How do they measure up? Differences in stakeholder perceptions of quality measures used in English community nursing.

OBJECTIVES: To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers. METHODS: A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users. RESULTS: Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care. CONCLUSIONS: Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders.

Made to measure? Assessing feasibility of quality indicators for district nursing.

UNLABELLED: Scant empirical information exists regarding the quality of district nursing (DN) services. This article reports the testing of 31 quality indicators (QI) in practice. METHOD: Twelve DN teams provided patient notes for audit. External auditors completed audit forms by cross-referencing between DN office records, patient notes from home, electronic GP records and discussions with DN team leaders. A patient experience questionnaire was piloted. FINDINGS: 277 (77%) patients' records were audited. Access to records was problematic. QIs required further refinement of their wording, modification of inclusion criteria, deletion of some QIs and inclusion of others. Telephone administration of the patient experience questionnaire was not feasible for the DN patient population. CONCLUSIONS: QIs can not be used 'off the shelf' and need testing and modification before routine use. Trained, external auditors with clinical backgrounds ensure an informed, uniform, objective approach to data collection, which is desirable as QIs might inform commissioners in a competitive field in future.

Developing quality indicators for community services: the case of district nursing.

BACKGROUND: Quality indicators exist for the acute and primary care sectors in the National Health Service (NHS), but until recently little attention has been given to measuring the quality of community services. The innovative project described in this paper attempted to address that gap. OBJECTIVES: To produce a framework for developing quality indicators for Bristol Community Health services. To develop a set of initial indicators for Bristol Community Health services using the proposed framework. METHOD: After familiarising ourselves with community services and NHS policy, gathering the views of stakeholders and consulting the literature on quality indicators, we designed a framework for indicator development, using the 'test' case of the district nursing service. The long list of possible indicators came from best practice guidelines for wound, diabetes and end of life care, the three conditions most commonly treated by district nurses. To narrow down this list we surveyed and held workshops with district nurses, interviewed service users by telephone and met with commissioners and senior community health managers. RESULTS: The final set of quality indicators for district nurses included 23 organisational and clinical process and outcome indicators and eight patient experience indicators. These indicators are now being piloted, together with two potential tools identified to capture patient reported outcomes. CONCLUSION: Developing quality indicators for community services is time consuming and resource intensive. A range of skills are needed including clinical expertise, project management and skills in evidence-based medicine. The commitment and involvement of front-line professionals is crucial.

Monitoring Change in Families Receiving Primary Mental Health Specialist Services: A Pragmatic Evaluation Within an Existing Service for the Under-Fives.

BACKGROUND: Specialist CAMHS-based services for pre-school age children are being introduced in the UK using different models of care. The clinical value of these new services requires assessment. METHOD:   Over 20 months a Primary Mental Health Specialist (Under 5s) service operating in South West UK was evaluated on a variety of themes including effectiveness. Recruited clients completed questionnaires on their own well-being (on two occasions) and their child's behaviour (on three occasions) over the intervention period. RESULTS: Of the 67 carers assessed at or shortly after recruitment using the General Health Questionnaire, 55.2% were at high risk of having a clinically significant affective mental condition. Despite a trend towards improvement, neither the GHQ-12 total score nor the proportion meeting the clinical criterion was statistically significantly reduced. The main index of child behaviour and emotional state demonstrated a statistically significant reduction in the number of disturbance-indicating behaviours over the service intervention period. The largest changes occurred between recruitment and the 4th visit. Selection bias cannot be excluded. CONCLUSIONS: Significant changes determined over a relatively short period of intervention is consistent with an effect of service, but direct attribution demands care as no control groups were included.

Developing attributes and levels for discrete choice experiments using qualitative methods.

OBJECTIVES: The rigour with which the first two stages of discrete choice experiments (attribute development and the choice of levels of these attributes) are generally conducted is questionable. This paper provides a case study describing how attributes and their levels were developed for a study of access to dermatology specialist services for non-urgent skin conditions. METHODS: Semi-structured interviews were conducted with 19 dermatology patients with non-urgent skin conditions. Informants were purposively sampled for maximum variation and interviews continued until all attributes were fully and clearly defined. An iterative approach was used with data collection and analysis proceeding concurrently. RESULTS: The interviews and parallel analysis generated three iterations. The first iteration comprised early exploratory work with expertise and waiting time emerging as important to informants. The second iteration continued to emphasize these attributes, but individualized care and convenience were added. By the end of the third iteration all attributes were fully elaborated. CONCLUSIONS: Qualitative methods enabled attributes to be defined. There was clear tension between the aim in qualitative work to explore and describe, and the reductiveness needed to encapsulate the different aspects of the service within a minimum number of attributes for use in the discrete choice modelling. Improved reporting of the methods of attribute development in all discrete choice experiments is required.

Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials.

BACKGROUND: The role of nurse practitioners in primary care has recently expanded. While there are some outcome data available for different types of consultations, little is known about the relative cost. AIM: To compare the cost of primary care provided by nurse practitioners with that of salaried GPs. DESIGN OF STUDY: Synthesis, modelling, and analysis of published data from the perspective of general practices and the NHS. DATA SOURCES: Two published randomised controlled trials. METHOD: A dataset of resource use for a simulated group of patients in a typical consultation was modelled. Current unit costs were used to obtain a consensus mean cost per consultation. RESULTS: Mean cost of a nurse practitioner consultation was estimated at 9.46 UK pounds (95% confidence interval [CI] = 9.16 to 9.75 pounds) and for a GP was 9.30 UK pounds (95% CI = 9.04 to 9.56 pounds) according to salary and overheads, that is, from the perspective of general practices. From the NHS perspective, which included training costs, the estimated mean costs were 30.35 UK pounds (95% CI = 27.10 to 33.59 pounds) and 28.14 UK pounds (95% CI = 25.43 to 30.84 pounds) respectively. Sensitivity analysis suggested that the time spent by GPs contributing to nurse practitioners' consultations (including return visits) was an important factor in increasing costs associated with nurse practitioners. CONCLUSION: Employing a nurse practitioner in primary care is likely to cost much the same as employing a salaried GP according to currently available data. There is considerable variability of qualifications and experience of nurse practitioners, which suggests that skill-mix decisions should depend on the full range of roles and responsibilities rather than cost.

Economic evaluation of a general practitioner with special interests led dermatology service in primary care.

OBJECTIVE: To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care. DESIGN: Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial. SETTING: General practitioner with special interest dermatology service covering 29 general practices in Bristol. PARTICIPANTS: Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest. INTERVENTIONS: Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care. MAIN OUTCOME MEASURES: Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial. RESULTS: Costs to the NHS for patients attending the general practitioner with special interest service were 208 pounds sterling (361 dollars; 308 euro) compared with 118 pounds sterling for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were 48 pounds sterling and 51 pounds sterling, respectively; costs of lost production were 27 pounds sterling and 34 pounds sterling, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were 540 pounds sterling per one point gain in the dermatology life quality index and 66 pounds sterling per 10 point change in the access scale. CONCLUSIONS: The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes.

Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial.

OBJECTIVE: To assess the effectiveness, accessibility, and acceptability of a general practitioner with special interest service for skin problems compared with a hospital dermatology clinic. DESIGN: Randomised controlled trial. SETTING: General practitioner with special interest dermatology service and hospital dermatology clinic. PARTICIPANTS: Adults referred to a hospital dermatology clinic and assessed by a consultant or the general practitioner with special interest service,. Suitable patients had non-urgent skin problems and had been identified from the referral letter as suitable for management by a general practitioner with special interest. INTERVENTIONS: Participants were randomised in 2:1 ratio to receive management by a general practitioner with special interest or usual hospital outpatient care. MAIN OUTCOME MEASURES: Primary outcomes were disease related quality of life (dermatology life quality index) and improvement in patients' perception of access to services, assessed nine months after randomisation. Secondary outcomes were patient satisfaction, preference for site of care, proportion of failed appointments, and waiting times to first appointment. RESULTS: 49% of the participants were judged suitable for care by the general practitioner with special interest service. Of 768 patients eligible, 556 (72.4%) were randomised (354 to general practitioner with special interest, 202 to hospital outpatient care). After nine months, 422 (76%) were followed up. No noticeable differences were found between the groups in clinical outcome (median dermatology life quality index score = 1 both arms, ratio of geometric means 0.99, 95% confidence interval 0.85 to 1.15). The general practitioner with special interest service was more accessible (difference between means on access scale 14, 11 to 19) and waited a mean of 40 (35 to 46) days less. Patients expressed slightly greater satisfaction with consultations with a general practitioner with special interest (difference in mean satisfaction score 4, 1 to 7), and at baseline and after nine months 61% said they preferred care at the service. CONCLUSIONS: The general practitioner with special interest service for dermatology was more accessible and preferred by patients than hospital outpatient care, achieving similar clinical outcomes. Trial registration ISRCTN31962758.

What prevents older people from seeking treatment for urinary incontinence? A qualitative exploration of barriers to the use of community continence services.

BACKGROUND: Urinary incontinence is a significant health problem for older people. Many people with incontinence do not seek services. Simple and effective treatments exist in primary care. OBJECTIVES: Our aim was to explore reasons why older people living in the community do not present for help with problems of urinary incontinence and to identify ways in which they may be assisted to access continence services. METHODS: In-depth interviews lasting an average of 1 h were conducted with 20 people aged over 65 years living in the community, purposively selected from a sample of patients who volunteered to be interviewed. RESULTS: Older people described ageing as a natural, degenerative process and had reduced health expectations. Urinary incontinence was commonly viewed as an inevitable aspect of ageing and, as such, something to be accepted and managed independently. Shame and embarrassment combined with generational differences in attitudes to disclosure about personal matters also prevented people from seeking advice. Relatively successful strategies to manage incontinence enabled people to contain their symptoms, although this was at a social, psychological and, in some cases, health cost. Older people in this sample had considerable co-morbidity, in many cases resulting in mobility problems. Despite regular contact with primary care professionals, they had seldom disclosed their urinary incontinence. CONCLUSION: A combination of personal attitudes and practical barriers prevent older people from seeking help for urinary incontinence. It is possible that older people would be more likely to seek help if asked specifically about urinary leakage by primary health care professionals.

Factors associated with variations in older people's use of community-based continence services.

Many people who have urinary incontinence and who may benefit from healthcare and professional advice do not currently access UK National Health Service services, even though effective treatments are available in the community. Older people have an increased prevalence of incontinence and a correspondingly increased need for continence services. Therefore, increasing older people's access to continence services has the potential to reduce inequalities and improve quality of life. The present study aimed to identify older people with urinary incontinence living in the community, to describe and compare the characteristics of users and non-users of continence services, and to identify factors which prevent older people seeking help. A cross-sectional postal survey of patients aged over 65 years registered with four general practices in an urban area found an overall prevalence of 39% of older people with urinary incontinence, only 15% of whom had accessed services. Two-thirds of respondents who reported that they experienced urinary leakage several times per week to all the time, and up to two-thirds of those reporting leakage of moderate or large volumes of leakage had not accessed services. The majority of older people are in regular contact with health professionals, and the greatest single influence on use of services was that of being asked whether there were continence problems by a health professional. Being married or having a partner, experiencing less pain generally, and suffering relatively high frequency and volumes of urinary leakage also appeared to be associated independently with continence service use. In conclusion, there appears to be considerable unmet need for continence services. Health professionals should be aware that incontinence is an important health problem for older people, and by asking older people specifically about urinary leakage, they could reduce inequalities in use of services.

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.

OBJECTIVE: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting. DESIGN: Systematic review of randomised controlled trials and prospective observational studies. DATA SOURCES: Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies. INCLUDED STUDIES: Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care. RESULTS: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations. CONCLUSION: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.