Can general practice provide useful information?--evaluation of a primary health care information project in northern England

Can general practice computer data be of use in assessing asthma service delivery and needs?

Objectives: To investigate the potential of general practice computer data in assessing asthma service delivery and need. To compare the epidemiology of coded asthmatics and those receiving asthma drugs with recognized patterns for asthma. To estimate asthma prevalence, preventer and reliever drug need and its possible cost in east London. Design: Descriptive study using asthma computer audits undertaken in June 1995 in five general practices selected for their interest in asthma.

Collecting information on the quality of prescribing in primary care using semi-automatic data extraction from GPs’ electronic medical records

OBJECTIVES

To evaluate a semi-automatic data extraction from the electronic medical record (EMR) of general practitioners (GPs) through a comparison with a paper sheets data collection simultaneously used in a primary care research project on the quality of prescribing for osteoarthritis in the elderly.

SUBJECTS

One hundred and fifty-two GPs using five different EMR-software systems participated with the semi-automatic data extraction from the EMR and 233 GPs collected data with paper registration sheets.

METHODS

The proportion of patients with respectively a drug prescription, paracetamol, a non-steroidal anti-inflammatory drug (NSAID) and ibuprofen were compared between the semi-automatic extraction and the paper data collection and among the EMR-software systems.

RESULTS

Using the semi-automatic data extraction, a significantly lower proportion of patients on drugs was obtained compared to the paper data collection (adjusted OR: 0.31; 95% CI 0.25-0.39). However, the proportion of patients on a specific type of drug was comparable. Within the results from the semi-automatic extraction, the results were heterogeneous among the different EMR-software systems.

CONCLUSIONS

The semi-automatic data extraction with multiple EMR-software systems proposed in this study seems suitable for quality of prescribing assessment in primary care. However, it may be less reliable when only a single EMR-software is used.

Use of a cross-sectional survey to estimate outcome of health care: the example of anxiety and depression

Our study proposes that a population-based cross-sectional survey can be used to estimate the outcome of health care by linking general practice morbidity records to the survey. Using the example of anxiety and depression to test this idea, we conducted a survey of an adult population registered with one general practice in the UK. The Hospital Anxiety and Depression (HAD) questionnaire was used to identify cases and controls. After mailing to a randomly selected adult population of 4002, there was an adjusted response rate of 66% (n = 2,606), with 416 (16%) high-score cases, 506 (19%) medium-score cases, and 1684 (65%) low-score controls. All cases were compared with a sample of controls (n = 450). In the 12 months before the survey, the high-score case group had experienced significantly higher GP contacts (n = 377 [91%] versus 354 [79%]), diagnoses for anxiety or depression (119 [29%] versus 21 [5%]), and related drug treatments (111 [27%] versus 22 [5%]) compared with the control sample. Most of the diagnoses and drug treatments had been initiated at least 9 months before the survey. The linkage between the survey and the clinical records suggested that the health outcome of previously identified anxious and depressed patients was poor, with an estimated two-thirds who will not have fully recovered within an average of 9 months. This study demonstrates the potential for using cross-sectional population surveys to estimate not only the need for health care but also the outcome of health care.

A survey of validity and utility of electronic patient records in a general practice

OBJECTIVE

To develop methods of measuring the validity and utility of electronic patient records in general practice.

DESIGN

A survey of the main functional areas of a practice and use of independent criteria to measure the validity of the practice database.

SETTING

A fully computerised general practice in Skipton, north Yorkshire.

SUBJECTS

The records of all registered practice patients.

MAIN OUTCOME MEASURES

Validity of the main functional areas of the practice clinical system. Measures of the completeness, accuracy, validity, and utility of the morbidity data for 15 clinical diagnoses using recognised diagnostic standards to confirm diagnoses and identify further cases. Development of a method and statistical toolkit to validate clinical databases in general practice.

RESULTS

The practice electronic patient records were valid, complete, and accurate for prescribed items (99.7%), consultations (98.1%), laboratory tests (100%), hospital episodes (100%), and childhood immunisations (97%). The morbidity data for 15 clinical diagnoses were complete (mean sensitivity=87%) and accurate (mean positive predictive value=96%). The presence of the Read codes for the 15 diagnoses was strongly indicative of the true presence of those conditions (mean likelihood ratio=3917). New interpretations of descriptive statistics are described that can be used to estimate both the number of true cases that are unrecorded and quantify the benefits of validating a clinical database for coded entries.

CONCLUSION

This study has developed a method and toolkit for measuring the validity and utility of general practice electronic patient records.

Continuing educational needs in computers and informatics. McGill survey of family physicians

OBJECTIVE

To describe family physicians' perceived educational needs in computers and informatics.

DESIGN

Mailed survey.

SETTING

General or family practices in Canada.

PARTICIPANTS

Physicians (489 responded to a mailing sent to 2,500 physicians) who might attend sessions at the McGill Centre for CME. Two duplicate questionnaires were excluded from the analysis.

METHOD

Four domains were addressed: practice profile, clinical CME needs, professional CME needs, and preferred learning formats. Data were entered on dBASE IV; analyses were performed on SPSS.

MAIN FINDINGS

In the 487 questionnaires retained for analysis, "informatics and computers" was mentioned more than any other clinical diagnostic area, any other professional area, and all but three patient groups and service areas as a topic where improvement in knowledge and skills was needed in the coming year. Most physicians had no access to computer support for practice (62.6%); physicians caring for neonates, toddlers, or hospital inpatients were more likely to report some type of computer support.

CONCLUSIONS

Family physicians selected knowledge and skills for computers and informatics as an area for improvement in the coming year more frequently than they selected most traditional clinical CME topics. This educational need is particularly great in small towns and in settings where some computerized hospital data are already available.

Relative activity and referral patterns for diabetes and non-diabetes in general practice

AIMS

To describe and compare general practice (GP) activity for patients with and without diabetes using a survey of general practices representing over 10% of the Welsh population.

METHODS

The Welsh GP Morbidity Database Project (GPMDP) collected data including demographic and lifestyle information and consultation data such as diagnosis, referral and surgical procedures. These data were analysed to establish the annual period prevalence of diabetes and compare the relative number of consultations and referrals.

RESULTS

A total of 4,182 diabetic patients were recorded (prevalence 1.41%) and accounted for 77,371 (4.4%) consultations. Patients with diabetes were four-times more likely to be referred to community services (relative risk (RR) 4.1, 95% CI 3.7-4.7), in particular district nursing (RR 3.8, 1.9-7.7), optician services (RR 8.9, 5.0-15.7), chiropody (RR 8.2 6.4-10.5) and dietician services (RR 21.2, 17.6-25.5). Patients with diabetes were also more likely to be followed-up in general practice (RR 6.7, 6.2-7.2) both within 1 month (RR 6.7, 6.2-7.2) and 1 month to 1 year (RR 9.7, 8.9-10.7). Emergency admissions were also more likely for patients with diabetes (RR 6.8, 6.2-7.5) as were elective admissions to general medicine (RR 5.6, 4.6-6.7), surgery (RR 1.8, 1.5-2.0) and opthalmology (4.2, 3.4-5.2).

CONCLUSION

The increased utilization of health services apparent in secondary care was confirmed in primary care. Further research is required to determine levels of community activity after initial referral.

Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities. Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny. Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.

Collecting morbidity data in general practice: the Somerset morbidity project

OBJECTIVE

To collect a valid, complete, continuous, and representative database of morbidity presenting to primary care and to use the data to help commission services on the basis of local need and effectiveness.

SETTING

Computerised general practices in Somerset.

METHODS

Participating general practices were selected to be representative of the district health authority population for general practice and population characteristics. All conditions presented at face to face consultations were assigned a Read code and episode type and the data were regularly validated. Data were sent by modem from the practices via a third party to the health authority each week.

MAIN OUTCOME MEASURES

Proportion of consultations coded and accuracy of coding.

RESULTS

11 practices agreed to participate. Validations for completeness during April 1994 to March 1995 revealed that 96.4% of the records were coded; 94% of the 1090 records validated had appropriate episode types and 87% appropriate Read codes. The results have been used to help formulate the health authority's purchasing plans and have enabled a change in the local contracts for surgery for glue ear.

CONCLUSIONS

The project has shown the feasibility of establishing a network of practices recording and reporting the morbidity seen in primary care. Early indications are that the data can be useful in evidence based purchasing.

The capture of socioeconomic data in general practice

BACKGROUND

It is common practice to record the reasons why patients have an encounter with the practice, but the collection of socioeconomic data with which to link this morbidity data is less easy to achieve.

AIM

To describe the social enquiry used in the Fourth National General Practice-based morbidity study (1991-1992) and to consider its effectiveness for use in practice.

METHOD

Socioeconomic data were collected suing a structured questionnaire administered by a trained interviewer. Data were provided by both consulting and non-consulting registered patients.

RESULTS

The interview technique proved to be acceptable to patients, interviewers and general practitioners, simple to administer, and inexpensive to collect. Eighty-three per cent of the 502,000 people included in the study provided social and occupational data. Less than 1.5% of patients refused to be interviewed. Fifty-four of the 60 practices achieved the target level of 90% of registered patients being successfully interviewed.

CONCLUSION

A method of socioeconomic data collection based on that used in the 1991-1992 study would be of benefit for health care planning, allocation of resources, design of performance indicators and epidemiological research.