Developing 'high impact' guideline-based quality indicators for UK primary care: a multi-stage consensus process

Background Quality indicators (QIs) are an important tool for improving clinical practice and are increasingly being developed from evidence-based guideline recommendations. We aimed to identify, select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence-based practice using routinely recorded clinical data in United Kingdom (UK) primary care. Methods We reviewed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘high impact’ QIs relevant to primary care based upon explicit prioritisation criteria. We then field tested the QIs using remotely extracted, anonymised patient records from 89 randomly sampled primary care practices in the Yorkshire region of England. Results Out of 2365 recommendations and QIs originally reviewed, we derived a set of 18 QIs (5 single, 13 composites – comprising 2-9 individual recommendations) for field testing. QIs predominantly addressed chronic disease management, in particular diabetes, cardiovascular and renal disease, and included both processes and outcomes of care. Field testing proved to be critical for further refinement and final selection. Conclusions We have demonstrated a rigorous and transparent methodology to develop a set of high impact, evidence-based QIs for primary care from clinical guideline recommendations. While the development process was successful in developing a limited set of QIs, it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine, structured recording of clinical care

Understanding "revolving door" patients in general practice: a qualitative study

<b>Background</b> "Revolving door" patients in general practice are repeatedly removed from general practitioners' (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.<p></p> <b>Methods</b> We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise "revolving door" patients and their impact from professionals' perspectives.<p></p> <b>Results</b> "Revolving door" patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when "revolving door" patients interacted with NHS staff.<p></p> <b>Conclusions</b> We utilise the "sensitising concepts" of legitimacy by drawing on literature about "good and bad" patients and "dirty work designations". We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with "revolving door" patients. We suggest this may have wider relevance for the problem doctor patient relationship literature

“When You’re Sitting on the Fence, Hope's the Hardest Part”: Challenges and Experiences of Heterosexual and Same-Sex Couples Adopting Through the Child Welfare System

Foster-to-adopt families can be viewed as systems that are influenced by many other systems (e.g., the legal system, the social service agency, and the birth family). The current qualitative study of 84 foster-to-adopt parents (members of 42 lesbian, gay, and heterosexual couples) examined the types of challenges that parents faced as they navigated multiple systems during the initial post-placement period. Some participants described the legal insecurity associated with their role as foster-to-adopt parents as impacting their personal well-being and their attachment to their children. Lack of support services and disorganization within social service agencies, as well as strained relationships with birth parents, were also identified as stressors for foster-to-adopt parents. Importantly, lesbian and gay participants faced additional concerns regarding the security of their placement, due to the possibility for discrimination within the various systems involved with the foster-to-adopt process. Participants as a whole also identified positive aspects of their experiences within various systems; for example, they appreciated child care subsidies, state-provided health insurance, and supportive social workers. Our findings provide insights into foster-to-adopt parents’ experiences during the initial post-placement period, and have implications for adoption services aimed to improve placement stability and enhance family functioning in foster-to-adopt families