Patients in Europe evaluate general practice care: an international comparison.

BACKGROUND: Patients' evaluations can be used to improve health care and compare general practice in different health systems. AIM: To identify aspects of general practice that are generally evaluated positively by patients and to compare opinions of patients in different European countries on actual care provision. METHOD: An internationally-validated questionnaire was distributed to and completed by patients in 10 European countries. A stratified sample of 36 practices per country, with at least 1080 patients per country, was included. A set of 23 validated questions on evaluations of different aspects of care was used, as well as questions on age, sex, overall health status, and frequency of visiting the GP. RESULTS: The patient sample included 17,391 patients in 10 different countries; the average response rate was 79% (range = 67% to 89%). In general, patients visiting their general practitioner (GP) were very positive about the care provided. For most of the 23 selected aspects of care more than 80% viewed care as good or excellent; in particular, keeping records confidential, GP listening to patients, time during consultations, and quick services in case of urgent problems were evaluated positively. Patients were relatively negative about organisational aspects of care. The evaluations in different countries were largely similar, with some interesting differences; for instance, service and organisational aspects were evaluated more positively in fee-for-service health systems. CONCLUSIONS: Patients in Europe are positive about general practice but improvements in practice management in some countries are requested. More research is needed to study the complex field of differences in expectations and evaluations between countries with different health systems.

Effect of mailed reminders on the response rate in surveys among patients in general practice.

Randomized trials were performed in Denmark and The Netherlands to determine the effect of mailed reminders on the response rate in surveys among patients in general practice. In both countries, general practitioners handed out questionnaires to 200 adult patients who came to visit them. An intervention group of 100 patients received reminders at 3 weeks after the visit, whereas a control group of the remaining 100 patients did not receive reminders. The response rate was significantly higher in the intervention groups than in the control group in The Netherlands (86% versus 55%, respectively) but not in Denmark (87% versus 81%, respectively). Mailed reminders can improve the response rate in surveys related to a general practice, but they are not effective in all situations.

Patients' priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP).

BACKGROUND AND OBJECTIVES: Improving the sensitivity of general practice to patients' needs demands a good understanding of patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ? METHODS: Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared. RESULTS: A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of patients' characteristics may have played a role in these differences. DISCUSSION: The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor-patient communication and accessibility of services are concerned.

[Interpretation of questionnaires. An translation method problem]. / Oversettelse av spørreskjema. Et oversett metodeproblem.

For use in a different cultural background, translated questionnaires need to be validated in the new context. International guidelines are needed for such validation, as precision in translation is an important methodological issue. The article consists in a review of the issue and recommended guidelines for the translation and validation of questionnaires, based on the authors' experience and international literature in the field. The authors participate in a European research programme (EU/BIOMED-Europep), set up to develop a questionnaire for exploring patients' priorities and their evaluations of important aspects of general practice.

General practice care and patients' priorities in Europe: an international comparison.

Insight into patients' priorities with respect to health care should complement the views of professionals and policy makers on what is thought to be appropriate health care. To determine the strengths and weaknesses of general practice care from patients' perspectives written surveys were performed among patients in Denmark, Germany, Israel, Netherlands, Norway, Portugal, Sweden and United Kingdom (n = 3540). The potential quality problems identified were spread over the different countries: the low involvement of general practitioners in out-of-hours services in Portugal; the low provision of routine screening in Sweden, Norway and The Netherlands; the lack of a defined patient population in Germany; the lack of a formal gatekeeper role to secondary care in general practice in Germany and Sweden; and the low number of home visits in Sweden.

Patients' knowledge and attitudes regarding sleep and hypnotics.

OBJECTIVE: To examine attitudes, opinions and knowledge regarding hypnotics and their use, sleep and sleep requirements among patients who have used hypnotics. DESIGN: A mailed questionnaire. SETTING: A primary health care centre serving 18,500 inhabitants. PATIENTS: 143 randomly selected patients for whom hypnotics had been prescribed at the health care centre at any time during the year previous to the study. MAIN OUTCOME MEASURES: Answers to 21 questions about sleep, sleep requirement, use and effect of hypnotics. RESULTS: Regular use of hypnotics over long periods is common. Participants endure sleeping problems before beginning to use hypnotics. Once on pills most patients take hypnotics without first trying to fall asleep. Knowledge about sleeping hygiene was good and household remedies are much used. Feelings of guilt about using hypnotics were not common. Elderly people were less informed than younger about the effects and disadvantages of use of hypnotics. CONCLUSION: Most patients are well informed about the benefits of hypnotics and possible abuse or addictive effects. Most begin using hypnotics after long-standing sleep problems and after trying various household remedies. Doctors have a lot of influence on patients' use of hypnotics and need to inform their patients well when hypnotics are first prescribed.

Is hypertension changing? Blood pressure development in cohorts of 50-year-old men between 1963 and 1993.

OBJECTIVE: To study secular trends in the prevalence and treatment of hypertension in the general population, and the disease course. DESIGN: Health examinations of cohorts of 50-year-old men in 1963, 1973, 1983 and 1993. SETTING: The city of Göteborg, Sweden (about 400,000 inhabitants). PARTICIPANTS: Random population samples of 50-year-old men. MAIN OUTCOME MEASURE: Mean blood pressure (BP) levels in the populations and among treated hypertensives, proportions of hypertensives, and frequency of high BP values (> or = 160/and or 95, and > or = 175/115 mmHg, respectively). RESULTS: The mean population BP decreased from 138.4/89.0 mm to 128.7/84.4 mmHg during the 30-year period (p < 0.0001). Mean BP levels among treated hypertensives decreased from 170/113 to 142/94 mmHg (p < 0.0001), and the proportion of men with high BP values diminished from 3.9 to 0.1%. Also BP levels among normotensives decreased significantly (p < 0.0001). CONCLUSION: The findings could partly be seen as a result of successful case-finding and treatment of hypertension in the region, but alteration of the natural course of hypertension cannot be excluded.

The concept of individualized hypertension care in general practice and outpatient clinics. The general practitioner hypertension practice study (III).

OBJECTIVE: To examine test ordering practice among general practitioners and hospital medical specialists according to the concept of individualized hypertension care. DESIGN: Mailed hypothetical case histories, with reference panels to categorize tests. SETTING: Uppsala-Orebro region in mid-Sweden. SUBJECTS: General practitioners (N = 90) and hospital medical specialists (N = 69) in randomly sampled primary health care centres and hospitals. MAIN OUTCOME MEASURES: Test ordering scores. RESULTS: 84% of invited GPs and 72% of specialists participated. According to reference panel standards, primary care physicians performed 75% of obligatory tests and specialists 88%. Superfluous tests constituted a larger proportion of the practice of hospital specialists (11-28%) than GPs (2-12%) in the six cases. Summarized examination scores revealed a wide practice variation within and between the two physician categories, specialists scoring significantly higher in three cases. Standardization of practice was more common among specialists, and differed significantly regarding serum potassium test, chest X-ray and ECG. Both groups deviated from current guidelines by omitting metabolic parameters. CONCLUSION: There is considerable practice variation in individualized hypertension care, which might influence treatment outcome. Practice audit and continuing medical education could contribute to care standardization according to guidelines.

Treatment preferences, return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (the General Practitioner Hypertension Practice Study)

OBJECTIVES: To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. DESIGN: Mailed case report questionnaires. SUBJECTS: Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. MAIN OUTCOME MEASURES: Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. RESULTS: The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. CONCLUSIONS: GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.

Swedish general practitioners' practice behaviour in hypertension care.

OBJECTIVE: To examine care organization and practice behaviour in hypertension care among Swedish general practitioners. DESIGN: A postal questionnaire followed by a structured interview, in a two-step study design. SETTING: Uppsala-Orebro region in mid-Sweden (population 1.9 mill.) PARTICIPANTS: General practitioners employed by counties, according to a register maintained by the Swedish Medical Association (N = 489). MAIN OUTCOME MEASURE: Practice behaviour score compared with a gold standard. RESULTS: 392 general practitioners returned the questionnaire, and the interview was accomplished with 222 of 232 who agreed to participate. Non-responder studies were carried out in both steps. Every fifth GP had access to a special hypertension clinic at their health centre, and 29% had specially trained nurses for hypertension care. 31% reported use of written guidelines. 47% declared they accepted higher BP-levels than recommended, although 78% agreed with official guidelines. The mean practice behaviour score was 8,77 (range 5-12, maximum score 12). CONCLUSION: Although a majority of GPs agree with official guidelines, there is a considerable variation in care organization and practice behaviour in hypertension care.

Long-term effect of pindolol on lipids and lipoproteins in men with newly diagnosed hypertension.

This is the first long-term study of pindolol in a population-based sample of men with newly diagnosed hypertension. Eighty-two patients, with a diastolic pressure of 100 mm Hg or more, were identified after screening 6000 men. Many patients were overweight. 82 population controls, matched by sex, age and body mass index, were also recruited. Fourty-eight per cent of the patients and 25% of the controls had a family history of hypertension. Serum triglyceride and urate values were higher in patients than controls at the baseline investigation. Seventy-four patients were followed for 1 year. The dose of pindolol averaged 7.7 mg once daily after 1 year. The diastolic blood pressure was reduced by 13.4 mm Hg. The target pressure of 95 mm Hg or less was achieved in 89% of the patients. The HDL-cholesterol concentration was normal and did not change, whereas the LDL-cholesterol concentration decreased by 0.15 mmol.l-1 during treatment. The total triglyceride values increased transiently up to 6 months, but no significant increase was seen after one year. It is concluded that pindolol had no adverse effect on serum cholesterol and its HDL- and LDL-fractions during 1 year of treatment.

A long-term study on the effect of pindolol on serum lipoproteins: a preliminary report.

1. Preliminary results are reported from a long-term study aimed at recording the concentrations of serum lipids and lipoproteins at 6, 12 and 24 months of treatment with pindolol in young/middle-aged males with moderate hypertension. 2. Seventy-three patients have been recruited, of whom 47 have completed 6 months treatment. After 6 months treatment 35/47 patients had attained the target blood pressure of less than or equal to 95 mm Hg and analysis of plasma lipid and lipoprotein concentrations revealed a tendency for an increase of serum triglycerides and a lowering of low density lipoprotein cholesterol.