[Factors linked to structural quality in the guidelines for clinical practice of physiotherapy]. / Factores asociados a la calidad estructural en las guías de práctica clínica de fisioterapia.

OBJECTIVE: To identify the characteristics associated with better structural quality of protocols.Design. Analytic and transversal.Setting. Health centres in Spain with physiotherapy protocols. PARTICIPANTS: Guidelines for physiotherapy practice or protocols worked out between 1990 and 1996, inclusive. MAIN MEASUREMENTS: The design quality of the documents was evaluated by using percentages of compliance with eight explicit validated criteria and the proportion of criteria complied with in each protocol out of the total possible. To identify the characteristics linked to structural quality, multiple and logistic regression multivariate analyses were performed. RESULTS: There was greater structural quality in documents worked out by teams of over five authors and after 1992. Variables that did not affect structural quality were the source of the protocol (Insalud or autonomous community with devolved powers) and the kind of professional (only physiotherapists or multi-disciplinary) who worked it out. CONCLUSIONS: The quality of the documents varies according to the date and the number of authors who work them out. There was significantly greater quality when this was after 1992 and there were over five authors. Therefore, under the opposite circumstances (few authors), there is greater risk of low-quality documents.

[Characteristics of primary care clinical guidelines associated with greater structural quality of the document]. / Características de las guías clínicas de atención primaria que se asocian a una mayor calidad estructural.

AIM: To identify characteristics associated with greater structural quality of clinical guidelines. DESIGN: Cross-sectional study. SETTING: Health centers in the region of Murcia (southeastern Spain). MAIN OUTCOME MEASURES: All clinical practice guidelines and protocols developed between January 1985 and January 1994 were reviewed. Of the 470 documents originally obtained, 462 were evaluated and 8 were excluded because of missing data. The quality of document design was evaluated in all materials. The rate of criteria compliance was calculated for each document. The characteristics that were associated with protocol quality were identified in two types of multivariate analysis: multiple regression (with compliance rate as the dependent variable) and logistic regression (with compliance rate referred to the mean as the dependent variable). RESULTS: Both analyses showed that structural quality was associated with specific health care areas, multidisciplinary design (p < 0.001), reference to chronic health problems (p < 0.001), design of the document specifically as a clinical practice guideline (p < 0.001), and reference to the health services offered at a given center (p < 0.001). In some analyses, greater quality appeared to be associated with heath centers that were also teaching centers, reference in the document to health care, and womens health programs. CONCLUSIONS: Document quality varied significantly in different health care areas, and certain characteristics (chronic health problems, multidisciplinary design and specific design, reference to specific health services offered) were associated with greater document quality. Reference to acute health problems, design by only one type of professional (physicians or nurses), inclusion as part of a larger program, and lack of reference to specific health services offered at a given center were characteristics with a greater risk for low document quality.

[The evaluation of the structural quality of clinical physiotherapy protocols produced in primary care. Members of the Protocol Evaluation Team]. / Evaluación de la calidad estructural de los protocolos clínicos de fisioterapia elaborados en atención primaria. Miembros del equipe de evaluacíon de protocolos.

OBJECTIVE: To evaluate the quality of the design (structural) of the clinical protocols elaborated in all the health centers, ambulatory or consulting of Spain with protocolized physical therapy activities. DESIGN: Observational retrospective study lasting 7 years. SETTING: Primary care of health. PARTICIPATING: All the clinical physical therapy protocols elaborated from 1990 to 1997. MEASUREMENTS: They are elaborated 8 criteria of quality of the design of the protocols. Assessment of the reliability inter-rather of those criteria, adding explanations to two of they. It is proceeded to the evaluation of the quality of the design of 158 gathered protocols, being obtained the number from nonfulfillments. RESULTS: Compliance of the criteria: 49.36% (78) have record system. 32.91% (52) have anticipated their/its/your/his evaluation. 20.88% (33) have some algorithm. 38.6% (61) have page of history and/or specific exploration. 96.83% (153) have a minor extension of 20 pages. Only 22.15% (35) have index. 36.7% (58) do not have formal writing defects and legibility and 22.7% (36) provide bibliography. Only one of the eight criteria is complianced in more than 50% of the protocols; it being fulfilled in less than 30% other three. By and large the clinical protocols present a total of 758 defects, with a defects average by protocol of 5.24 (0 defects in a case). CONCLUSIONS: The structural quality of the clinical physical therapy protocols elaborated in primary attention until 1997 is decreases (globally fulfil 40.03% of the proposed criteria). The decrease quality of the protocols is significantly heterogeneous between the autonomous community and the elaboration years. They are necessary corrective measures to improve this situation.

[The evaluation of the quality of so-called "clinical protocols" in primary care developed in the Autonomous Community of Murcia. The Group for the Evaluation and Improvement of Clinical Protocols]. / Evaluación de la calidad de los denominados "protocolos clínicos" de atención primaria elaborados en la Comunidad Autónoma de Murcia. Grupo de Evaluación y Mejora de los Protocolos Clínicos.

OBJECTIVE: To evaluate the quality of the design (structural) of the clinical protocols worked out in the Murcia region. DESIGN: Descriptive evaluation. Retrospective, over 8 years. SETTING: Primary health care. PARTICIPANTS: The professionals from the 31 health centres in the Murcia Region with activities covered by protocols. MEASUREMENTS AND MAIN RESULTS: The 519 documents written between January 1985 and January 1994, of which 470 were obtained and classified, were the object of the study. 11 criteria for the design quality of the protocols were worked out, based on the bibliography and a previous experiment. The inter-observer reliability of these criteria were assessed and two of them were rejected. Then the quality of the protocols design was evaluated through rates of compliance with the 9 standard and previously validated explicit criteria. 55.1% (259) of the documents fitted the accepted definition of protocol. 42.3% (199) had a recording system. 20.2% (95) had foreseen their evaluation. 41.7% (196) had some algorithm. 38.1% (179) had an anamnesis and/or examination page. 88.9% (418) were under 20 pages. Only 11.9% (56) had an index. 57.7% (271) had no formal defects of hand-writing or legibility. Only 14.7% (69) had a bibliography. Only three of the nine criteria were satisfied in over 50% of cases; three more, in under 30%. Overall, the clinical protocols had 2488 defects, with an average per protocol of 5.29. CONCLUSIONS: The formal quality of the primary care clinical protocols worked out in the Autonomous Community of Murcia is very low. Corrective measures to improve this situation should be taken.

[The factors that influence the use of clinical protocols according to the opinion of health center coordinators. The Research Group on the Evaluation and Improvement of Clinical Protocols]. / Factores que influyen en el uso de los protocolos clínicos, según la opinión de los coordinadores de los centros de salud. Grupo de Investigación sobre Evaluación y Mejora de los Protocolos Clínicos.

OBJECTIVES: To find the factors that affect the use of clinical protocols in primary care, in the view of primary care team coordinators, and the reasons why they are little followed, and to bring together suggestions for improvement. DESIGN: An opinion study, through a telephone survey. SETTING: Primary health care. The health centres in Murcia with protocolized activity: 31 at the start of the project. PARTICIPANTS: The coordinators and those in charge of nursing, 62 people in all. MEASUREMENTS AND MAIN RESULTS: After a pilot study, a structured telephone survey was carried out, administered by a trained interviewer who posed two open questions: why do you think that the professionals at your centre do not use the existing protocols more often? and: what suggestions would you make to improve the protocols and have them used more? A specialist company did the field-work in June and July 1996. There was a 98% reply rate. To the first question, coordinators thought that low use could be explained by excess demand and lack of time for consultations (33% of all replies), although they also cited other organisational problems in the centre, defects in protocols and lack of training. Those in charge of nursing gave very similar replies, with excess demand (39%) predominating. To the second question, on increasing the use of protocols, coordinators suggested that the protocols needed to be improved (44.8% of replies), and also cited the need for improvements in organisation and on-going training. Very similar answers came from the nursing side, where 43.5% highlighted the need to improve the protocol documents. CONCLUSIONS: The coordinators assumed that the clinical protocols were used little and could be improved. In their view the basic reason for their low use is excessive pressure from the patient-load. The key to using them more is improvement in the protocol documents.

[Reasons for anxiety in primary care professionals. A resident-tutor comparison]. / Motivos de ansiedad en los profesionales de atención primaria. Comparación residentes-tutores.

OBJECTIVES: 1) To find the reasons for PC professionals' anxiety when going about their normal work. 2) To check whether training and experience affect the assessment of the reasons of Family Doctors for anxiety. DESIGN: A descriptive study using a questionnaire. SETTING: PC health centres with second-year family and community medicine (FCM) residents from the Murcia Teaching Unit. PARTICIPANTS: All second-year FCM residents from the Teaching Unit (28) in December 1995 and their tutors. MEASUREMENTS: Open questionnaire based on three points: Causes of anxiety in on-demand consultations; causes of anxiety in scheduled consultations; other reasons for anxiety connected with the Health Centre. RESULTS: The three most anxiety-producing causes in relation to each question were: a) on-demand consultation: residents (R)--unfinishable consultations, lack of time, clinical problems; tutors (T)--unfinishable consultations, a lot of patients waiting outside, manipulative patients. b) Scheduled consultation: R--clinical problems, consultation too long, difficulties in reaching a solution; T--consultation too long, patients without an appointment and interruptions in the middle of the consultation. c) Other reasons for anxiety: R--not being off the day after being on call, having to do research work, and emergency calls; T--emergency calls, research work and temperature problems. CONCLUSIONS: Clinical problems are the causes of anxiety with the greatest difference between tutors and residents. Regulated training in the health centre and professional experience seem to act positively on some of the causes of anxiety.

[An evaluation of the protocols of the CME program. Do they satisfy the criteria for the working out of clinical protocols?]. / Evaluación de protocolos del programa FMC. Cumplen los criterios para la elaboración de protocolos clínicos?

OBJECTIVE: To evaluate the protocols published in the journal Formación Médica Continuada (FMC) since its appearance. DESIGN: An evaluation study. SETTING: The journal FMC in Primary Care. PARTICIPANTS: Clinical protocols (11) published by the journal, and the people who have composed them. INTERVENTIONS: An evaluation based on the criteria for composing clinical protocols proposed by Saura et al. MAIN RESULTS: Overall these proposals complied with 56.9% of the proposed criteria. None of them (0%) complied with all the norms that a protocol must meet. On analysing independently each criterion, the following were satisfied in all the protocols evaluated: the designation, index of pages, definition of the problem and bibliography. The protocol for COPE in Primary Care satisfied 75% of the criteria and was the protocol which complied with most criteria. The battered child protocol satisfied 41.66% of the criteria and was the protocol satisfying the least number of criteria. CONCLUSIONS: These are good protocols, in that overall they satisfy a large part of the proposed criteria, despite the fact that these are demanding criteria. However they can and must improve.

[Research in action. How to assist the integration of residents of family and community medicine in health centers]. / Investigación en la acción. Cómo facilitar la incorporación de los residentes de MFyC al centro de salud.

OBJECTIVES: To find the causes of worry in second-year family and community medicine (FCM) residents on their arrival at health centres. DESIGN: A descriptive study. A survey with 4 questions on difficulties found in the on-demand clinic, in consultations by appointment, other causes of anxiety and problems foreseen a priori. SETTING: Health centres in the Murcia Region with second-year FCM residents. PARTICIPANTS: All the second-year FCM residents (28) on their arrival at health centres in November, 1995. RESULTS: The three points of most concern to residents were: 1. On-demand clinic: unfinishable consultations, lack of time and clinical problems. 2. Consultations by appointment: clinical problems, over-long consultations and difficulties in resolving the consultations. 3. Other causes of anxiety: not having the day off after being on call, research work and emergencies. 4. Problems foreseen a priori: a lot of patients in a short time, not creating problems for the tutor and unemployment at the end of the residency. CONCLUSIONS: The short time to attend each patient and clinical problems are what cause most difficulty. This was the first time the difficulties residents had to integrate into Health Centres were surveyed. The initiative was greatly appreciated by them.

[Reliability of coding of diagnoses recorded in the computerized information system at primary health care centers]. / Fiabilidad de la codificación del diagnóstico registrado en las hojas de consulta del sistema de información informatizado de centros de atención primaria (SICAP).

OBJECTIVE: To find the reliability of the coding of diagnoses in the doctor's note in this computer system and to analyse where there are most discrepancies. DESIGN: An observational study. The concordance between the reason for consultation, codified by an external assessor, and the coding of the main diagnosis. SETTING: Health Districts 17 (Murcia/Barrio del Carmen) and 66 (Molina de Segura/La Ribera) in the Autonomous Community of Murcia. PATIENTS: A sub-sample of 228 consultations, belonging to a larger study of 1,904 general medical consultations (total: 98,768 consultations). MEASUREMENTS AND MAIN RESULTS: There were discrepancies between the coding of the reason for consultation and the diagnosis in 23% of the consultations recorded. The reason for consultation was not correctly recorded in 12.3%. The diagnostic group or section with the highest level of agreement was number XVIII or the supplementary section; and with the least agreement in XVII (injuries and adverse side-effects) and Number V covering mental disorders. CONCLUSIONS: Quality control of information and its validation enables errors and problems in the systems to be identified and corrected. This study points to the need to improve the filling-out of the reason for consultation and activity carried out, in order to obtain afterwards a more reliable coding of the diagnosis.