Yes / Objectives: To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. Design: Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. Setting: 111 primary care practices in Leeds and Bradford, UK. Participants: We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. Main outcome measures: Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. Results: Opioid prescribing in the adult population almost doubled for weaker opioids over 2005–2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31–3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). Conclusions: While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids. / e National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (Grant Reference Number PB-PG- 1010-23041).

Thesis (PhD)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: District hospitals play a pivotal role in the district health system of the Western Cape and other provinces of South Africa. It is a dual role, supporting both primary health care services and serving as a gateway to higher levels of care. Most district hospitals are in rural areas, staffed by generalist medical practitioners who provide health services often supplied by specialists in urban areas. There is a paucity of research and published material on the scope of practice of district hospital practitioners in South Africa, as well as the factors influencing the performance of their duties. There were two main objectives for this study. Firstly, to identify the professional knowledge and skills of medical practitioners delivering district hospital services in the Western Cape and to compare these with service platform needs. Secondly, to use the information gathered to make recommendations regarding human resource development and appropriate education and training and continuing professional development of these doctors. The study was conducted in three phases to ensure coherent evolution of investigation, co-ordination and response. Phase One was a comprehensive survey, utilising district hospital data, medical officer questionnaires and in-depth interviews to determine the professional knowledge and skills of medical practitioners working in district hospitals in the Western Cape. This information gathering endeavour resulted in a skills and knowledge compendium being formulated. It established that the spectrum of functions required of these doctors was extremely wide - ranging from the management of undifferentiated problems to performing complex surgical procedures, as well as providing a vital public health function. Two main factors influenced their performance, namely their working conditions and the education and training which they received.In common with rural practice in other countries, it was apparent that the working environment had a major impact on attitudes and functioning. These findings were developed into a conceptual framework depicting the negative influences that can build up and result in these doctors opting out of rural practice. In addition, other influences were established having a profound effect on doctors’ satisfaction, mainly in the realm of education and training. This gave rise to a second more comprehensive framework being evolved, encapsulating the positive and negative factors enhancing or retarding efficiency and satisfaction in the workplace. Phase Two of the study consisted of the validation of the findings of the basic research data. In keeping with the second aim of the study, the education and training perspectives of rural and district hospital practice were explored. The deficiencies exposed have implications for undergraduate and postgraduate education and training, as well as for continuing professional development programmes. Phase Three concentrated on the exploration of ways and means of defining and maintaining ongoing professional competence for district hospital practice. This was approached by using the data captured in Phase One and refined in Phase Two to pose a series of educational problems to a group of experts. Using the Delphi Technique, a series of electronic exchanges achieved consensus on a range of topics varying from educational content to learning modalities and modern adult teaching techniques applicable to district hospital practice. This research presents information defining the circumstances, experiences and needs of medical practitioners working in district hospitals in the Western Cape province of South Africa. It reveals clear challenges to the capacity, attitudes, costs, isolation, political will, monitoring and organisation which will be crucial in the development of future human resource strategies.It, furthermore, defines the educational objectives, content and methods required to establish and maintain the ongoing professional competence of medical practitioners delivering district hospital services in the Western Cape. / AFRIKAANSE OPSOMMING: Distrikshospitale speel ‘n sentrale rol in die distriksgesondheidstelsel van die Wes- Kaap en ander provinsies in Suid-Afrika. Dit is ‘n dubbele rol wat beide primêre gesondheidsorgdienste ondersteun en optree as ‘n deurgang vir verwysing na hoër vlakke van sorg. Die meeste distrikshospitale is te vinde in plattelandse gebiede. Dit is hier waar die algemene geneeskundige praktisyn dienste lewer wat gewoonlik deur spesialiste in stedelike gebiede verrig word. Daar is ‘n gebrek aan bestaande navorsing en publikasies oor die omvang van praktyk van geneeshere in distrikshospitale in Suid- Afrika, sowel as onvoldoende inligting in verband met faktore wat die funksionering van hierdie praktisyns beïnvloed. Hierdie studie het twee hoofdoelwitte vervat. Die eerste doelwit was die bepaling van die professionele kennis en vaardighede van geneeshere werksaam in distrikshospitale in die Wes-Kaap, en die vergelyking daarvan met die behoetes van die diensplatform. Die tweede doelwit was om hierdie inligting te gebruik om aanbevelings te doen aangaande menslike hulpbronontwikkeling en toepaslike onderrig, opleiding en voortgesette professionele ontwikkeling vir hierdie geneeshere. Die studie is in drie fases uitgevoer om samehangende ontwikkeling van ondersoek, koördinasie en respons te verseker. Fase Een het bestaan uit ‘n omvattende opname van die professionele kennis en vaardighede van geneeshere werksaam in distrikshospitale in die Wes-Kaap deur die gebruik van distrikshospitaaldata, vraelyste vir geneeshere, en in-diepte onderhoude. Die resultate is gebruik om ‘n omvattende stel kennis en vaardigheidsareas te identifiseer. Fase Een het bewyse gelewer dat die rol en funksie van dokters in distrikshospitale uitsonderlik wyd is en wissel tussen die hantering van ongedifferensieërde probleme en die uitvoer van komplekse chirurgiese prosedures, sowel as ‘n belangrike rol in openbare gesondheid. Werksomstandighede en onderrigen opleiding is geïdentifiseer as die twee belangrikste invloede wat die uitvoer van hierdie praktisyns se pligte beïnvloed. Soortgelyk aan plattelandse praktyke in ander lande, het dit duidelik geword dat werksomstandighede ‘n groot invloed op houdings en funksionering het. Hierdie bevindings is saamgevoeg in ‘n konseptuele raamwerk om die negatiewe invloede toe te lig wat veroorsaak dat hierdie geneeshere die plattelandse diens verlaat. Ander faktore wat ‘n beduidende uitwerking op praktisyns se werksbevrediging gehad het, veral wat onderrig en opleiding betref, is saamgevat in ‘n tweede en omvattende raamwerk wat die positiewe en negatiewe invloede op effektiwiteit van dienslewering en werksverrigting uitspel. Fase Twee van die studie het bestaan uit die bevestiging van die bevindings van die basiese navorsingsinligting. Perspektiewe in die onderrig en opleiding vir plattelandse praktyk is ondersoek in oorleg met die tweede doelwit van die studie. Verskeie implikasies vir voorgraadse en nagraadse onderrig en opleiding en voortgesette professionele ontwikkelingsprogramme is uit ontblote tekortkomings geïdentifiseer. Die omskrywing en die behoud van professionele bevoegdheid is in Fase Drie ondersoek. Data verkry in Fase Een, en verfyn in Fase Twee, is gebruik in die ontwikkeling van ‘n reeks opvoedkundige vraagstukke. ‘n Groep deskundiges is daarna die taak gestel om konsensus te bereik oor ‘n spektrum van onderwerpe, insluitend toepaslike inhoud, metodes van leer en moderne volwasse onderrigtegnieke vir distrikshospitaal praktykvoering. Die Delphi tegniek met herhalende elektroniese rondtes is hiervoor gebruik. Hierdie navorsing lewer inligting wat die omstandighede, ondervindings en behoeftes van geneeshere werksaam in distrikshospitale in die Wes-Kaap provinsie van Suid- Afrika beskryf.Die navorsing onthul duidelike uitdagings vir die kapasiteit, houdings, koste, isolasie, politieke wilskrag, monitering en organisasie van strategieë vir die ontwikkeling van menslike hulpbronne. Dié navorsing definieër hierbenewens die opvoedkundige doelwitte, inhoude en metodes wat nodig is vir die vestiging en instandhouding van die professionele bevoegdheid van distrikshospitaalpraktisyns in die Wes-Kaap.

Submitted in partial fulfilment of the requirements for the degree of Masters in Business Administration (MBA), Business Studies Unit, Durban University of Technology, 2008 / The pharmaceutical industry is in the midst of a fundamental transformation. Time and cost constraints are forcing marketers to search for new ways to maintain and grow brand awareness. The amount of time that doctors allow for representatives to market their products is becoming less and less and as a result products are not getting the exposure they used to. Organisations that find innovative ways to maintain exposure of their products may gain a competitive advantage over those organisations that rely on traditional marketing methods. The prolific increase in the use of the internet may provide pharmaceutical organisations with a complementary channel to market their products. The objective of this study is to determine the levels of internet technology adoption among general practitioners. The Technology Acceptance Model (TAM) is one of the most influential research models in studies of the determinants of information systems/ information technology (IS/IT) acceptance. In TAM, perceived usefulness and perceived ease of use are hypothesised and empirically supported as fundamental determinants of user acceptance of a given IS/IT. Using TAM, this study sets out to determine general practitioners’ intention to use the internet as a source of pharmaceutical information. The literature review provides an extensive evaluation on the development of TAM and its application in different technologies. Based on these findings, the researcher developed this study to investigate internet technology acceptance in the pharmaceutical industry. Use is made of the descriptive survey method and data is retrieved from a sample of 105 general practitioners in Kwazulu-Natal. The observation is made via the benefit of a questionnaire. The process of sampling is that of convenient sampling. The analysis is quantitative and makes use of statistical analysis appropriate for the data. Analysis of the survey results produces useful insights into the factors influencing internet technology adoption by general practitioners. When analysing the independent variables, respondents were not in strong agreement about the perceived usefulness nor the perceived ease of use of internet technology as a source of pharmaceutical information. However, positive results from the relationships between the independent (perceived usefulness and perceived ease of use) and dependent variables (attitude and intention to use) provide valuable data with which organisations may develop internet-based marketing strategies. Based on the survey findings, recommendations using the Beynon-Davies (2004) Internet Adoption Model are suggested.

The overall aim of this thesis is to define a candidate set of quality indicators that are evidence-based, feasible to implement, and have the potential to improve the quality of care provided for children in UK general practice. The indicators were developed using a three-stage process. First, the areas and aspects of care of highest priority for quality indicator development were identified. This was achieved by seeking the views of primary care clinicians and by undertaking a formal analysis of unplanned hospital admissions for ambulatory care sensitive conditions. Then, the evidence-base to underpin indicator development was identified through an overview of Cochrane systematic reviews of interventions relevant to the primary care of children. A search of SIGN and NICE national guidelines was also conducted to inform the evidence-base. Lastly, an expert panel determined the formulation and selection of indicators by applying the RAND appropriateness methodology. This process created a final set of 26 quality indicators in six priority areas: early recognition of potentially serious illness (n=7); child protection and safeguarding (n=4); mental health (n=4); health promotion (n=1); routinely managed conditions (n=6); and general practice management (n=4). The main strength of these indicators is that they reflect a strong professional consensus on their validity and feasibility. The main weakness is that the indicators are underpinned by evidence mainly derived from expert opinion rather than formal research; the requirement for professional consensus means that they do not challenge existing models of care delivery.

La France est caractérisée par un bon état de santé global et d'importantes inégalités sociales de santé. Le renouveau d'intérêt pour ces dernières est l'occasion de questionner une définition univoque centrée sur les résultats au détriment des procédures, dans un pays qui a axé ses politiques de lutte sur le système de soins. La médecine générale y a une place particulière par son apparition récente en tant que spécialité universitaire et la nécessité de se définir qui s'ensuit. Elle est décrite tout à la fois comme pivot du système de soins, agent de santé publique ou chantre d'une relation inter-individuelle et d'une prise en charge globale. Si la médecine est fondée sur les données de la science, elle est aussi une profession prudentielle en ce qu'elle prend en compte des situations singulières, générant de l'incertitude dans la pratique. Parmi les sources de singularité, l'aspect social, tant du patient que du médecin, est à considérer. Dans sa pratique, ce dernier éprouve cependant une diversité de social. Tantôt obstacle à son activité professionnelle et vu comme extérieur au médical, tantôt élément apparenté aux données de la science par l'épidémiologie, il peut aussi être une brique de la construction individuelle du patient sur laquelle s'appuyer, conduisant parfois à une moralisation des conduites et des identités. Les caractéristiques sociales du médecin sont quant à elles souvent oubliées, comme s'il était neutre ou simple représentant de la science. C'est pourtant dans l'interaction entre ces deux mondes que se jouent aussi les inégalités sociales de santé et tout se passe comme si le médecin ne pouvait bien soigner que ses semblables. / France is characterized by a good overall health status and high social inequalities in the health sector. The renewed interest in health inequalities is the opportunity to question a unique definition focused on results at the expense of processes, in a country where policies on tackling inequalities are based on the health care system. General practice has a particular position in this system, as a new academic speciality, which still needs to figure out how to define itself. It is described simultaneously as a heath care system gatekeeper, a public health officer or an advocate for inter-individual relationship and holistic care. While medicine is based on scientific evidence, it is also a prudential profession as it considers singular situations, generating uncertainty in practice. Among singular sources, social characteristics of both patients and doctors have to be considered. However, in their practice, physicians experience a diversity of social. Sometimes a barrier to the professional activity and considered external to the medical world, sometimes considered as part of scientific evidences by epidemiology, it could also be considered as a component of the individual construction of the patient on which the physician can rely, with the potential to lead to a moralization of behaviours and identities. The physician's social characteristics are often omitted, as if doctors were neutral or mere representatives of science. It is however in the interaction between these two worlds that social determinants of health inequalities can be found, and it seems that a physician could only provide good care to patients sharing the same similarities.

Submitted by Suzana Dias (suzana.dias@famerp.br) on 2018-11-06T17:52:28Z No. of bitstreams: 1 ThomasEugenioPortes_dissert.pdf: 4704566 bytes, checksum: 455f651179bd9a6a5c7ae40f35183cda (MD5) / Made available in DSpace on 2018-11-06T17:52:28Z (GMT). No. of bitstreams: 1 ThomasEugenioPortes_dissert.pdf: 4704566 bytes, checksum: 455f651179bd9a6a5c7ae40f35183cda (MD5) Previous issue date: 2018-03-22 / Medical teaching has changed over time, requiring the expansion of active learning methodologies, such as problem-based learning. Student assessment is an important stage in the learning process and represents a challenge for medical schools. In this direction, two changes were made in the assessment instruments of the tutorial component: 1) the application of short answers questions applied before the closing section of the tutoring meeting, and 2) a change in the critical reasoning evaluation called "Triple Jump" to "Double Jump". Objectives: This study aims to evaluate the impact of these new assessments on students' grades as well as the reliability and validity of these instruments. Methodology: Quantitative, retrospective research, studying the impact of the changes made in the assessment methods in all the grades obtained in the Tutorial teaching component, by the second semester of 2015 and the complete 2016 year of medical students of the "Faculdade FACERES de São José do Rio Preto". Results: 1) Overall, after the introduction of the Short Answer Question, there was an increase in the scores of the summative tests and the final averages scores of students. 2) The Double Jump test maintained the ability to discriminate well-performing students from those with lower performance. Conclusions: The new evaluation tools have proved effective in improving students' performance. The Double Jump test proved to be an equivalent to Triple Jump. / A formação do médico tem mudado ao longo do tempo, exigindo a expansão das metodologias ativas de ensino, como o aprendizado baseado em problemas. A avaliação dos discentes é uma importante etapa do processo de aprendizagem e representa um desafio para o corpo docente. Neste sentido, duas mudanças foram feitas nos instrumentos de avaliação do componente curricular de tutoria: 1) a aplicação de uma prova dissertativa de respostas curtas aplicada antes da sessão de fechamento da tutoria, e 2) a mudança da avaliação de raciocínio crítico denominada “Salto triplo” para “Salto Duplo”. Objetivos: O presente trabalho visa avaliar o impacto destas novas avaliações nas notas dos alunos assim como a fidedignidade e a validade destes instrumentos. Metodologia: Pesquisa quantitativa, retrospectiva, estudando o impacto das mudanças efetuadas nos sistemas de avaliação em todas as notas do componente curricular de Tutoria, do segundo semestre de 2015 e de 2016, dos alunos do curso de medicina da Faculdade FACERES de São José do Rio Preto. Resultados: 1) De forma global, após a introdução da questão de resposta curta ocorreu aumento nas notas das provas somativas teóricas e médias finais. 2) A prova Salto Duplo manteve a capacidade de discriminar alunos com bom desempenho daqueles com desempenho inferior. Conclusões: Os novos instrumentos de avaliação se mostraram eficazes em melhorar o desempenho dos alunos. A prova “Salto Duplo” se mostrou uma alternativa equivalente ao “Salto Triplo”.

The development of community health services (CHS), characterised in particular by the emergence of general practitioners and the establishment of community health centres, is one of the top priorities on the policy agenda for urban health reform in China. The primary and secondary levels of hospitals are being urged to change functions, shifting from traditional hospital services to CHS. This study aimed to contribute to the development of training strategies for CHS through documenting the policy, administrative and institutional arrangements of the CHS programs, identifying performance problems, and analysing relevant determinants that underpin the practice and performance of CHS. Document analysis, indepth interview and questionnaire survey were adopted as main methodological approaches. The study was undertaken in Chengdu and Panzhihua, which included observation of 14 community health centres, interview with 23 general practitioners and managers, and a random sample survey among 1041 residents. This study revealed that the top priority of the CHS programs was to try to stay alive through competing with other health institutions for consumers who could afford medical charges and to provide clinical services that would generate good revenues. The accessibility to medical care for the community residents had not been improved significantly. Poor response to local population health issues, inefficient use of resources and poor quality of services were amongst the key performance problems. There was little prospect of the CHS institutions achieving sustainable development. There was a widespread agreement among the CHS managers and practitioners that training is an essential strategy in improving the CHS performance. However, when policy, system, and cultural barriers are not properly addressed, training means little. There were evident organisational failings and lack of inter-governmental collaborations and leaderships in developing CHS. The lack of policy coherence with respect to organisational incentives impeded the achievement of the goals of CHS. There was also a lack of consumer participation and support. These findings have implications for both policy development and training arrangements. The development of CHS needs to be considered as a system change rather than in terms of isolated institutional developments. Training arrangements for CHS need to offer competencies for a wide range of organisations and professionals to enable them to improve their daily works and also to contribute to solving some of the system problems. The training programs developed for governmental officials, hospital and CHS managers, general practitioners, community nurses, public health workers, pharmacists and other CHS practitioners need to be aligned with a unified goal and facilitate the development of the supportive environments and inter-organisational collaborations (partnerships).

The study investigated the self-reported information needs and information-seeking behaviour of 143 general practitioners in their delivery of patient care to the elderly on the Gold Coast. The study sought to obtain an information profile in order to begin discussion on the need for possible infrastructures that may need to be considered in any planning strategies concerned with access to and provision of relevant, accurate and timely information to general practitioners which affects their delivery of patient care to the growing number of elderly patients. A ten-page questionnaire utilising both structured and unstructured questions was returned by 61.9 percent of the survey population. Demographic characteristics indicated that respondents were representative of general practitioners in Australia. Respondents frequently needed information with 40 percent requiring it '1 - 4 times a week' and 78 percent 'once a month or more often'. Information on medical fact was required most frequently, 29 percent, medical opinion 27 percent, and non-medical information 23 percent. The study found support for the proposition that computerised information systems need to be enhanced and made widely known and available to general practitioners to assist them in obtaining information that they need in delivery of patient care to the elderly. There is a great need by these general practitioners for non-medical information as well as medical information. Therefore, the development of a database of non-medical information containing information on local agencies and services is of high priority. Library information delivery services should also be de-institutionalised in terms of lifting restrictions to services provided to enable general practitioners greater access to information. Library services should aim to provide remote access to information via telephone, fax and modem with emphasis on value added services aimed at solving a particular specific information need as well as straight-out bibliographic search services and document delivery services. Continuing medical education in the form of CME courses, conferences and meetings should focus on specific information needs of general practitioners in this area of patient care to the elderly. The need for information on cardiology, orthopaedics, dermatology, physiotherapy, podiatry, pharmaceutical benefits, home help, Meals-on-Wheels and nursing home placement were areas of particular interest identified by respondents in this study.

"June 2002" / Bibliography: p. 347-360. / xiii, 360, [200] p. : ill. ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.Med.Sc.)--University of Adelaide, Dept. of Public Health, 2002

The general practitioner has a central position in the health care system, but demands have increased and there are signs of exhaustion in the corps. Patient-centredness is beneficial for the patients and probably for the outcome of health care. In Balint groups general practitioners study and gain further understanding of the physician-patient relationship by means of the participants’ own experiences. This thesis aims at studying experienced effects of Balint groups on the working life of general practitioners. General practitioners with and without Balint group experience are compared by means of a questionnaire, using statistical methods. General practitioners with Balint group experience are interviewed. Both these studies show positive experiences of Balint group participation in the physicians’ working life in terms of feeling of control and satisfaction, and on relations to patients, particularly patients with complex problems. A new instrument for measuring physicians’ degree of patient-centredness is presented. It can be used in groups of physicians to evaluate training programmes or by the individual physician to detect decline in patient-centredness as an early sign of burnout. Balint groups are viewed critically in interviews with Balint group leaders, focussed on difficulties and dropouts from the groups. Balint groups are found to fit into modern theories of small groups as complex systems, submitted to group dynamics that are sometimes malicious. Professionally conducted Balint groups seem to be a gentle, efficient method to train physicians, but with limits. Participation of a member demands a stable psychological condition and an open mind, and obligatory Balint groups are questioned. The thesis concludes that Balint groups are generally beneficial for general practitioners’ working life as a means to enable the physicians endure, even thrive in their job. The method facilitates development of new understanding of the physician-patient relationship with possible positive effects for the patient as well.