Community General Practitioners Research Articles

Survey on continuing medical education needs for general practitioners in community

One hundred and seventeen general practitioners from five community health service centers in Shanghai Pudong, Baoshan, Minhang, Jing'an and Luwan Districts were randomly selected for survey. The current situations, the intention and the related factors in GP continuing were surveyed by using self-designed questionnaire. The survey showed that the rate of continuing was 73.5%, which was lower than the requirements of the Ministry of Health. There were significant differences in motivation (for credit and promotion ), training needs ( doctor and patient communication or basic theory ), training mode ( on-line education or short term study ), and teaching methods ( classroom lecturing or PBL ) among GPs with different length of service (all P<0.05). The results indicate that to improve the quality of continuing medical for GPs in community it is necessary to strengthen supervision, broaden the training channels to meet the different needs of general practitioners. Key words: General practitioner; Education, continuing

Antibiotics Dispensing for URTIs by Community Pharmacists and General Medical Practitioners in Penang, Malaysia: A Comparative Study using Simulated Patients

In Malaysia, doctors in private clinics (often called dispensing doctors) are permitted to dispense medicines. This potentially may compromise rational dispensing of medicines in general and antibiotics in particular. This study explored, assessed and compared dispensing of antibiotics between Community Pharmacist (CP) and General Practitioners (GPs) regarding symptomatic diagnosis, antibiotic categories, adherence to therapeutic doses and promotion of generic antibiotics. The study used trained Simulated Patients (SPs), who used a scenario of common cold symptoms at GP private clinics and community pharmacies to observe and explore the practice of antibiotics dispensing. The study was conducted within the period of May to September 2011 in Penang, Malaysia. The data was analysed using descriptive statistics, Chi-square and Fisher's Exact Tests at alpha level of 0.05. GPs dispensed more antibiotics than CPs (p= 0.001) for common cold symptoms. They dispensed more Amoxicillin (n = 14, 35%) than CPs (n = 11, 11%) (p < 0.001) and more Tetracycline (n = 3, 7.5%) while no CP dispensed this category (p = 0.022). On the other hand, CPs (n = 11, 11%) suggested brand antibiotics where as GPs dispensed only generic antibiotics (p < 0.001). Generally GPs comply better with the symptomatic diagnosis standard e.g. when asking SPs about the symptoms they had, all GPs (n = 40, 100%) complied better with this standard. Despite that, they dispensed more antibiotics (n = 26, 65%) than CPs (n = 29, 29%) (p = 0.001). GPs (n = 22, 55%) also are better than CPs (n = 16, 16%) in adherence to therapeutic doses (p< 0.001). Findings showed poor adherence to rational dispensing of antibiotics by both providers. Although, GPs adhere better to symptomatic diagnosis and therapeutic dosing of antibiotics than CPs, they unnecessarily prescribe and dispense more antibiotics for Upper respiratory tract infection (URTI) symptoms. Establishing prescription guidance and regulatory actions, especially for URTIs treatment, and separating of medication dispensing are seemed to be crucial steps for the reform.

Effect of clinical competence training for general practitioners and influencing factors

Objective To evaluate the effect of clinical competence training for general practitioners in Shanghai. Methods Total 759 general practitioners participated in clinical competence training from July 2011 to October 2012 in Shanghai. The theoretical and practical operation scores of all the 759 trainees were compared before and after the training and the influencing factors of training effect were analyzed. Results The trainees, including 260(34.26%) males and 499 (65.74%) females, had average working experiences (13.6±7.1) years. The average total scores before and after training were(67.40±8.57)and (73.61±7.20) (t=17.96, P<0.01). The practical operation scores were improved more significantly, the average scores of physical examination before and after training were (12.90±3.76) and (14.00±3.51), scores of clinical skill before and after training were (9.41±4.80) and (13.40±4.02) (t=6.31 and 19.01, P<0.01). Among seven items of physical examination test, scores of four items(cardiopulmonary examination, abdominal examination, neurological examination and thyroid examination) were significantly higher than those before training (P<0.05 or <0.01). Scores of all 7 items of clinical skill test were higher than those before training (P<0.01). The main factors influencing the effect of training were gender, educational background, score before training and type of practice (P<0.01 or <0.05). Conclusions The clinical competence of general practitioners can be improved after the training. The training contents should be optimized in consistent with conditions of community health and general practitioners in the future. Key words: General practitioner; Training; Clinical competence

Evaluation of health care providers’ role transition and satisfaction in hospital-at-home for chronic obstructive pulmonary disease exacerbations: a survey study

BackgroundHospital-at-home is an accepted alternative for usual hospital treatment for patients with a Chronic Obstructive Pulmonary Disease (COPD) exacerbation. The introduction of hospital-at-home may lead to changes in health care providers’ roles and responsibilities. To date, the impact on providers’ roles is unknown and in addition, little is known about the satisfaction and acceptance of care providers involved in hospital-at-home.MethodsObjective of this survey study was to investigate the role differentiation, role transitions and satisfaction of professional care providers (i.e. pulmonologists, residents, hospital respiratory nurses, generic and specialised community nurses and general practitioners) from 3 hospitals and 2 home care organisations, involved in a community-based hospital-at-home scheme. A combined multiple-choice and open-end questionnaire was administered in study participants.ResultsResponse rate was 10/17 in pulmonologists, 10/23 in residents, 9/12 in hospital respiratory nurses, 15/60 in generic community nurses, 6/10 in specialised community nurses and 25/47 in general practitioners. For between 66% and 100% of respondents the role in early discharge was clear and between 57% and 78% of respondents was satisfied with their role in early discharge. For nurses the role in early discharge was different compared to their role in usual care. 67% of generic community nurses felt they had sufficient knowledge and skills to monitor patients at home, compared to 100% of specialised community nurses. Specialised community nurses felt they should monitor patients. 60% of generic community nurses responded they should monitor patients at home. 78% of pulmonologists, 12% of general practitioners, 55% of hospital respiratory nurses and 48 of community nurses was satisfied with early discharge in general. For coordination of care 29% of community nurses had an unsatisfied response. For continuity of care this was 12% and 10% for hospital respiratory nurses and community nurses, respectively.ConclusionA community-based early assisted discharge for COPD exacerbations is possible and well accepted from the perspective of health care providers’ involved. Satisfaction with the different aspects is good and the transfer of patients in the community while supervised by generic community nurses is possible. Attention should be paid to coordination and continuity of care, especially information transfer between providers.

Short-term training of direct observation procedural skills (DOPS) for community general practitioner trainers

Objective To evaluate the efficacy of short-term training of direct observation procedural skills (DOPS) for community general practitioner (GP) trainers. Methods Thirty six GP trainers participated in one-day workshop of DOPS. The participants were interviewed with questionnaire before and after the training program and the training video was scored. Results 47.2%(17/36) of GP trainers knew and briefly understood DOPS before the training. 41.7%(15/36) of them had a rough idea of how to use it and only 2.8%(1/36) had used it before. All of these trainers wanted to learn how to perform DOPS. The vast majority of GP trainers completely or basically understood the standards for evaluation of 11 items of DOPS after the training. The accuracy rates of 4 items were close to or more than 50.0% in 9-point scale and 7 items exceeded 50.0% in 3-rank system. There was significant difference in accuracy rates of 6 items between the two scoring system (all P <0.01). Conclusions Community GP trainers recognize the advantages of DOPS in assessment of clinical skills and have strong intention of application. The efficacy of short-term workshop is satisfactory, but the evaluators need more training and practice. Key words: General practitioner; Teacher training; Direct observation of procedural skills

Factors Influencing the Turnover Intention of Chinese Community Health Service Workers Based on the Investigation Results of Five Provinces

After the implementation of the new health reform, the Chinese government paid increasing attention to developing its community health service (CHS). The focus is mainly on cultivating community general medical practitioners but paying less attention to the working status and occupational demands of in-service CHS workers. CHS requires a stable team that can provide good service to community residents. At present, the demission rate of CHS workers is high. Studying how to increase the stability of CHS workers is noteworthy. The goal of this study is to ascertain the key factors that influence the CHS worker turnover intention to increase their work satisfaction and stability. A total of 100 CHS organizations were sampled randomly in 10 cities from 5 Chinese provinces for this study. All CHS workers from these organizations took a questionnaire survey. In total, 3,212 valid answer sheets were collected. Pearson Chi square test and Binary logistic regression were used to analyze the related influencing factors that result in CHS worker turnover intention. A total of 38.7% of those who accomplished the questionnaire intended to quit. The influencing factors that result in CHS worker turnover intention are (1) socio-demographic factors such as age, post of duty, professional title, and working seniority, and (2) other work-related factors such as pay packets, learning and training opportunities, promotion and personal development space, and working stress. CHS workers were less satisfied with the balance between payment and work quantity, promotion opportunity, and working conditions. Based on the results, the government should pay more attention to the various demands of CHS workers in service, especially by increasing their income, providing more learning and training opportunities, and increasing the degree of their work satisfaction to avoid turnover intention and ensure the stability of the CHS workforce.

WS6.1 A cross-sectional evaluation of factors influencing adherence in children with cystic fibrosis

Objectives: To evaluate adherence to enzyme supplements, vitamins and chest physiotherapy in children using a multi-method approach and to examine factors influencing adherence. Methods: Adherence to therapy was measured using scores from the self-reported parent and child ( 11 years) Medication Adherence Report Scale (MARS), prescription refill history from community pharmacy and General Practitioner prescription issue history. Adherence was determined when the participant scored 80% in all applicable measurement methods. Furthermore, beliefs about medication were assessed in children 11 years and parents using a modified Beliefs about Medicine Questionnaire (BMQ), quality of life was assessed using the Cystic Fibrosis Questionnaire-Revised and parental depressive symptoms were examined using the Center for Epidemiologic Studies Depression Scale. Results: 100 children with cystic fibrosis (birth to 18 years) and their parents were recruited from the paediatric cystic fibrosis centre at the Royal Belfast Hospital for Sick Children between November 2010 and September 2011. Adherence varied between treatment and adherence measure (Table 1). Conclusion: Logistic regression analysis indicated that increased child age and low parental necessity beliefs were significant, independent drivers of non-adherence to enzyme supplements and chest physiotherapy.

Cooperation between community pharmacists and general practitioners in eastern Germany: attitudes and needs

Regions of decreasing medical supply with long distances to pharmacy or practice require a good collaboration between practitioners and pharmacists. To determine and compare the attitudes of community pharmacists and practitioners towards each other regarding collaboration. Setting Mecklenburg-Western Pomerania in Germany. 749 general practitioners and practitioners specialized in diabetes care as well as 344 community pharmacists received a 38-item survey regarding their interrelations and attitudes towards each other. Descriptive statistics of the practitioners' attitudes towards pharmacists in comparison to the pharmacists' attitudes towards practitioners in terms of perception of their role, reliability, functions, frequency and helpfulness of contact, cooperation in promoting medication adherence and quality of communication. Response rates were 19.4 % (n = 145) for practitioners and 24.4 % (n = 84) for pharmacists. 144 (76.6 %) of practitioners and 79 (71.5 %) of pharmacists strongly trusted the other health care providers' statements and expertise (p = 0.0076). Practitioner-pharmacist interactions on average were of low frequency. They were, however, perceived to be helpful. The majority of pharmacists (62.7 %) regard their responsibility to ensure adherence with long-term medication to be equal to that of general practitioners. In contrast, the vast majority of practitioners (90.1 %) estimated their proportion of responsibility for adherence to long-term medication to be 75 % or more. At the same time, practitioners perceived the pharmacists' current influence on patient adherence to long-term medication as generally positive (65.0 %). This is in line with the pharmacists' self-perception (94.7 %). The general trust of both health care providers towards each other is a good pre-condition for further collaborations. However, increased frequency in practitioner-pharmacist-interactions is necessary. Additionally, the role perceptions of pharmacists and practitioners should be harmonised as there are still misunderstandings in the responsibilities of both parties.

The Evaluation of General Practitioners’ Awareness/Knowledge and Adherence to the GOLD Guidelines in a Shanghai Suburb

The aim of this study was to determine levels of awareness of basic knowledge concerning control and prevention of chronic obstructive pulmonary disease (COPD) among general practitioners (GPs) in a Shanghai suburb and to evaluate adherence to GOLD (COPD) guidelines in primary care. All 593 practitioners, including rural and urban community GPs at 15 primary care centers in the Songjiang district of Shanghai, were questioned, comprising 331 from urban communities and 262 from rural. Only 115 GPs (19.4%) understood that COPD is categorized into acute exacerbation and stable stages, and 328 GPs (55.3%) recognized that treatment for COPD patients was still required during stable stages. A total of 235 GPs (39.6%) knew that oxygen therapy should be administered for >15 h/d as regular home therapy. In 97 cases of stage III and IV COPD, only 1 patient had accepted long-term home oxygen therapy. Prescriptions that conformed with the GOLD recommendations occurred in approximately 8% of patients according to GOLD COPD severity staging. Basic knowledge of prevention and treatment of COPD was seriously lacking in GPs. Additional training is clearly needed.

Cost-effectiveness and quality of life in surgeon versus general practitioner-organised colon cancer surveillance: a randomised controlled trial

ObjectiveTo assess whether colon cancer follow-up can be organised by general practitioners (GPs) without a decline in the patient's quality of life (QoL) and increase in cost or time to...

Training general practitioners in hypertension management with expert-guided network tracing system

Objective To evaluate the application of “expert-guided network tracking system” in training community general practitioner for hypertension management.Methods Total 855 general practitioners (GPs) from 20 community health service centers in Hangzhou,Jiaxing and Shaoxing of Zhejiang province were divided into two groups: 430 GPs from 10 community health centers received training for hypertension management using “ expert-guided networking tracking system” (intervention group) in December 2008 and 425 GPs from another 10 health centers received conventional training (control group).Questionnaire surveys about the knowledge and skill of hypertension management were conducted before and 3 y after training.Results The awareness rates of knowledge about hypertension prevention and control,non-drug therapy and drug therapy increased from 37.0％ (159/430),45.6％ (196/430),42.8％ (184/430) to 66.8％ (284/425),81.4％ (346/425),77.6％ (330/425),respectively and the accuracy of case analysis increased from 38.4％ (490/1290) to 73.3％ (946/1290) (P ＜0.01) after training in intervention group.Meanwhile the knowledge and case management abilities in control group were also improved after conventional training,but the degree was significantly lower than that in the intervention group.Conclusions “Expert-guided networking tracking system” can significantly improve the knowledge and skills for hypertension management in community general practitioners. Key words: Hypertension; Community health services; Questionnaires; Training

Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers

BackgroundAdvocates for quality and safety have called for healthcare that is patient-centred and decision-making that involves patients.ObjectiveThe aim of the paper is to explore the barriers and facilitators to patient-centred...

PHP111 Development of National Medicine Brand Substitution Guidelines and Pilot Assessment of Its Adoptability among Community Pharmacist and General Practitioners in the State of Penang, Malaysia

PHP111 Development of National Medicine Brand Substitution Guidelines and Pilot Assessment of Its Adoptability among Community Pharmacist and General Practitioners in the State of Penang, Malaysia

Education of foreign community general practitioners and its enlightenment

Community medical staff construction centered on general practitioner is a basic engineering to improve the quality and enhance the level of basic medical and health service system.The developed western countries have up-to-date experiences in general and further education of community general practitioners.By combining these experiences with China's national conditions,this thesis explored the 'targeted recruitment-employment mode' for general practitioners and discussed the reform in curriculum,teaching content and teaching organization in order to promote the practice base construction and further education after graduation as well as to cultivate all-around talents of high quality who can meet the requirements of the basic-level medical work. Key words: Community general practitioners; Colleges and universities; Targeted recruitment-employment mode

Assessment of the management of cases of fever and malaria by general practitioners in the central Highlands of Madagascar, 2009-2010

The aim of this study was to determine the frequency of confirmed malaria among patients with fever in the central Highlands of Madagascar, the clinical utility of treating this fever, and the involvement of community general practitioners in improving malaria management. This descriptive, prospective study took place from July 1, 2009, through June 30, 2010. Patients consulting for fever were classified into 2 groups: the first (G1) included all children younger than 5 years and the second group (G2) children 5 years or older and adults. In G1, 1383 cases of fever included 145 (10.5%) confirmed cases of malaria. The corresponding numbers in G2 were 1172 and 276 (23.5%). The prevalence of malaria was highest between December and May. In G1, the main clinical signs associated with a positive rapid diagnostic test (RDT) were pallor, jaundice, seizures, and failure to eat. In G2, a positive RDT was associated with pallor, coma, and jaundice. Treatment of patients with positive RDTs was based on quinine (51%) or artemisinin-based combination therapy (49%). Malaria remains endemic in the central Highlands of Madagascar. Efforts should be undertaken to improve prescription of antimalarial drugs.

Developing the libraries and health partnership

Developing the libraries and health partnership

Can Redesigning a Laboratory Request form Reduce the Number of Inappropriate PSA Requests without Compromising Clinical Outcome

Introduction: Unnecessary laboratory utilization due to inappropriate test-ordering behaviour among hospital clinicians and community general practitioners is an ongoing problem in many hospitals and primary care trusts throughout the UK and abroad. In January 2007, our hospital removed the ‘tick box’ for PSA from its laboratory tests request form, in a managed way, with the intention of reducing unnecessary requests for this test. Here we address the impact this action had on the number of PSA tests being requested and its downstream effects on prostate cancer diagnosis. Methods: Using our laboratory database we compared the number of hospital and local GP requests for PSA, before and after modification of our laboratory form (requests from 2004 to 2006 were compared to 2007). We then correlated this data with the number of fast-track target referrals (2 week wait) from primary care for suspected prostate cancer, the results of prostate biopsies, and the number of prostate cancers being diagnosed, over the same time period. Results: Mann—Whitney non-parametric testing demonstrated a 17% reduction in the median number of PSA requests since the change was introduced ( p = 0.001). Subset analysis revealed an 18% reduction in GP requests ( p = 0.002). However no change was found in the number of prostate cancer diagnoses being made ( p = 0.86) and the number of target referrals for suspected prostate cancer ( p = 0.59) in the months of April, May, June, July, August and September of 2004–2006 as compared to the same months in 2007. The rate of patients undergoing biopsy increased in the post intervention period from 15.5 to 18.5 patients per month. The rate of negative biopsies remained stable, changing from 7.2 to 7.3 per month, and the rate of positive biopsies increased from 8.3 to 11.2 per month. This change reduced the false negative rate (suspected cancer, negative biopsy) from 46% to 40% in the period following the intervention. The rate of target referrals leading on to cancer showed a small increase after the intervention from 2.9 to 3.3 per month. Conclusions: Our study shows that with this simple modification to the design of our laboratory request form, whereby the doctor must make an active written decision to order a PSA test, there was a significant reduction in the number of PSA requests, both in the hospital and in the community, without patient safety being compromised as measured by maintaining the number of fast-track target referrals for suspected prostate cancer and the number of prostate cancers diagnosed.

Sources of pre-admission medication information: observational study of accuracy and availability

To identify the accessibility of sources of pre-admission medication (PAM) information, to quantify agreement between the PAM list and the 'gold-standard' PAM list (GS-PAML) and to categorise disagreements. A random selection of patients with chronic illness admitted via accident and emergency to one of two study hospitals in the Republic of Ireland were recruited. For each patient, a GS-PAML was compiled and PAM lists were obtained from each relevant source, including patient own medications, general practitioner (GP) referral letter, past inpatient prescription (Kardex) and discharge summary, nursing home letter and personal communication with GP staff, community pharmacy staff and nursing home staff. Data were collected regarding availability for use of each source and allergy status. The GS-PAML was compared to each PAM, and disagreements were identified and categorised. Data were collected for 134 patients. Community pharmacy and nursing home staff were most accessible to researchers when undertaking the medication history (>90%), followed by GP staff (66%). Except for nursing home sources, agreement between PAML and GS-PAML was low (2-17% of patients, 44-77% of medications). The community pharmacy PAML most frequently agreed with the GS-PAML (17% of patients, 77% of medications) followed by GP staff (10% of patients, 69% of medications). Previous (within the last 6 months) discharge summaries (3% of patients, 49% of medications) and GP referral letters (2% of patients, 44% medications) agreed least frequently. Nursing home (100%) and GP (91%) staff provided most accurate allergy information. Drug omission (>35%) was the most common disagreement for all sources except nursing home staff. GP staff and community pharmacy PAMLs contained a considerable proportion of commission discrepancies. Community pharmacy and GP staff were identified as the most available and accurate sources of PAM information and should be prioritised when undertaking admission medication reconciliation in a busy clinical environment.

Providing Palliative Care for Cancer Patients: The Views and Exposure of Community General Practitioners and District Nurses in Japan

ContextThe role of general practitioners (GPs) and district nurses (DNs) is increasingly important to achieve dying at home. ObjectivesThe primary aim of this region-based representative study was to clarify 1) clinical exposure of GPs and DNs to cancer patients dying at home, 2) availability of symptom control procedures, 3) willingness to participate in out-of-hours cooperation and palliative care consultation services, and 4) reasons for hospital admission of terminally ill cancer patients. MethodsQuestionnaires were sent to 1106 GP clinics and 70 district nursing services in four areas across Japan. ResultsTwo hundred thirty-five GPs and 56 district nursing services responded. In total, 53% of GPs reported that they saw no cancer patients dying at home per year, and 40% had one to 10 such patients. In contrast, 31% of district nursing services cared for more than 10 cancer patients dying at home per year, and 59% had one to 10 such patients. Oral opioids, subcutaneous opioids, and subcutaneous haloperidol were available in more than 90% of district nursing services, whereas 35% of GPs reported that oral opioids were unavailable and 50% reported that subcutaneous opioids or haloperidol were unavailable. Sixty-seven percent of GPs and 93% of district nursing services were willing to use palliative care consultation services. Frequent reasons for admission were family burden of caregiving, unexpected change in physical condition, uncontrolled physical symptoms, and delirium. ConclusionJapanese GPs have little experience in caring for cancer patients dying at home, whereas DNs have more experience. To achieve quality palliative care programs for cancer patients at the regional level, educating GPs about opioids and psychiatric medications, easily available palliative care consultation services, systems to support home care technology, and coordinated systems to alleviate family burden is of importance.

Preliminary studies on establishment of indicator system to evaluate basic capacities of trainers of training for community general practitioners in Shanghai

Objective To explore establishment of indicator system to evaluate basic capacities of trainers of training for community general practitioners (GPs) to standardize their capacity building and management.Methods Questionnaire survey was conducted among 190 trainers of training for community health managers and GPs who were involved in community health-care and health-care service management in 12 districts of Shanghai to investigate what basic capacities the trainers should have.Delphi expert consultation method was used to construct an evaluation indicator system.Firstly, an evaluation form was formulated based on the preceding questionnaire.Then, two rounds of expert consultation were carried out with 28 experts specialized in general practice, training for GPs, public health and health management.The last step was to set up an evaluation indicator system based on experts' opinions with statistical analysis.Results The newly-established system consisted of five first-grade indicators including comprehensive performance, capacities and personal willingness, background of education and career, personal potential for professional development, capacity in general practice and capacity in training for GPs, and 57 second-grade indicators.Activity coefficient of the experts was all 100%, authority coefficients of the experts were 0.85,and harmonious coefficient of importance of the evaluation was 0.190 and 0.225 ( all P ＜ 0.01 ),respectively, in two rounds of Delphi consultation.Conclusions The preliminarily established indicator system to evaluate capacities of trainers of training for community GPs in diverse aspects can be used as reference for quality critria in selection of trainers of training for community GPs. Key words: Education, medical, continuing; General medicine; Clinical competence; Delphi technique; Evaluation studies