Decision-making In Primary Care Research Articles

Variables that influence diagnosis and treatment of the eating disorders within primary care settings: A vignette study

This study examined the influence of clinical and nonclinical features of case presentation on the diagnosis and treatment of eating disorders in primary care. Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated. Outcome variables included the primary diagnosis and the treatment course selected for each case. Female cases were more likely to receive an eating disorder diagnosis, even when their symptoms were identical to those of males. Nonclinical demographic variables also influenced treatment decisions. Weight status and physical comorbidity had a limited influence on treatment pathways. Nonclinical features of case presentations are used when making eating disorder diagnoses and in selecting treatment. Decision-making in primary care does not reflect recommendations from clinical guidance, and this disparity might increase the risk of complications in the care of sub-groups of eating-disordered patients.

Improving Care for Depression: There's No Free Lunch

Primary care clinicians know depression well, yet diagnostic and treatment failures are common. In answer to the pressing need to do better, the elegant study by Dobscha and colleagues in this issu...

Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice.

A cluster-randomised controlled trial in general practice Physician-patient communication plays a key role in treatment decisions in primary care. We aimed to reduce the antibiotic prescription rate for acute respiratory tract infections using a short training programme in patient-centred communication. We conducted a cluster-randomised controlled trial in 45 general practices in Switzerland. Thirty physicians received evidence-based guidelines for the management of acute respiratory tract infections; 15 physicians randomised to the full intervention additionally received training in patient-centred communication. A further 15 physicians, not randomised, served as a control to blind the physicians in the other two groups to the true comparison. The primary outcome was the antibiotic prescription rate reported by pharmacists. Secondary outcomes were patient satisfaction and enablement, re-consultation rates, days with restrictions, and days off work. 1108 adults with acute respiratory infections were screened between January and May 2004. Outcomes were measured in 837 consultations; 624 patients had follow-up interviews at 7 and 14 days. The antibiotic prescription rate reported by pharmacists was low in both full and limited intervention groups (13.5% and 15.7% respectively) but only half of the antibiotics were prescribed according to guidelines (53.8% and 53.1%). No significant differences were seen between the two randomised groups in primary and secondary outcomes. In both groups patient satisfaction was high (median score for both 68 out of 70). In this trial, patient-centred communication training did not reduce the rate of antibiotic prescriptions below an already unusually low level. Even with this low prescription rate, patient satisfaction with received care was high.

Shared decision-making in primary care: Tailoring the Charles et al. model to fit the context of general practice

Objective To explore the application of the original Charles et al. model of shared treatment decision-making [Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681–92; Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651–61] in the context of general practice, and to determine whether the model needs tailoring for use in this clinical context. Methods Conceptual paper, presenting the defining characteristics of general practice compared to the original clinical context for which the model was developed (i.e. life threatening disease with different treatment options), and exploring how the model can be tailored for use in the context of general practice. Results We identify two areas where the original model requires tailoring: sharing the decision-making around agreeing on an agenda for each consultation; and adapting the information transfer component of the model to acknowledge that doctors may not be the only, or even the main, source of technical information for patients. Finally, we explore the importance of shared decision-making in the context of chronic disease. Conclusion The Charles et al. model can be tailored for use in general practice. Practice implications Tailoring the model for use in general practice has implications for research, in terms of identifying the additional physician competencies needed for implementation. Policy makers who wish to promote shared decision-making need to ensure that incentives which prioritize access and health outcomes do not militate against shared decision-making in general practice.

RCN claims primary care decisions are already made

RCN claims primary care decisions are already made

Measuring health status: information for primary care decision making

Primary Care Trusts (PCTs), charged with improving the health of their population, need to measure the extent to which patients actually benefit from the health care that is provided for them. One way of achieving this is to measure health status of patients over time. The study described here reports on the feasibility of administering the EQ-5D in general practitioner (GP) surgeries and identifies how the results might be used by practices and PCTs to improve the health of their populations. The study took place in an opportunistic sample of 1942 patients attending GP surgeries. One year later, patients who had provided contact details were sent another EQ-5D together with a request for additional information about their use of health care services in the intervening time period. A total of 770 patients completed this follow-up questionnaire. There were significant age effects associated with variation in self-reported health status and also associated with top-level Read diagnostic codes in some groups of patients. The results showed that EQ-5D could be used by individual GP practices to identify patients with specific health problems. This knowledge can also be used by PCTs and other primary care organisations, to better target scarce health resources.

Osteoporosis prevention starts in adolescence.

To review the factors that influence the development of osteoporosis later in life, to relate those factors to adolescent health behaviors, and to provide nurse practitioners (NPs) with information on which to base evaluation and management decisions in primary care. Review of selected scientific literature with a focus on adolescent health and osteoporosis. Osteoporosis is a major public health concern that affects more than 10 million people in the United States, resulting in annual costs to our health care system in excess of 13.5 billion dollars. Approximately 40% of women will experience a fracture due to osteoporosis. NPs should aim osteoporosis prevention efforts toward adolescents by encouraging habits that promote bone growth and development. It is imperative that female adolescents achieve adult peak bone mass prior to the age of 30, and the bone-building years before the age of 18 are especially important. NPs are ideally positioned to provide the screening and counseling to ensure that adolescents have the best chance to develop the habits that will result in peak adult bone mass.

Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care

Greater patient involvement has become a key goal of health care provision. This study explored the way in which general practitioners (GPs) in the UK manage the dual responsibilities of treating individual patients and making the most equitable use of National Health Service (NHS) resources in the context of the policy of greater patient involvement in decision-making. We undertook a qualitative study incorporating a series of interviews and focus groups with a sample of 24 GPs. We analysed GP accounts of decision-making by relating these to substantive ethical principles and the key procedural principle of explicitness in decision-making. GPs saw patient involvement in positive terms but for some GPs involvement served an instrumental purpose, for instance improving patient ‘compliance’. GPs identified strongly with the role of patient advocate but experienced role tensions particularly with respect to wider responsibilities for budgets, populations, and society in general. GPs had an implicit understanding of the key ethical principle of explicitness and of other substantive ethical principles but there was incongruence between these and their interpretation in practice. Limited availability of GP time played an important role in this theory/practice gap. GPs engaged in implicit categorisation of patients, legitimating this process by reference to the diversity and complexity of general practice. If patient involvement in health care decision-making is to be increased, then questions of scarcity of resources, including time, will need to be taken into account. If strategies for greater patient involvement are to be pursued then this will have significant implications for funding primary care, particularly in terms of addressing the demands made on consultation time. Good ethics and good professional practice cost money and must be budgeted for. More explicit decision-making in primary care will need to be accompanied by greater explicitness at the national level about roles and responsibilities. Increased patient involvement has consequences for GP training and ways of addressing rationing dilemmas will need to be an important part of this training. Further research is needed to understand micro-decision-making, in particular the spaces in which processes of implicit categorisation lead to distorted communication between doctor and patient.

Treatment options for seasonal allergic rhinitis

Background:Seasonal Allergic Rhinitis (SAR) or ‘hay fever’ is a common, complex disorder resulting in nasal and ocular symptoms. Treatments for SAR aim to minimise symptoms, improve quality of life and reduce the risk of developing any co-existent disease. Improving the evidence-base for treatment decisions in primary care is now a priority for the NHS.Methods:We used standard systematic review methods to conduct a systematic review of all randomised control studies (1990-2002) evaluating the effectiveness of treatments for SAR. For a study to be included all patients had to be at least 12 years with a physician confirmed diagnosis of hay fever. The minimum length of follow-up was stipulated as being 2 weeks. The interventions and comparisons analysed were those including topical or systemic antihistamines, decongestants, leukotriene antagonists and ipratropium bromide. Steroids were not included as they are preventative rather than curative. Our primary outcome measure was rhinitis quality of life using the validated Juniper Rhinitis Quality of Life Questionnaire. Secondary parameters of effectiveness included visual analogue rhinitis symptom score completed by the doctor and/or patient, medication usage and medication usage scores, days off school or work and adverse events.Results:We found 68 trials satisfying our inclusion criteria, although only four of these had used formally validated outcome measures (Juniper-RQLQ) to assess clinical effectiveness. Because of the heterogeneous nature of the studies identified, we used a narrative overview to summarise data. Three trials have shown that oral fexofenadine significantly improves disease specific quality of life and evidence from one trial indicates that a combination of oral monteleukast and loratadine is also clinically effective. Numerous trials indicate that a number of oral antihistamines with/without oral decongestants improve rhinitis symptoms. Topical levocabastine is also of benefit in reducing rhinitis symptoms but there is at present confliciting evidence on the usefulness of other topical treatments (azelastine and ipratropium bromide).Conclusions:Fexofenadine and a combination of oral monteleukast/loratadine should be regarded as first line interventions for the medical treatment of SAR. There is evidence to suggest that other oral antihistamines and intranasal levocabastine are also likely to be of clinical benefit.

Clinical management of urinary tract infection in women: a prospective cohort study.

It is unclear how symptoms of urinary tract infection (UTI) influence clinical management in terms of diagnostic testing and treatment with antibiotics. Our aim was to assess how 11 symptoms associated with UTI related to the probability of being tested (near patient test or urine culture) or treated with antibiotics by their GP, and to see if the same 11 symptoms were associated with (i) confirmed infection from urine culture and (ii) re-consultation complaining of the same symptoms within 1 month. A prospective cohort study of 160 patients consulting their GP with symptoms of UTI in eight general practices in Avon, UK was carried out. Association between symptoms and the probability of being (i) tested by the near patient test, (ii) tested by urine culture or (iii) treated empirically with antibiotics were examined. The association between symptoms and the probability of being treated empirically or tested (near patient test or mid-stream urine) was examined. Likelihood ratios for symptoms and near patient test results compared with two 'gold standards' for diagnosis of UTI were calculated and their impact on post-test probability of UTI determined. GPs were far more likely to treat empirically patients with symptoms of dysuria and frequency [odds ratio (OR) 6.50, 95% confidence interval (CI) 2.02-20.89] or dysuria alone (OR 5.24, 95% CI 1.62-16.95). They were far less likely to perform diagnostic tests in patients with dysuria and frequency (OR for near patient testing 0.34, 95% CI 0.14-0.83; OR for urine culture 0.15, 95% CI 0.04-0.56). The prior probabilities of UTI were 25% (positive urine culture) and 29% (re-consultation within 1 month), respectively, for each of the 'gold standards' used. Individual symptoms and near patient tests did not raise the posterior probability of UTI irrespective of which 'gold standard' was used. The most useful symptom was a history of vomiting (likelihood ratio 2.96, 95% CI 0.3-31.2), but this occurred in only three patients. Current clinical practice results in a large proportion of patients receiving unnecessary antibiotic treatment. Individual symptoms of UTI are an inadequate guide on which to base diagnostic testing and antibiotic treatment decisions in primary care. Either this diagnostic inaccuracy should be acknowledged as an inevitable part of clinical practice or more accurate clinical prediction rules that incorporate symptoms, signs and near patient test results that are applicable in everyday clinical practice are required.

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

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. 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. 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. 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.

A clinical informaticist to support primary care decision making

Objectives—To develop and evaluate an information service in which a “clinical informaticist” (a GP with training in evidence-based medicine) provided evidence-based answers to questions posed by GPs and nurse practitioners....

A clinical informaticist to support primary care decision making

A clinical informaticist to support primary care decision making

Primary care and emergency department decision making.

To determine the effect of primary care status on decision making in the pediatric emergency department (ED). Urban tertiary care children's hospital. Examining physicians prospectively completed questionnaires describing the presence of and their familiarity with patients' primary care providers (PCPs), as well as several relevant clinical factors. We prospectively surveyed care for patients with triage temperature of 38.5 degrees C or higher or symptoms of gastroenteritis between August 1, 1999, and February 15, 2000. Intravenous fluid use, hospital admission status, rates of diagnostic testing and interventions, mean total costs, and length of ED stay. Among 1166 nonreferred patients, no PCP was identified for 164 patients and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted vital signs, triage category, initial appearance, patient care setting (main ED or urgent care clinic), time of day, day of week, certainty of diagnosis, or perceived importance of follow-up. Mean unadjusted direct hospital costs for diagnostic testing were significantly higher for the group without PCPs, $23 vs $16. In regression models controlling for age, ethnicity, insurance status, patient care setting, ED attending physician, temperature, and initial appearance, the absence of a PCP was associated with an increased likelihood of diagnostic testing. Compared with a subset of the cohort with PCPs who were familiar to the treating physicians, the group without PCPs also had a significantly higher rate of intravenous fluid administration. In this patient population, ED physicians may vary their assessment and management decisions based on primary care status.

Antibiotics and shared decision-making in primary care.

Antibiotics are often prescribed to patients with respiratory tract infections who are unlikely to benefit. Models of physician-patient interaction may help understanding of this problem and inform the design of communication skills interventions to enhance appropriate prescribing. The 'paternalistic model' of the consultation remains common in the setting of acute respiratory tract infections. However, the four assumptions that could support this model are not valid for most of these patients, because: best treatment is controversial; management is inconsistent; physicians are not in the best position to evaluate trade-offs between management options without understanding patients' perspectives; and many pressures (apart from patients' agendas) intrude into the consultation. One alternative is the 'informed model' of consulting, but this does not take society's interests into account. The 'shared decision-making model', however, provides a framework for addressing both clinicians' and patients' agendas, and could guide the development and evaluation of specific consultation strategies to promote more appropriate use of antibiotics in primary care.

Primary care decision making in response to psychological complaints: the influence of patient race

Eighteen general practitioners indicated diagnostic and treatment decisions in response to patient vignettes. Results indicated that White patients were more likely to be correctly diagnosed as having anxiety than any other complaint. Asians were just as likely to receive a physical diagnosis as they were to receive one of anxiety. Copyright © 2000 John Wiley & Sons, Ltd.

Emotions, Ethics, and Decisions in Primary Care

Previous articleNext article No AccessEmotions, Ethics, and Decisions in Primary CareJulia ConnellyJulia ConnellyUniversity of Virginia, Charlottesville Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Volume 9, Number 3Fall 1998 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/JCE199809302 © 1998 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.

Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care

This prospective observational study was aimed at evaluating the appropriateness of use of upper gastrointestinal endoscopy (UGE) in primary care in a country with open access to and high availability of the procedure. Outpatients were consecutively included in two clinical settings: Setting A (20 primary care physicians during 4 weeks) and B (university-based outpatient clinic during 3 weeks). In patients undergoing UGE, appropriateness of referral was judged by explicit Swiss criteria developed by the RAND/UCLA panel method. Patient visits (8135) were assessed. Six hundred eleven patients complained of upper gastrointestinal symptoms. Physicians decided to perform UGE in 63 of these patients. Twenty-five (40%) of the endoscopies were rated appropriate, 7 (11%) equivocal, and 31 (49%) inappropriate. Overuse of UGE occurred in 5.1% (setting A: 4.7%; setting B:6.5%; p = 0.39) of the patients who presented with upper gastrointestinal symptoms. The decision to perform UGE in previously untreated dyspeptic patients was the most common clinical situation resulting in overuse. Inappropriate use of UGE is high in Switzerland. However, to better reflect primary care decision making, overuse should be related not only to patients referred for a medical test, but also to the number of patients who complain of the symptoms that would be investigated by the procedure.

PDRD--a computer-based primary care decision support system.

This article identifies the current stage of development and assessment of computer-assisted decision support systems in the domain of general practice. Physician's Desk Reference and Database (PDRD), an electronic medical database, is presented, and a plan for assessment of PDRD is briefly discussed.