Family Practice Vol. 19, No. 1, 53-56
© Oxford University Press 2002
Original Paper |
Shared care in gastroenterology: GPs' views of open access to out-patient follow-up for patients with inflammatory bowel disease
School of Postgraduate Studies in Medical & Health Care, University of Wales, Swansea, Singleton Park, Swansea SA2 8PP,
a Princess Street Surgery, Gorseinon, Swansea SA4 4US and
b Department of Health Sciences and Clinical Evaluation, University of York, Heslington, York YO10 5DD, UK.
Cheung WY, Dove J, Lervy B, Russell IT and Williams JG. Shared care in gastroenterology: GPs' views of open access to out-patient follow-up for patients with inflammatory bowel disease. Family Practice 2002; 19: 53–56.
Received 23 August 2000; Revised 14 May 2001; Accepted 3 September 2001.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Objective. The aim of this study was to ascertain GPs' views about open access to out-patient follow-up for patients with inflammatory bowel disease (IBD).
Methods. Semi-structured interviews and a postal survey were carried out in general practices in West Glamorgan UK, each with at least one IBD patient taking part in a randomized trial of open access versus routine follow-up, which has been reported elsewhere. A total of 112 GPs from 53 general practices who referred the 180 study patients to specialist gastroenterological care in Neath or Swansea were included in the study. Main outcome measures were GPs' experience of the trial; preferences between methods of out-patient follow-up; and their views about enhancing open access follow-up.
Results. Sixty-nine GPs from 40 practices took part in the practice-specific data collection and 91 returned 156 patient-specific questionnaires. They expressed a strong preference for open access follow-up, for both specific patients (108/156 patients) and IBD patients in general (47/69 GPs). Preference for extending open access follow-up to other chronic conditions was not so strong (21/69 GPs). A substantial number of GPs considered their experience of the trial limited (30/69), and few GPs were aware of the shared care guideline distributed before the trial started (8/69). Few GPs encountered any problems in the management of the study patients (9/69) and <50% of the GPs used a Cumulative Encounter Form (29/69) developed for the study. Most GPs were supportive of giving patients written guidelines (56/69) and establishing a gastroenterological (GI) nurse practitioner (45/69).
Conclusions. Open access follow-up of patients with IBD is supported by GPs. The approach would probably be improved by the distribution of written information to patients, the establishment of a GI nurse practitioner and an integrated approach between the nurse, hospital specialist, GP and patient.
Keywords. GP, hospital relationship, inflammatory bowel diseases, shared care.
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Introduction |
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Many different schemes for the shared care of patients with chronic disease evolved during the 1990s,1 and GPs have expressed willingness to contribute to this.2 In 1995, we set up a shared care scheme for patients with inflammatory bowel disease (IBD), which we evaluated from 1995 to 1998.
After distributing shared care guidelines to all local GPs, we recruited 180 patients aged over 18 years, with quiescent or mildly active but stable IBD, into a randomized controlled trial.3 Patients at two hospitals were allocated randomly to routine or open access follow-up. For those allocated to open access follow-up, the responsibility for care was transferred to the GP in return for guaranteed rapid access to specialist care when either the patient or the GP judged it necessary.
We designed a Cumulative Encounter Form (CEF), based on principles tested in the care of other chronic conditions,4–6 to maintain two-way communication between primary and secondary care. CEFs were updated by both hospital specialists and GPs and transmitted by fax after each patient visit. The normal recall system continued for those who required continuing surveillance by colonoscopy because of the risk of cancer.
The trial showed a significant patient preference for open access follow-up, but no significant difference in patients' quality of life between the two groups.3 To complement these findings, we studied the views of GPs on all aspects of the scheme at the end of the trial.
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Methods |
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We carried out this study from May to July 1999. The study population comprised 112 GPs from 53 general practices who had originally referred the 180 patients in the trial3 to specialist gastroenterological care in Swansea and Neath.
We collected GPs' views about the care of individual patients by structured postal questionnaires. We assessed their views of the open access scheme and patient care in general by semi-structured group interviews and postal questionnaire.7
Four GPs undertook the interviews as part of Morgannwg Medical Audit Advisory Group (MAAG) practice audit visits. Out of the 21 practices identified after stratification for referral, 13 looking after 51 trial patients met MAAG criteria for practice audit visits and participated in the interviews. The interview scheduled was piloted, and applied flexibly, taking account of interview dynamics.8 GPs were encouraged to use the patient-specific questionnaires to help discussion. Interviews were taped with consent and transcribed to supplement field notes. We sent a questionnaire derived from the interview schedule to the remaining 40 practices with 129 trial patients. We asked practice managers to encourage at least one partner to complete this questionnaire.
Three of us (IC, JD and BL) independently coded statements from the questionnaires and the transcripts9 into three categories: positive, negative and neutral. Inter-rater reliability was assessed by Cohen's kappa.10 Differences were resolved by discussion. Comparability of questionnaire and interview findings was analysed by chi-square tests. We also used kappa to compare patient preferences identified in the trial3 with GP views in this study.
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Results |
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Response rate
Ninety-one GPs (81% of 112 participating) from 40 practices returned 156 patient-specific questionnaires (87% of the trial population of 180). Sixty-nine GPs also took part in the practice-specific data collection (37 through group interviews and 32 through postal questionnaires), giving a response rate of 61% (69/112). Twelve of the 13 selected practices completed group interviews. One could not be arranged because the single GP had retired. The mean number of study patients covered by each interviewed practice was 3.9, slightly but not significantly higher than that covered by each practice surveyed by post (3.2). There was substantial agreement between the three researchers in coding GPs' statements (kappa = 0.65, 0.63 and 0.63).
Comparison of findings from interviews and postal questionnaires
Responses to interviews and postal questionnaires were generally similar, though there were significant differences in awareness of the IBD shared care guideline, experience of using CEFs and attitudes to extending open access to other chronic conditions (Table 1
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Experience of the randomized trial
Thirty GPs felt they had limited experience of the trial. Twenty-nine practices had only one or two patients in the trial. Nine GPs had experienced problems with the management of study patients. Only eight were aware of the IBD shared care guidelines, and even those who were aware had not studied them in detail.
Fewer than half the respondents had used the CEF, and few perceived any real benefits. Some regretted that the design of the form was not compatible with A4 records.
Preferences for open access
A preferred follow-up method was given in 143 of the 156 patient-specific questionnaires returned. For 69% (108/143), open access was preferred, for reasons which included: stability of the patient's condition; access to the specialist when needed; sensible patient; saving of time; and the large number of follow-up appointments for other conditions.
There were 122 pairs of patients and GPs who both indicated a preference. Only 73 pairs were in agreement, a level not significantly greater than chance (kappa = 0.083).
A few GPs were concerned that patients with open access might be ‘lost’ to follow-up. Although the shared care guidelines and correspondence with GPs at patient recruitment stated that the recall system would continue for those requiring colonoscopy, some doctors were still uncertain who was responsible for this. Some were also concerned that patients might underestimate the significance of minimal symptoms and not seek advice until too late.
GPs were divided about extending open access follow-up to other chronic conditions. Significantly fewer of those interviewed favoured the idea (Table 1
). Those in favour pointed out that long-term success would need: educational sessions for GPs about shared care guidelines; leaflets for patients about warning signs; and time in out-patient departments for open access patients to be seen at short notice.
Views about enhancing open access
Most GPs were in favour of giving patients written guidelines about their follow-up. It was believed that this would empower patients, giving them confidence about when to self-refer and how to work the system, thus improving care in general.
Many favoured the creation of a gastrointestinal (GI) nurse specialist post to support shared care. Reasons included: success in other subspecialities; accessibility for advice to patients and GPs; arranging hospital appointments; reducing medical workload; and recalling patients for screening.
Those not in favour were uncertain about the contribution of such posts in other subspecialities, believing that it was not appropriate for nurses to book appointments, and more out-patient work might be generated.
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Discussion |
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Response rate was good for patient-specific data (81%) and reasonable for practice-specific data (61%). There was substantial agreement between the three researchers coding the comments independently.
GPs preferred open access out-patient follow-up for most of their IBD patients but were more dubious about extending open access to other chronic conditions.
Most patients also preferred open access follow-up,3 but there was poor agreement between their preferences and those of their GPs. Decisions about method of follow-up should involve the patient, GP and hospital specialist.
Most GPs felt shared care would be enhanced by a GI nurse practitioner and by empowering patients to take responsibility for their own care with explicit patient guidelines. Both proposals have potential to enhance open access follow-up but would need rigorous evaluation.
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Acknowledgments |
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The authors thank the following for contributions to the study: Drs Barbara Weatherill and Bridget Kirsop interviewed colleagues in primary care; Ms Jayne Morgan, Mrs Hayley Dickinson and Mrs Susie Lucas provided information science support; and Mrs Gaynor Demery and Miss Julia Demery provided administrative support. The Iechyd Morgannwg Health Authority Medical Audit Advisory Group allowed interviews with GPs as part of practice audit visits. Above all, the authors thank the GP and practice staff who participated in the study. The study was funded by the NHS R&D Primary–Secondary Care Interface Programme and the Iechyd Morgannwg Health Authority.
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References |
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Williams JG, Cheung WY, Russell IT, Cohen DR, Longo M, Lervy B. Open access follow-up for inflammatory bowel disease: a pragmatic randomised trial and cost-effectiveness study. Br Med J 2000; 320: 544–548.
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