Geoffrey Quail MBBS, DDS(hons), M Med, MDSc, DTM&H, FRACGP, FRACDS, FACTM”.
ABSTRACT
The value of attending the same medical practitioner in achieving optimal patient care. compliance with treatment and a favourable outcome is generally accepted and there a many publications to support this concept. Most however concerns patient satisfaction and there is little written of an objective nature. Asthma and diabetes allow measurement of an outcome end point and so asthma was chosen to study. This work formed patt of an evaluation of asthmatic patients in a general practice setting at the former 6 RAAF Hospital Lavetton.
Seven parameters were quantitated by doctors and patients and t he results show clearly that continuity of care by a single practitioner achieved a more favourable outcome in the majority of cases.
Much has been written about the doctor-patient relationship and indeed the success of treatment appears to some extent to depend on the commitment of both parties to work together for the best possible outcome. A 1990 study’ found that over 90% of general practitioner (GP) visits were to the same doctor, however since then this has appeared to have decreased2 3
There is some evidence that continuity of care by a skilled empathetic practitioner is an important contributor to quality of care in family practice and is likely to lead to a more favourable outcome as measures by improved compliance with treatment, patient knowledge of their complaint and greater involvement in their own care than if patients moved from doctor to doctor. 3 4 Indeed, continuity of care is central to the philosophy and teaching of family practice5. However, much of the discussion has been of a subjective nature and there are few studies reported which compare treatment outcomes in a group of patients attending one as against random practitioners and in these reports, the results are frequently inconclusive.
Chronic diseases such as diabetes and asthma lend themselves to comparative studies of measurable parameters in relation to treatment outcome. O ‘Connor 6 found that in adults with diabetes. those patients who identified a regular doctor were more likely to have better glycaemic control and to have received more recommended elements of care.
AIMS OF STUDY
- to determine whet her those patients who attend the same practitioner demonstrate a greater degree of control of their asthma symptoms and a more favourable treatment outcome than was seen in a group of patients with no particular doctor.
- to compare the degree of understanding of asthma and of the drugs prescribed in the two groups.
- to evaluate and compare patients’ management of an acute episode of asthma in the two groups.
METHOD
The study formed part of an overall evaluation of the standard of care provided for patients with asthma. It was conducted in a general practice setting – the Out Patients Department at 6 RAAF Hospital Laverton.
Approval for the project was first obtained from the Australian Defence Medical Ethics Committee.
Letters were then written to all eight general practitioners working in the practice inviting them to ask their patients with asthma to join the study. It was emphasised that in addition to evaluating the quality of care, the exercise was to be under taken to ascertain the severity of asthma in the Australian Defence Force (ADF}, and evaluate management. with a view to optimising quality of care. In all but one case patients accepted the invitation.
Participating patients presented to the investigator and all agreed to sign a consent form. Subjects were assured that their responses would be known only to the assessor; they then completed a 25 part questionnaire based on the Asthma Management Plan (AMPHandbook)1. The assessor was on hand to clarify any questions. At interview. respiratory function tests both before and after bronchodilatation with salbutamol were performed in accordance with the recommendations of Pierce and Johns R.
The results were collated and analysed. Confidence Intervals for proportions were calculated using the Exact Method. Where indicated. percentage response and p values were also derived.
In order to quantify t he results. acceptable answers to the six questions in which scoring is possible were constructed using the AMP Handbook and standard respiratory medicine texts. Marks were awarded according to the degree of accuracy of the answers provided.
Questions so quantified were:
what do you understand by the term asthma?
what do you think happens in an asthma attack?
what is the value of the peak flow meter?
how do you manage an attack?
what are the actions of drugs you use for asthma?
when do you take your drugs ?
The severity of asthma was graded as mild, moderate or severe
Patient Assessment of Severity Patients were asked to consider severity of their asthma in light of: number and frequency of symptoms early morning symptoms impact on work and lifestyle dependence on medication requirement of medical treatment If they thought their asthma well controlled and caused minimal disability patients were encouraged to grade it as mild.
If despite complying fully, asthma disrupted their work or lifestyle. they should grade it as severe. For those who considered they did not fall into either group, it was suggested they grade it as moderate.
Medical Assessment of Severity
For patients assessed by a respiratory physician (32 cases). an indication of severity was provided in their report. Their work-u p included a methacholine challenge in most cases.
GP medical assessment was based on:
occurrence of sym ptoms
extent of disability
medical treatment and its frequency
medication required evaluation of pre and post beta agonist respiratory function tests
Asthma considered mild if:
episodic, infrequent, only with recognised trigger factors, quickly resolved requires minimal and infrequent medication, forced expiratory flow rate> 75% of predicted value between exacerbations and minimal response to beta agonists
Asthma severe if:
debilitating symptoms occur daily or if long term
steroid therapy required.
respiratory function tests (RFfs) indicative of severe obstructive airways disease
Patients not conforming to these criteria were considered to have moderate ast h ma
Doctors initial impression of severity was compared with symptoms found at audit together with results of respiratory function tests.
M OD E L ANSWERS TO QUES QUESTIONNAIRE:
Definition of asthma: a condition characterised by symptoms of wheeze, cough and tightness in chest which results from increased responsiveness of airways to certain stimuli that cause constriction of the airway and increased bronchial secretions9
marks awarded if response included in lay terms the following features: symptoms of wheeze, cough and tightness in chest variable air flow obstruction increased responsiveness to stimuli
Mechanism: answer: irritation causes bronchial passages to contract and secretions to accumulate within the air passages a pass recorded if mentioned one of: irritation causes secretions, bronchial constriction
Value of Regular Peak Flow Measurements Answer: the device measures volume of air that can be forcibly expelled from the lungs and so gives an indication of current respiratory function and effect of beta agonists
Management of an Attack: Patients were asked to describe their actions in the event of an asthma attack. The Asthma Management Handbook Guidelines7 was used to establish the appropriateness of their management and their action plan was scored in accordance with the Guidelines.
For mild asthma as judged by symptoms. attendances frequency of medications. RFTs and notes on severity; judicious use of salbutamol and obtaining medical advice promptly if problem persisted was the appropriate answer. For the more severe asthmatic, the above plus the use of the peak flow meter and use of cortico-steroids inccordance with physician’s instructions was the required answer.Marks were awarded in accordance with the Asthma Management Handbook.
RESULTS
There were ten females and thirty six males in the study which is consistent with the patient population in t he practice.Ages ranged from 18-55 years. This too reflects the age range on the Base. In this report, figures represent percentages unless specified.
ATTEND SAME DOCTOR
Fifty four percent of patients sought to attend the same doctor where possible.
Thu s: n= 25 in the same doctor group
n= 21 in the random doctor group
RELATIONSHIP WITH TREATING DOCTOR
93 % reported a good relationship with their treating doctor.
Tables can be found in the full download edition
PATIENTS CURRENTLY SMOKING
Smoking was marginally less common (12%) in the same doctor compared to the Random Doctor group (19%) but was not statistically significant (p=0.686).
FREQUENCY OF SYMPTOMS
There was no correlation between frequency of symptoms and attendance in the two groups (p=0.834).
TABLE 4. MANAGEMENT OF AN ASTHMA ATTACK
Tables can be found in the full download edition
TABLE 5. KNOWLEDGE ASSESSMEN T
Tables can be found in the full download edition
DISCUSSION
There was a relatively low number of patients that attend the on e doctor (54%), in the study This may be related to the frequency with which defence force personnel move. between bases and thus do not have sufficient time to establish a therapeutic relationship with a doctor. Patients with mild disease were almost equally divided between those attending the same doctor and those not. Of the nine with more severe disease. five had a particular doctor but the numbers are too small for the difference to be clinically significant.
It is reassuring to record that 93% had a positive relationship w ith their doctor. This equates with the data published by Papagiannisa 10 who found that overall patient satisfaction as 88.3%. Some bias exists as the presence of the investigator at t he time of response may have influenced some patients.
Attending the same doctor was more likely to result in better management of symptoms and receiving a personalised plan (tables I,4). These findings are consistent with t hose of Foreno 11 who found that a group of adolescents with a regular GP were more likely to have their lung function measured and an AMP than those with no family doctor.
There was a remarkable similarity in doctor and patient assessments of the severity (table 2) with patients having more severe asthma opting to attend one doctor. Medical review classified more cases into t he moderate and severe groups than did patients.
In the ADF, members medically unfit face discharge from the Service. It is not surprising therefore that patients tendered to grade their asthmas as less severe than their doctor (table 2). It is reassuring that those individuals with severe asthma endeavoured to attend the one doctor.
The benefit of attending the same doctor is illustrated by finding that no patient in the Same doctor group worsened in the period between initial presentation and final assessment whereas 24% did in the Random group. Further, 32% in the Same doctor group improved in contrast to 9% in the Random group (table3).
Satisfactory management of an attack was much more likely if patients attended the one doctor p=0.039. (table 4)This observation supports the findings of Sweeneyl2 that lack of continuity of care was associated with additional morbidity.
The Same doctor group clearly outscored the random group in all aspects of asthma education. In particular, if the marks for questions on the knowledge tested by asking for a definition of asthma (table 5b) and lung changes that produce symptoms (table 5c) are combined, only 2% of patients in the Same Doctor group failed in contrast with 38% in the Random group.
Evaluation of responses to mailed questionnaires lend support to the hypothesis that patients attending t he same doctor are more likely to receive preventive health instruction5·8• 13 • In this study the presence of the assessor whilst the questionnaire was completed helped eliminate any ambiguity and provided a consistency in the grading of responses. It is clear that those who routinely attended the same doctor had a significantly greater understanding of asthma and its pathophysiology. In addition they were more likely to describe a personalised asthma management plan and manage an attack more satisfactorily.
Given that patients could reasonably expect better care from the same doctor, it is interesting to speculate why 50% now visit different general practitioners. Convenience. time constraints. a simplistic view of medicine and a preference for specific doctors for certain complaints are some of the reasons proposed. Factors outside the patient’s control may also operate for example, availability of a certain doctor in a group practice or the use of a deputising service after hours. Stokes etaJI conducted a postal survey of 1.500 family practitioners in three countries concerning the value they placed on continuity of care under three aspects: ability to provide different types of care, importance of this and their attitude towards continuity of care. They found that in all aspects they placed high value on being able to so provide (p< 0.00 I).
Whilst it is clear that in the study sample. continuity of care by the one practitioner achieved a more favourable outcome in the majority of case, it should be noted that this is not a randomised trial and so the results should be viewed in this context.
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