Patients' experiences and satisfaction with out-of-hours GP home visiting provided by a GP cooperative.

BACKGROUND: Within the UK, patients place a fairly high value on the out-of-hours GP home visiting service. Although satisfaction with the range of out-of-hours services has been found to be high, little is known about patients' specific experiences of the home visiting services. OBJECTIVE: To investigate the satisfaction with, and experiences of, patients receiving a GP out-of-hours (OOH) home visit from a GP cooperative. METHODS: A postal questionnaire study sent to all patients receiving a home visit from a single cooperative. The questionnaire asked patients a range of questions about their experiences of the home visiting service that they received and also contained a validated satisfaction measure. RESULTS: The OOH home visiting services largely provide care for an older population, most of whom consider that they are either too ill to travel or have limited mobility. The majority (43%) of home visits are made during the daytime at weekends, with just 25% of visits made during the night-time. If the home visit was not available, 67% of patients stated that they would have phoned for an ambulance or gone directly to hospital. The majority of patients (87%) were satisfied with the overall home visiting service that they received; however, 32% of patients were dissatisfied with the time it took for them to see a doctor or a nurse. CONCLUSIONS: Although the OOH services have received considerable criticism over the past 5 years, this study reveals that patients remain largely satisfied with the service and would have called 999 or gone directly to hospital if there had been no service.

Potential barriers to the laparoscopic management of ectopic pregnancies: a regional UK study.

In this regional UK study across seven hospitals, we examined the potential barriers to undertaking a laparoscopic approach to the surgical management of ectopic pregnancies. Across the region 84% of surgically managed ectopic pregnancies were undertaken laparoscopically, although out of hours operating resulted in a higher rate of laparotomies. Trainees perceived themselves to be competent in carrying out laparoscopy for ectopic pregnancies and reported their training as adequate. Perceived barriers to training were a lack of operating time, service commitments, reduced working hours arising from the European working directive, and a lack of laboratory training facilities. In order to maintain and improve the laparoscopic rate for the management of ectopic pregnancies, it is necessary to ensure that trainees have more supervised operating time and better access to laboratory training facilities.

Adult cystic fibrosis patients' experiences of primary care consultations: a qualitative study.

BACKGROUND: "Expert patient" programmes have been introduced in the UK as a new approach to chronic disease management for the 21st century. The average survival age of those with cystic fibrosis (CF) has steadily increased such that the majority of those with the condition now live into adulthood. Currently, specialist CF centres deliver the core of medical care, with primary care providing access to prescribed medicines, referral to other services, and care of non-CF needs, however, it is necessary to provide a more comprehensive service for adult CF patients, involving both specialist centres and primary care. To date, little is known about these expert patients' experiences of primary care. AIM: To investigate how young adults with CF perceive and experience primary healthcare services. DESIGN OF STUDY: Qualitative study. SETTING: One specialist CF centre in southeast England. METHOD: Interview study of 31 patients with CF, aged 18 years or over. RESULTS: Adults with CF consult in primary care on two distinct levels: as lay and expert patients. When consulting as experts, patients tend to operate as consumers of health care and perceive a satisfactory doctor-patient relationship to be influenced by three factors: GPs' understanding of how people live with CF, GPs' ability to prescribe certain specialist medications, and sensitive management of the cost of health care for adults with CF. A doctor-patient relationship based on trust and understanding is seen as desirable, but requires that these factors are addressed both by the GP and the patient. CONCLUSION: Expert patient policy has focused on the role of patients with common chronic conditions in secondary and tertiary care, with little consideration of how adults with rare chronic illness and their GPs manage health problems that can be addressed in primary care. Enabling easy access to holistic care, as well as establishing successful trusting relationships with people with long-term rare conditions, is a necessary foundation for expert patients to take an active role in their care.

The changing face of obstetric fistula surgery in Ethiopia.

OBJECTIVE: To examine the incidence and type of obstetric fistula presenting to Hamlin Fistula Ethiopia over a 4-year period. STUDY DESIGN: This is a 4-year retrospective survey of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia, where approximately half of all women in the country are treated. The operation logbook was reviewed to identify all new cases of obstetric fistula presenting from 2011 to 2015. New cases of urinary fistula were classified by fistula type (high or low), age, and parity of the woman. RESULTS: In total, 2,593 new cases of urinary fistulae were identified in the study period. The number of new cases fell by 20% per year over the 4 years (P<0.001). A total of 1,845 cases (71.1%) were low (ischemic) fistulae, and 804 cases (43.6%) of these had an extreme form of low circumferential fistula. A total of 638 (24.6%) women had a high bladder fistula, which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy, and 110 (4.2%) women had a ureteric fistula. The incidence of high fistulae increased over the study period from 26.9% to 36.2% (P<0.001). A greater proportion of multiparous women had a high bladder fistula (70.3%) compared with primigravid women (29.7%) (P<0.001). Conversely, a greater proportion of primiparous women experienced a low circumferential fistulae (68.6%) compared with multiparous women (31.4%) (P<0.001). CONCLUSION: There appears to be a decline in the number of Ethiopian women being treated for new obstetric urinary fistulae. However, the type of fistula being presented for treatment is changing, with a rise in high fistulae that very likely occurred following cesarean section and a decline in the classic low fistulae that arise following obstructed childbirth.

Can a community-based maternal care package in rural Ethiopia increase the use of health facilities for childbirth and reduce the stillbirth rate?

OBJECTIVE: To measure the impact of a maternal health package on health facility delivery and stillbirth rates. METHODS: This is a cross-sectional study in Ethiopia where a maternal package was integrated into eight health centers across three regions. The package included trained midwives with a mentoring program, transport for referral, and equipment and accommodation for the midwives. Ten health centers without the package but in the same districts as the intervention centers and eight without the package in different districts were randomly selected as the comparison groups. Women living in the catchment areas of the 26 health centers, who delivered a baby in the past 12 months, were randomly selected to complete a face-to-face survey about maternal health experiences. RESULTS: The maternal package did not significantly affect the stillbirth or facility delivery rates. Women were positively influenced to deliver in a health facility if their husbands were involved in the decision concerning the place of birth and if they had prior maternal experience in the health center. Barriers to delivering in a health facility included distance and ability to read and write. CONCLUSION: Women served by health centers with a maternal health package did not have significantly fewer stillbirths and were not more likely to deliver their babies in a health facility. Husbands played an important role in influencing the decisions to deliver in a health facility.

What is being assessed in the MRCGP oral examination? A qualitative study.

BACKGROUND: Oral examinations are a popular method of assessment within medicine, being capable of measuring candidates' ability to carry out tasks or develop skills (operational knowledge). One example of this is the oral examination for membership of the Royal College of General Practitioners (RCGP), which is designed to assess candidates' decision-making skills and the professional values that underpin these decisions. While the reliability of oral examinations has been investigated, to date, little is known about their ability to measure what they set out to measure (validity). AIM: To investigate the content validity of the MRCGP oral examination, with particular focus on its ability to assess the process of decision-making. DESIGN OF STUDY: An evaluation of oral examination video recordings, using qualitative methods. METHOD: The MRCGP oral examinations are video recorded as part of an ongoing quality assurance programme. Fifty of the recordings carried out in 2002 were selected randomly and analysed for content and dialogue patterns reflecting the assessment of the decisionmaking process. RESULTS: All examiners used the specified contexts outlined in the examination objectives to present candidates with dilemmas. The assessment of decision-making skills, however, was limited by a tendency among examiners to present the candidate with new, more complex dilemmas rather than giving them the opportunity to discuss the implications, make choices and ultimately, justify their decision. Moreover, while examiners frequently asked candidates questions relating to professional values, they rarely asked them to demonstrate how those values support their decisions. CONCLUSION: In order that the benefits of oral examination can be fully realised, questions need to be structured in a way that encourages candidates to discuss all stages of the decision-making process.

Why do general practitioners from France choose to work in London practices? A qualitative study.

BACKGROUND: Growing concerns about the ability to maintain and increase the general practitioner (GP) workforce has led to active recruitment of GPs from overseas. However, little is known about why these GPs choose to leave their countries and come to work in London. AIM: To investigate the motivations and expectations of French GPs migrating to work in general practices in London. DESIGN OF STUDY: A qualitative study using semi-structured interviews. SETTING: General practice induction programme in southeast London. METHOD: Individual interviews with 31 French GPs, who attended an induction programme for international recruits, were taped, transcribed, and analysed using a categorical approach. RESULTS: Three factors led to the process of migration: instigating factors, creating the stimulus for migration; activating factors, based on the perception that English general practice offered greater opportunities; and facilitating factors, which make migration possible. Particular emphasis was placed on personal and professional instigating factors, with a desire for new cultural experiences and a widespread discontent surrounding the infrastructure of French general practice, playing crucial roles in the stimulus to migrate. Ease of travel and a paid induction programme facilitated the move to their chosen destination. CONCLUSION: French GPs' decisions were part of a process of migration influenced by a series of integrated factors. Consideration of these factors will not only enhance recruitment to English general practice, but will also facilitate foreign GPs' transition to work in the National Health Service (NHS) and, ultimately, maximise their retention.

Endometriomas as a marker of disease severity.

STUDY OBJECTIVE: Although superficial endometriosis can be treated effectively and safely by most gynecologic surgeons, deep infiltrating disease (DIE) needs to be treated in specialist endometriosis centers. For women to be treated in the most appropriate setting, it is necessary to identify if they have DIE. DESIGN: Prospective observational study (Canadian Task Force classification II-2). SETTING: Dedicated pelvic pain clinic attracting both secondary and tertiary referrals. PATIENTS: A total of 295 women with histologically confirmed endometriosis. INTERVENTIONS: Prospective intraoperative data were collected to investigate the role of endometriomas as a marker for DIE, and in particular, rectosigmoid disease. MEASUREMENTS AND MAIN RESULTS: In all, 61 (21%) women had an endometrioma. A significantly greater proportion of women with an endometrioma had accompanying endometriotic disease affecting the bowel compared with women without an endometrioma (77% vs 21%; p<.001). A strong relationship existed between presence of endometrioma and posterior cul-de-sac obliteration, rectosigmoid disease, and involvement of the seromuscular layer of the bowel. The presence of an endometrioma significantly increased the probability of having rectosigmoid disease, with a positive likelihood ratio of 6.96 (95% CI; 4.04-12.00). However, the absence of an endometrioma did not preclude having rectosigmoid disease, with a negative likelihood ratio of 0.55 (95% CI; 0.45-0.67). CONCLUSION: Although endometriomas provide a useful marker for DIE, the absence of an endometrioma does not preclude the presence of DIE, although a significantly lower proportion of women without an endometrioma will have DIE when compared with women with an endometrioma.