. Substantial differences existed between practices in each of the four locally assigned quality bands. The weakest practices had catchment areas three times as large as those of the strongest practices. When corrected for medical staffing, the difference was eight times as great. A calculated measure of patient dispersion showed that the practice population of the strongest practices was four times as densely clustered as that of the weakest practices, whose patients were more widely geographically dispersed. CONCLUSIONS: Large variations exist in the size of catchment areas of inner city practices even when corrected for numbers of doctors and patients. These differences are associated with variations in quality of care.

Catchment Area, Health↗
PubMed1998

Structure and process: the relationship between practice management and actual clinical performance in general practice.

OBJECTIVES: The precise relationship between practice management (structure) and the doctor's actual performance (process) in general practice is tenuous. Analysis of their mutual relationship may yield insight into the way they contribute to outcome and into corresponding assessment procedures. METHOD: In a cross-sectional study, consultations of 93 GPs were videotaped in their own practice and assessed by peer-observers on medical performance and on communication with patients, followed by a practice visit by a non-physician observer using a validated Visitation Instrument to assess Practice management and organization (VIP). Pearson correlations (observed and disattenuated for unreliability of the instruments) between scores on 22 practice management dimensions and scores of 16 selected cases on medical performance and communication were calculated. The predictive value of specific practice management aspects for actual performance was determined by multiple regression analysis, with performance scores as dependent variables and scores on the 22 management dimensions and GPs' professional characteristics as independent variables. RESULTS: Nine practice management dimensions correlated significantly with medical performance and so did five dimensions with actual communication. Overall, most associations were weak. Combined with demographic variables (age for medical performance and working single-handedly for communication), 26% of variance in medical performance scores could be explained by only three practice management dimensions. One practice dimension (delegation of medical tasks to the practice assistant) explained 11% of variance in communication with patients. Organization of quality assessment activities explained most of the variation in medical performance. CONCLUSIONS: Practice management (structure) and actual performance (process) seem to be largely autonomous constructs. Quality improvement and assessment activities should emphasize that practice management is different from actual performance. Structure and process may contribute to patient outcome independently of each other.

Adult↗
PubMed2000

[Effectiveness and efficiency of ambulatory diabetes education programs. A comparison of specialty practice and general practice].

BACKGROUND AND OBJECTIVE: The increasing incidence of NIDDM requires adequate proof of the effectiveness and efficiency of out-patient programmes for diabetics. This study aimed at examining which of the two methods may promise the better results under controlled expenses--modifications of the present standardized diabetes education program in the general practice or specifically developed diabetes education programme in specialist diabetes practice. PATIENTS AND METHODS: 75 diabetics took part in the different out-patient diabetes education programmes at one special practice for diabetology or one of seven general practitioner practices, respectively. The self-developed intensive diabetes education programme of the special practice led by two specialists in diabetology and a dietician was compared with the diabetes education programme of the general practices performed by a doctor's assistant. 38 diabetics in eight training groups at the specialist for diabetology and 37 patients in seven training groups at the general practices were instructed. 32 patients in total (18 patients at the specialist practice and 14 patients at the general practices) additionally received an evaluated support programme which addressed psychosocial impediments related to the topics of a structured diabetes therapy. All patients were asked to complete a questionnaire before, right after, 3 and 6 months after the programme. Weight and glycosylated haemoglobin (HbA1c) were measured before, 3 and 6 months after the programme. RESULTS: The mean weight and glycosylated hemoglobin of all groups decreased as expected. However, the patients of the general practices achieved more lasting reduction of these objective parameters. All patients stated impairments of their quality of life, but the patients of the specialist practice felt more impaired. The motivational support programme achieved only few positive results. CONCLUSION: The standardized diabetes education programme of the general practices and the more intensive and expensive diabetes education programme achieved equally valuable results. Regarding time and expenses, the standardized diabetes education programme may be the more efficient method of NIDDM out-patient education.

Aged↗
PubMedDate not supplied

Practice-based preceptoral residency training in family practice.

BACKGROUND AND OBJECTIVES: Highly specific accreditation requirements have led to a uniform approach in US family practice continuity training. In this paper, we describe an experiment in practice-based preceptoral continuity training. METHODS: We assessed the impact of assigning a resident to a private faculty practice for the second- and third-year levels of family practice continuity training. Data analysis included comparisons of practice demographics, clinical content, training costs, and resident assessment of training quality. RESULTS: The preceptoral resident practice better approximated community demographic patterns than did the established residency practice. However, the preceptoral resident practice had relatively fewer visits for hypertension and diabetes mellitus than did the established residency, preceptoral site faculty, and National Ambulatory Medical Care Survey practices. Resident training at the preceptoral site resulted in a positive training expense differential of $69,300 calculated on an annual per third-year resident basis. The preceptoral resident expressed high levels of satisfaction with the quality of family practice center training. CONCLUSIONS: Practice-based preceptoral continuity training in family practice appears feasible in terms of clinical content exposure and may offer substantial financial advantages. Important questions remain, particularly about the quality of teaching and supervision in a preceptoral training model.

Family Practice↗
PubMed1997

Defining the practice population in fee-for-service practice.

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.

Adolescent↗
PubMed1975

The orginization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings.

Data are presented on office-based general practitioners and pediatricians working in varying practice settings. Fee-for-service physicians spend more time in direct patient care activities than those in prepaid practice, and devote more time to each patient. The data suggest that the patient load characteristic of general practice in prepaid groups encourages a more assembly line practice which is less responsive to patients than the pattern characteristic of fee-for-service practice. Prepaid physicians work during scheduled hours and may deal with increased load by processing patients more rapidly. Fee-for-service physicians tend to respond to increased demand by working longer hours. The responsiveness of primary care physicians to patient problems seems to reflect primarily their social orientations to medical practice and the time pressures they face. Varying practice settings result in different techniques of coping with the pressures of practice. Data are also presented on sociodemographic and professional characteristics of primary care physicians in varying settings, workload, use of diagnostic and laboratory procedures, social orientations to medical practice, satisfactions and dissatisfactions, and attitudes toward sociopolitical aspects of medical care. Suggestions are offered for improving the responsiveness of prepaid practice.

Adult↗
PubMedDate not supplied

From good medical practice to best medical practice.

Medical and other professionals know what good practice is. It is in accordance with ideal procedures and standards of one's own practice. As actors we assess our practices from inside. If questions of quality assessment or quality assurance are raised at all, they are to be raised and answered by the professionals themselves. From that internal perspective, the idea of better or best medical practice is rejected as superfluous; or, perhaps, even nonsensical. This article suggests that concepts of best medical practice, as expressed from outside the profession e.g. economic efficiency, are not adequate in themselves if our interest lies in changing existing practice. Defined from outside, such concepts would be alien to the medical profession. Going from good practice to best practice, the article proposes, can be done on the basis of expanding the metaphor of self-transcendence. In self-transcendence the individual or profession changes or develops strategies and activities by adopting the standpoint of some perspective outside its own practice, and then integrating this perspective into practice. Self-transcendence by the medical profession can be carried out by their integrating a moral ideal from normal life into professional practice-essentially the notion of prescribing support of the weak. Such integration implies, inter alia, that the profession must take account of the scarcity of resources when assessing their practice.

Clinical Medicine↗
PubMed1994

Beyond reflection: practical wisdom and the practical syllogism.

The relationship between the way nurses think and the actions they perform is one of the key debates within the nursing profession. It has been assumed that the thinking that precedes and follows nursing actions has been described within the reflective practitioner doctrine. It is suggested that this is not so, as the reflective doctrine has not only failed to explicate the link between theory and practice but some reflective theorists have perpetuated the theory-practice gap by separating thought and action. Instead it is argued that Aristotle's conceptions of Practical Wisdom and the Practical Syllogism provide a framework in which the link between thinking and doing are described. Practical wisdom is a form of knowledge that can be claimed by those who purport to deal with human good. Unlike theoretical knowledge, practical wisdom ends not in an intellectual conclusion but in the actual performing of some action designed to produce good for fellow humans. These actions are taken only after the practically wise person decides, consciously or unconsciously, the most effective and morally right option. The practical syllogism is that particular feature of critical thinking that links theory and practice in practice professions. The practical syllogism describes the means-end considerations that underpin all actions undertaken by nurses. It is not suggested that all the deliberations of those with practical wisdom is syllogistic in nature but that this is a central feature of the way in which nurses approach the care they deliver.

Humans↗
PubMedDate not supplied

Advanced practice nursing role delineation in acute and critical care: application of the strong model of advanced practice.

PURPOSE: This purpose of this study was to differentiate between the roles of clinical nurse specialists and acute care nurse practitioners. BACKGROUND AND SIGNIFICANCE: Hypothesized blending of the clinical nurse specialist and acute care nurse practitioner roles is thought to result in an acute care clinician who integrates the clinical skills of the nurse practitioner with the systems knowledge, educational commitment, and leadership ability of the clinical nurse specialist. Ideally, this role blending would facilitate excellence in both direct and indirect patient care. The Strong Model of Advanced Practice, which incorporates practice domains of direct comprehensive care, support of systems, education, research, and publication and professional leadership, was tested to search for practical evidence of role blending. METHODS: This descriptive, exploratory, pilot study included subjects (N = 18) solicited from an academic medical center and from an Internet advanced practice listserv. Questionnaires included self-ranking of expertise in practice domains, as well as valuing of role-related tasks. Content validity was judged by an expert panel of advanced practice nurses. RESULTS: Analyses of descriptive statistics revealed that clinical nurse specialists, who had more experience both as registered nurses and in the advanced practice nurse role, self-ranked their expertise higher in all practice domains. Acute care nurse practitioners placed higher importance on tasks related to direct comprehensive care, including conducting histories and physicals, diagnosing, and performing diagnostic procedures, whereas clinical nurse specialists assigned greater importance to tasks related to education, research, and leadership. CONCLUSIONS: Levels of self-assessed clinical expertise as well as valuing of role-related tasks differed among this sample of clinical nurse specialists and acute care nurse practitioners. Groundwork has been laid for continuing exploration into differentiation in advanced practice nursing roles. IMPLICATIONS: As the clinical nurse specialist role changes and the acute care nurse practitioner role emerges, it is imperative that advanced practice nurses describe their contribution to health care. Associating advanced practice nursing activities with outcomes will help further characterize these 2 advanced practice roles.

Adult↗
PubMed1994

Towards better practice management: a national survey of Scottish general practice management.

Surveys a 50 per cent sample of Scottish practices (stratified by health board area), concerning whether they had a practice manager and who had responsibility for practice management tasks. The overall response rate was 73 per cent, with 63 per cent of responding practices employed a practice manager. Reports the findings from practices employing a manager, and reveals marked variations in levels of managers pay and responsibility. The development of practice management structures varied with only 85 per cent of practices holding regular practice management meetings. The results suggest that practices which previously coped without a manager have recognized the need for one as the complexity of practice administration increases and that the traditional career path of managers involving internal promotion is changing.

Administrative Personnel↗
PubMed1996

Understanding practice management: a qualitative study in general practice.

Reports a qualitative study of practice managers' roles and responsibilities in eight practices in the Grampian region of Scotland. Observes wide variations in the roles and responsibilities of managers associated with the size and fundholding status of the practice. Notes that larger practices had better developed management structures allowing the managers to delegate tasks and undertake a more proactive planning and executive role, and that medium and smaller practices had less well developed management structures and managers were more likely to act as practice administrators with limited autonomy. Concludes that practice managers are playing an increasingly important role in general practice. Also that the influential role of the practice manager in the development of practice policies and the transfer of administrative responsibilities from the partners to the manager have all contributed to a change in general practitioners' perceptions of the practice manager.

Administrative Personnel↗
PubMed1996

Why don't all general practices offer structured diabetes care? A comparison of practices that do not with those that do.

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.

Diabetes Mellitus↗
PubMed1993

General practice workload during normal working hours in training and non-training practices.

The aim of this study was to design and test a form to review workload in training and non-training practices. The study was conducted in the Oxford, Reading and Milton Keynes districts over a period of one week and involved 31 training and 21 non-training practices consisting of 156 and 66 doctors, respectively. Doctors in training practices (excluding trainees) spent a mean of one hour less per week in contact with their patients than doctors in non-training practices. Doctors in training practices spent approximately the same time per week on administration as those in non-training practices, one hour more in both meetings and non-practice work and almost two hours more in training and studying. The mean total practice workload per doctor in training practices was two hours more than in non-training practices and, when non-practice work was included, the difference increased to three hours. Compared with other doctors, trainees saw fewer patients in the surgery, in clinics and on visits, but spent more time on studying and training. This study produced broadly similar results to previous surveys, although doctors in the present study saw fewer patients each week and spent more time with each patient than in other studies.

Data Collection↗