Family Medicine Update

Depression and the nature of Trinidadian family practice: a cross-sectional study.

BMC Fam Pract. 2007 Apr 26;8(1):25

Authors: Maharaj RG

ABSTRACT: BACKGROUND: Depression is the most common mental disorder; in an ambulatory care setting, 5 to 10% of patients meet the criteria for major depression. Despite extensive documentation in primary care internationally, Trinidadian studies published on depression have been primarily hospital based and focussed on suicide. The objectives of this study were to determine the prevalence of depression, the predictors of depression and the commonest reason for the encounter (RFE) among adult patients attending Trinidadian fee-for-service family practice. METHODS: This was a cross-sectional descriptive survey of consecutive patients taken from a stratified random sample of family practices in the north-west region of Trinidad. To measure depression the Zung scale was modified for use as a brief diagnostic tool. This modified Zung scale, when tested against a psychiatric interview, revealed that at a cut off point of 60, the scale had a specificity of 94% (95% CI 87-100), a sensitivity of 60% (95% CI 45-75), and a likelihood ratio for a positive test result of 10 (95% CI 6-42). RESULTS: 508 patients from 28 practices participated; a response rate of 85%. Participants were primarily younger, 18-49 years (66.7%), female (69.5%), and educated, with 72.8% having received a secondary school, technical school or university education. Sixty-five (12.8%) of the respondents (95% CI 9.9-15.7) were determined to be depressed. Chi-square analysis revealed no statistically significant association between depression and age, ethnicity, education levels, occupation or marital status (p >0.05). Binary logistic regression indicated that the only useful predictors of the probability of being depressed were age (p<0.003), level of education achieved (p<0.032) and marital status (p<0.04). The 508 participants had 630 RFE, with check-ups (17.5%) being the commonest, followed by joint pains (13.4%) and upper respiratory infections (10.5%). CONCLUSION: The Trinidadian family physician has to maintain a high index of suspicion in the knowledge that as many as one of every eight adult patients at their clinics may be depressed.

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Major policy changes for primary care: potential lessons for the US New Model of family medicine from the quality and outcomes framework in the United Kingdom.

Fam Med. 2007 Feb;39(2):96-102

Authors: Lester H, Hobbs FD

The Future of Family Medicine project in the United States has identified a series of core values and a New Model of practice for family medicine aiming to transform the health and health care of the nation. There are, however, few empirical examples of its effectiveness and acceptability in practice. Recent experiences of changes to primary health care in the United Kingdom (UK), particularly the introduction of the Quality and Outcomes Framework, which rewards practices for delivering evidence-based care, may provide some useful lessons for practitioners and policy makers as they implement aspects of the New Model. In this paper, the authors, who lead the Expert Review of the Quality and Outcomes Framework, critique the five characteristics of the New Model that offer the most relevant learning points for both health care systems and reflect on lessons for both clinicians and policy makers, highlighted by the experience of implementing policy change in the UK. They suggest that incremental implementation, underpinned by robust pilot data and in-depth understanding of the influence of motivation on performance, are key and conclude that sharing issues that have worked well, and less well, are important in helping both countries develop good quality patient care.

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Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN).

J Am Board Fam Med. 2007 Mar-Apr;20(2):115-23

Authors: Elder NC, Graham D, Brandt E, Hickner J

CONTEXT: Reporting of medical errors is a widely recognized mechanism for initiating patient safety improvement, yet we know little about the feasibility of error reporting in physician offices, where the majority of medical care in the United States is rendered. OBJECTIVE: To identify barriers and motivators for error reporting by family physicians and their office staff based on the experiences of those participating in a testing process error reporting study. DESIGN: Qualitative focus group study, analyzed using the editing method. SETTING: Eight volunteer practices of the American Academy of Family Physicians National Research Network. PARTICIPANTS: 139 physicians, nurse practitioners, physician assistants, nurses, and staff who took part in 18 focus groups. INSTRUMENT: Interview questions asked about making reports, what prevents more reports from being made, and decisions about when to make reports. RESULTS: Four factors were seen as central to making error reports: the burden of effort to report, clarity regarding the information requested in an error report, the perceived benefit to the reporter, and properties of the error (eg, severity, responsibility). The most commonly mentioned barriers were related to the high burden of effort to report and lack of clarity regarding the requested information. The most commonly mentioned motivator was perceived benefit. CONCLUSION: Successful error reporting systems for physicians’ offices will need to have low reporting burden, have great clarity regarding the information requested, provide direct benefit through feedback useful to reporters, and take into account error severity and personal responsibility.

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