Background: Increased pressure, rising demand and cost constraints have driven a need for radical service re-design in the NHS. To deliver re-design objectives it is necessary to understand how they are perceived by service users and providers. Aim: To investigate the views of patients and health care professionals (HCP) on aspects of health policy and service re-design affecting primary care. Setting: Patients and HCPs from one geographical area in England. Method: Themes from phase one qualitative interviews were explored quantitatively using a questionnaire in phase two and a discrete choice experiment (DCE) in phase three. Factor analysis was used to explore HCP responses in phase two. In phase three the DCE was administered to explore patients‟ relative priorities of a range of attributes. Results: HCPs had concerns that the Quality Outcomes Framework (QOF) detracted from the patient‟s agenda and did not improve health outcomes. GPs felt continuity of care was important Monday through Friday but were not keen on its provision out of hours. Neither did they feel nurses could run chronic disease management clinics without a GP present. Patients felt continuity could be provided by different HCPs for different conditionsPatients stated continuity of care and consultation duration were the most important attributes in a primary care service. However, in the DCE they prioritised both being seen on the day and by a GP over longer appointments. Patient preference to be seen by a GP may reflect the low uptake of non-medical prescribing in the area. Conclusion: Continuity of care, while remarked as being important to both HCPs and patients, appears less important when weighted against other primary care service attributes. HCPs appear to want longer consultations whereas patients saw time as encompassing both the time to wait for an appointment and consultation length. For patients, the quality of the time with a HCP may be more important than its duration, additionally patients appear to want choice but not necessarily to choose.

Background: Prescribing errors are the most frequent type of error in the medication use process. High risk medicines (HRMs) are a sub-class of medications that if used erroneously have potentially devastating consequences which defined by Institute for Safe Medication Practices (ISMP) as the drugs that bear a heightened risk of causing significant patient harm when they are used in error. Therefore, prescribing errors with HRMs are of concern to healthcare professionals that are responsible for ensuring mitigating patient safety. This thesis examines to what extent prescribing errors with HRMs in hospital occur, the causes of prescribing errors with HRMs and the differences to non-HRMs and the prescribing errors with HRMs during the on-call period. Method: The research adopted a mixed methods approach to explore prescribing errors with HRMs in hospitals and three studies were undertaken. The first study was a systematic review of the literature to explore the prevalence and incidence of prescribing errors with HRMs in hospitals. The second study was a secondary analysis of 59 existing interviews with foundation year doctors to explore the causes of prescribing errors with HRMs and compare them to those for non-HRMs reported in the same interviews. The third study was a qualitative study of the challenges of prescribing HRMs safely during the on-call period. This final study involved six focus groups with foundation year doctors (total participants number was 42). Results: Overall, findings demonstrated that there is paucity of studies that explored the prevalence of prescribing errors with HRMs and this literature showed inconsistency in definitions of prescribing errors, HRMs lists, severity scales and study methods (Study One). This resulted in a very wide range of prevalence of prescribing errors with HRMs. In terms of causes of prescribing errors with HRMs (Study Two), prescribing HRMs was considered a complex task for participants, especially those requiring dosage calculations, errors in the legal prescription requirements for controlled medications occurred with HRMs only and the on-call period was a particularly challenging period to prescribe safely especially with HRMs. In Study Three, the reasons found for this include the nature of the on-call period as a fast-paced environment, the methods of communication such as the bleep system, lack of accessibility to patient information and lack of plan from the primary team. Conclusions: HRMs form part of general medications, meaning they share similar traits, but the potentially devastating consequences of HRMs and the complicated task posed by prescribing them makes errors in their prescription profound. Therefore, HRMs need closer attention and more concern from healthcare professionals, researchers and policymakers. Such attention could result in a significant reduction in adverse outcomes and improved patient safety.

Os medicamentos são um recurso terapêutico que vêm ganhando cada vez mais importância no tratamento dos pacientes, o que tem levado várias instituições nacionais e internacionais a implementarem esforços no sentido de estimularem boas práticas de prescrição. Entretanto, várias influências têm levado médicos ao redor do mundo a adotarem práticas irracionais de prescrição, levando a custos cada vez mais elevados e riscos para a saúde dos doentes. Este estudo teve por objetivos descrever as práticas de prescrição de uma amostra de médicos de Curitiba, Paraná, a partir de respostas dadas a um questionário auto-aplicado, bem como investigar se médicos atuando na Estratégia Saúde da Família (ESF) prescrevem de forma diferente dos que atuam em Unidades Básicas de Saúde (UBS) e em outros serviços e explorar o uso de um questionário auto aplicado para este fim. Trata-se de um estudo transversal com uma amostra de conveniência. Foram entrevistados 17 indivíduos nas unidades da ESF, 22 em UBS, 5 no Hospital Universitário Cajuru e 5 no Centro Clínico Nossa Saúde através de um questionário sobre dados demográficos e com 20 questões em uma escala Likert de 5 pontos que explorava ideias a respeito da prescrição de fármacos. O escore resultante destas questões foi comparado aos dados demográficos e foi constatado que médicos sem especialidade, médicos de família e comunidade, médicos da ESF, que atuam em apenas um local de trabalho, que se encontram nas faixas etárias entre 25 e 34 anos e entre 40 e 59 anos de idade e que se formaram entre os anos de 1985 a 1994 e entre 2005 e 2012 obtiveram escores maiores. Estes resultados permitem levantar a hipótese de que médicos na cidade de Curitiba com este perfil prescrevem de forma mais racional do que seus pares. / Medicines are therapeutic options which are gaining more and more importance in the treatment of patients, leading several national and international institutions to efforts in order to stimulate good prescribing practices. However, many influences have led physicians around the world to adopt irrational prescribing practices, leading to increasingly high costs and risks to patients\' health. This study aimed to describe the prescribing practices of a sample of doctors from Curitiba, Paraná, from responses to a self-administered questionnaire as well as to investigate if doctors working in the Family Health Strategy may prescribe differently of those working in Basic Health Units and in other services and to explore the use of a self-applied questionnaire for this purpose. This is a cross-sectional study with a convenience sample. 17 individuals were interviewed in Family Health Units, 22 in Basic Health Units, 5 in the Cajuru University Hospital and 5 in the Nossa Saúde Clinical Center through a questionnaire on demographic data and 20 questions in a 5-point Likert scale that explored ideas concerning drug prescription. The resulting score from these questions was compared to demographic data and it was found that doctors with no medical specialty, family and community physicians, those working in Family Health Units, those working in just one workplace, who are in the age groups between 25 and 34 years and between 40 and 59 years of age and who graduated between the years 1985 to 1994 and between 2005 and 2012 had higher scores. These results raise the hypothesis that physicians in the city of Curitiba with this profile prescribe more rationally than their peers.

No description available.

Améliorer la qualité de la prise en charge des personnes âgées vivant en EHPAD est un impératif. L'influence des caractéristiques organisationnelles des EHPAD sur la qualité de la prise en charge des résidents est mal connue. Nos travaux de recherche ont porté sur trois objectifs : 1) Rechercher les facteurs organisationnels en EHPAD qui ont un impact sur les prescriptions potentiellement inappropriées de neuroleptiques, ces médicaments faisant l'objet d'une attention particulière chez les personnes âgées en EHPAD ; 2) Déterminer la valeur ajoutée de l'intervention d'un gériatre au sein d'EHPAD pendant 18 mois par rapport à la restitution simple d'un audit qualité, sur les prescriptions potentiellement inappropriées de neuroleptiques ; 3) Proposer des actions concrètes d'amélioration de la prise en charge globale des résidents d'EHPAD concernant notamment les transferts inappropriées des résidents d'EHPAD vers les urgences, et la prévention du déclin fonctionnel des résidents. Pour répondre aux deux premiers objectifs, nous avons utilisé les données de l'étude IQUARE (Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) un essai multicentrique comparatif ayant pour objectif d'évaluer l'impact d'une intervention globale d'éducation gériatrique pour le personnel d'EHPAD sur des indicateurs de qualité. Pour le troisième objectif, nous proposons d'une part la structuration d'un hôpital de jour ayant pour vocation de ne recevoir que des résidents d'EHPAD avec la possibilité de les prendre en charge dans des délais courts afin de limiter les transferts inappropriés des résidents d'EHPAD vers les urgences. D'autre part, nous avons participé à une task force d'experts composée de médecins gériatres cliniciens et chercheurs dont l'objectif était de proposer des actions de prévention du déclin fonctionnel des résidents d'EHPAD. Sur les 6275 résidents inclus dans IQUARE, 1532 (24.4%) avaient au moins une prescription de neuroleptique parmi lesquels 1019 (66.5%) étaient potentiellement inappropriées. Nous avons montré que les résidents d'EHPAD dans lesquels intervenait un nombre important de médecins généralistes différents (plus de 30 pour 100 lits), étaient plus à risque de recevoir une prescription inappropriée de neuroleptiques que ceux vivant dans des EHPAD avec moins de 10 médecins généralistes pour 100 lits. Dans cette même étude IQUARE, nous n'avons pas mis en évidence d'effet positif de l'intervention d'un gériatre au sein d'EHPAD pendant 18 mois par rapport à la restitution simple d'un audit qualité, sur la réduction des prescriptions inappropriées de neuroleptiques 18 mois plus tard. [...] / Improving the quality of care for nursing home residents is a real concern. A better understanding of the factors determining a good quality of care in nursing homes (NH) is necessary. This thesis deals with three aims: 1) Determining whether facility characteristics - and in particular the number of attending general practitioners (GPs) in NH - are associated with inappropriate neuroleptic prescribing ; 2) Studying the effect of a quality assurance approach in a NH, with or without the intervention of a geriatrician, on potentially inappropriate neuroleptics prescription at 18 months (T18); 3) Offering practical actions improving medical care in NH in order to reduce potentially avoidable transfers to emergency rooms and to prevent disability and functional decline for NH residents. To meet the two first objectives, we used the data from the Impact of a QUAlity exercise study on the change in practices and the functional decline of Residents in EHPAD (IQUARE), a comparative multicenter trial aiming at assessing the impact of a global education intervention for NH staff based on quality indicators. As for the third objective, on the one hand, we implemented a new day hospital characterized by its being exclusively dedicated to NH residents and its ability to provide patient care within a short period of time. On the other hand, we took part in a Task Force discussion of experts in NH care and research, to implement strategies to prevent or to slow disability and functional decline for NH residents.Among the 6275 residents included in IQUARE study, 1532 (24.4%) had at least one prescription for a neuroleptic drug. Compared with nursing homes with <10 GPs/100 beds, nursing homes with more than 30 GPs/100 beds were exposed to a greater risk of potentially inappropriate neuroleptic prescribing. We have not shown the added benefit of geriatrician intervention in a global effort to decrease potentially inappropriate neuroleptic prescribing. This result can be explained by the strong impact of the quality assurance audit restoration at each NH with a 20% decrease of the potentially inappropriate neuroleptic prescribing for the two study groups. Over this thesis, we have opened a responsive day hospital dedicated to NH residents. This day hospital could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. Improving the quality of care for nursing home residents also means preventing and/or slowing the functional decline of residents. A Task Force of experts emphasized the need for cultural change to incorporate physical activity for nursing home residents and implement multidomain interventions to delay disability. To conclude, this work has identified factors having an influence on potentially inappropriate care and suggests simple areas to improve the quality of care.

No description available.

<p>This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough.</p><p>GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection.</p><p>In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions.</p> / On the day of the public defence the status of the articles IV and V was: Accepted.

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This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough. GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection. In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions. / On the day of the public defence the status of the articles IV and V was: Accepted.

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