Search

Objective: The narrow ICD-10 and DSM-IV definition of hypochondriasis makes it rarely used yet does not prevent extensive diagnosis overlap. This study identified a distinct hypochondriasis symptom cluster and defined diagnostic criteria. Method: Consecutive patients (N=1,785) consulting primary care physicians for new illness were screened for somatization, anxiety, depression, and alcohol abuse. A stratified subgroup of 701 patients were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and questions addressing common hypochondriasis symptoms. Symptom patterns were analyzed by latent class analysis. Results: Patients fell into three classes based on six symptoms: preoccupation with the idea of harboring an illness or with bodily function, rumination about illness, suggestibility, unrealistic fear of infection, fascination with medical information, and fear of prescribed medication. All symptoms, particularly rumination, were frequent in one of the classes. Classification allowed definition of new diagnostic criteria for hypochondriasis and division of the cases into 'mild' and 'severe.' The weighted prevalence of severe cases was 9.5% versus 5.8% for DSM-IV hypochondriasis. Compared with DSM-IV hypochondriasis, this approach produced less overlap with other somatoform disorders, similar overlap with nonsomatoform psychiatric disorders, and similar assessments by primary care physicians. Severe cases of the new hypochondriasis lasted 2 or more years in 54.3% of the subjects and 1 month or less in 27.2%. Conclusions: These results suggest that rumination about illness plus at least one of five other symptoms form a distinct diagnostic entity performing better than the current DSM-IV hypochondriasis diagnosis. However, these criteria are preliminary, awaiting cross-validation in other subject groups.

Magnetic resonance imaging (MRI) and transvaginal ultrasound imaging can both detect uterine myomas but only MRI can accurately determine the exact position of the tumors. This is important when planning surgical removal of the tumors so the surgeons can determine which type of operation will be best.

Introduction Chlamydia trachomatis is the leading cause of bacterial sexually transmitted diseases, occurring in 3-14% of women attending family planning clinics.[1 2] Women are affected most by the consequences of [...]

Objective: To evaluate the effectiveness of a structured information campaign aiming to recruit young adults for a Chlamydia trachomatis test by use of a non-invasive, home obtained and mailed sample. [...]

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing [...]

Musculoskeletal illness is a common cause of absenteeism from work, workers' compensation claims, and disability retirement.[1-3] A population-based survey in 1994 showed that within a year, 69% of the population [...], Background and Purpose. Both musculoskeletal illness and mental illness characterized by somatic symptoms are common in primary care, and it is hypothesized that many patients with musculoskeletal illness have relatively poor mental health. The purpose of this study was to describe the characteristics of patients in general practice in Denmark who are referred to physiotherapists with signs and symptoms of musculoskeletal illness. Subjects and Methods. One hundred ninety-four general practitioners, representing 124 practices, participated in a survey of 2,042 consecutive patients with musculoskeletal illness. Results. The diagnoses were generally poorly defined. Compared with the general population, patients with musculoskeletal illness had markedly poorer physical health and poorer mental health. Patients with poorly defined diagnoses did not differ from patients with well-defined diagnoses in terms of physical health, but they scored lower on the mental health component summary scale of the Danish version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Conclusion and Discussion. Of the patients referred to physiotherapists by general practitioners in Denmark, the subgroup with poorly defined diagnoses had lower mental health scores than those with well-defined diagnoses, suggesting that a biopsychosocial approach to care may be appropriate for this group of patients. [Jorgensen CK, Fink P, Olesen F. Patients in general practice in Denmark referred to physiotherapists: a description of patient characteristics based on general health status, diagnoses, and sociodemographic characteristics. Phys Ther. 2001;81:915-923.] Key Words: General practice, Mental health, Musculoskeletal illness, Physical health, Physical therapy.

24-Hour Primary Care Eds Chris Salisbury, Jeremy Dale, Lesley Hallam Radcliffe Medical, 19.95 £, pp 248 ISBN 1 85775 311 9 Rating: *** During the past few decades European general [...]

After some 30 years of medical development focusing largely on hospitals, organ specialisation, and high technology, the 1960s saw the revitalisation of general practice (in some countries known as family [...]

Urogenital infections with Chlamydia trachomatis are widespread and usually asymptomatic. Major complications from infection include ectopic pregnancies and female infertility.[1] Although contact tracing reduces the prevalence of chlamydia infection,[2] the [...]

Urogenital infections caused by Chlamydia trachomatis are common and may cause female infertility and ectopic pregnancy. Such infections are treatable but as C trachomatis often causes no symptoms they may' [...]

In the borderland between health, illness, and disease, general practice assumes a principal role in securing the smooth working of a complex health care system and satisfying the needs of [...]

Physical complaints not attributable to verifiable, conventionally defined diseases, i.e., medically unexplained or functional somatic symptoms, are prevalent in all medical settings, but their classification is contested as numerous overlapping diagnoses and syndrome labels have been introduced. This study aims to determine whether functional somatic symptoms cluster into distinct syndromes and diagnostic entities.

Objectives. To determine whether adding a reminder procedure to the personal handing out of questionnaires to patients by general practitioners (GPs) in a patient evaluation survey added further information to the study and whether this influenced the results of the evaluations fed back to the GPs.Design. Patient evaluation survey in general practice.Study participants. 6822 patients consulting 60 GPs in a Danish county. GPs were voluntarily participating in a national patient evaluation project.Intervention. We used the EUROPEP instrument for patient evaluation in general practice. It contains 23 items in five dimensions and two additional questions on general satisfaction. GPs were randomized into two groups with and without a reminder procedure.Main outcome measure. Scores in the six assessment dimensions and patient characteristics were compared for the primary and the reminder respondents and between the two randomization groups. In the analyses, we adjusted for the clustering of patients.Results. We found that the use of a reminder procedure increased the response rate. Respondents to a reminder were younger than the primary responding patients and were more critical in their GP assessment. Patient evaluations of the individual GPs were statistically significantly more critical if these reminder responses were included. Absolute differences were too small to have any practical implications.Conclusions. Adding a reminder procedure to the face-to-face handing out of questionnaires to patients by the GPs increased the response rate significantly but produced no clinically significant differences in the assessment of the GPs.

For a variety of reasons, GPs are working more and more with unfamiliar patients. The proposed new British GP contract stipulates that in future patients will register with a practice, rather than with a named GP and a recent new definition of general practice did not mention continuing care. There has been persistent confusion about the definition of continuity of care. Evidence for the benefit of patients usually seeing the same doctor is still limited. In this paper we describe some discrete elements of continuity, emphasize the importance of interpersonal continuity and suggest how this may work. The contributions of informational continuity (especially good records) and of excellent consulting skills are put in context. We conclude that further evidence is needed to demonstrate the added value of interpersonal continuity in general practice and that this needs a clear theoretical basis. We propose that such a theory will define the concept of multi-dimensional diagnosis as the key strength of our discipline and that continuity, especially interpersonal continuity, is an important factor in achieving this economically and in a way which satisfies both patients and professionals.

This paper uses three typical case stories from general practice to demonstrate that a GP simultaneously considers four dimensions when making a diagnosis and planning subsequent treatment of a patient in the consultation: (i). a biomedical dimension; (ii). a culture and context dimension; (iii). a medico-psychological dimension; and (iv). a network and social dimension. By taking this diagnostic and therapeutic approach, the GP adds value to the total performance of the health care system. It is demonstrated that a GP needs theoretical, research-based knowledge and skills within all four dimensions, and that it is necessary for a GP to work together with both medical and non-medical disciplines when defining the research and teaching agenda. It is stressed that consultation and communication skills are important tools for any doctor, and the value of continuity of care is discussed. Finally, the implications of the diagnostic approach with respect to planning research and teaching programmes are discussed, and the need for a better balance is stressed.

The literature shows that patients positive opinions of general practice care are associated with being older, of lower educational level, lower social status and being married, but there is no association with the sex of the patient. The health related characteristics of patients, such as self-reported health status, chronic condition and utilization of care, also predict judgements of the quality of some aspects of general practice care. This study investigated whether, in addition to individual effects, combinations of patient characteristics can also influence opinions of care, and whether these findings are valid in different European countries.A self-completion questionnaire was developed and given to consecutive patients in five general practices in each of eight European countries. There were 48 questions covering five aspects of care: availability and access, organisation and co-operation, medical care, relationship and communication, information and support and an overall opinion. There were a further 16 questions on patient characteristics. One way analysis of variance, using SPSS software, was used to compare mean scores for each aspect of care for different values of the patient characteristic. Multivariate analysis was used to investigate the interaction effects between pairs of patient characteristics, which, individually were found to influence opinion. Further tests were made to identify any interaction between the effect of each patient characteristic and the country of residence.1008 (response rate 63) questionnaires were completed. The patient characteristics which influence patients opinions were found to be age, levels of education and professional qualification, length of relationship with the practice, and whether they have a chronic condition. However, there are no interaction effects between these characteristics. Importantly these effects were found to be valid in all countries in this study. The patient characteristics which do not appear to influence opinions of care are sex, levels of utilization of care and self-reported health status.When surveying opinions of patients about general practice care, since patients of different characteristics will give different views of the same service, the sample of patients whose views are surveyed should aim to account for these predictable differences. Decisions on changes in care provision should be based only on the results of patient opinion surveys in which the characteristics of the sample of patients responding to the survey were taken into account.

The aim of the present study was to compare patient and GP priorities for general practice care.

A literature review compared the diagnostic effectiveness and accuracy of transvaginal sonography (TVS) hysterosonographic examination (HSE), hysteroscopy (HY), and magnetic resonance imaging (MRI) in abnormalities of the uterine cavity and endometrium in premenopausal patients referred to surgery and women with abnormal uterine bleeding. The studies varied much in terms of patient selection, number of observers, blinding and experience of observers, and definition of abnormality criteria. The diagnostic effectiveness of the techniques reviewed varied TVS only reached intermediate quality levels as a diagnostic tool for exclusion of uterine cavity abnormalities and no data support that MRI, TVS, HY, or HSE may exclude hyperplasia without concomitant endometrial sampling. HY and HSE were equally effective and apparently outperformed TVS, especially for identification of polyps. However, all techniques carried a significant number of false positive results. MRI does not satisfy current diagnostic demands for detection of endometrial abnormalities, but it is sufficiently accurate for submucous myoma (SM) evaluation. TVS, HSE, and HY carry much observer variation as opposed to MRI. In experienced hands TVS should be a first choice modality, but its precision and consistency fall short of current needs and it should therefore be supplemented by other techniques. HSE or HY performed by experienced clinicians should be used as supplements to TVS for exclusion of polyps. MRI can be recommended as the first choice modality for exact evaluation of SM uterine in-growth before advanced minimal invasive treatment of myomas. Clinicians should be aware that modern imaging techniques may yield highly idiosyncratic results when used by inexperienced staff, and efforts should be made to reduce such observer variation.

Background The need to optimize frequent attender (FA) care and to economize on scarce resources in primary care has given rise to calls for intervention. However, precise knowledge of the specifics of this need is scarce, as is knowledge of how best to orchestrate intervention vis‐à‐vis particular FA groups. The aim of the study was to analyse the need for a special FA status consultation and to analyse if such need springs from physical, mental or social factors among FAs.Method Half of the 270 general practices in the County of Aarhus, Denmark, were randomly allocated to the study group (in total 132 practices; 220 general practitioners (GPs)). From these practices age‐ and gender‐stratified samples of FAs were drawn. FAs were defined as the top 10 per cent attenders in 12 months. Questionnaires were used to elicit FA and GP attitudes to the introduction of a status consultation and to obtain GPs' evaluation of their FAs' physical, mental and social status. The special FA consultation was introduced as a reimbursed half‐hour consultation where the FA and the GP could discuss the patient's current and future care status.Results Over three‐quarters of the FAs would accept the offer to have the status consultation, and the GPs would recommend it for one‐fourth of their FAs. The expressed need was highly associated with an expected positive effect on health (prevalence ratio (PR) for GPs: 11.7 (8.9–15.5), PR for FAs: 1.6 (1.5–1.8)) and a decrease in attendance (PR for FAs: 1.4 (1.3–1.5)). The GPs quoted physical, mental and social indications for the consultation. The FAs who had high levels of functional symptoms were most likely to accept the consultation.Conclusions There was an expressed need for an FA status consultation, which may lead to a positive effect on health and attendance. The GPs pointed to physical, mental and social indicators for a special FA consultation.

Objective: To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity.

In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03–1.33]) on SCL and 1.28 (1.06–1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99–1.36] for SCL and OR 1.31 [1.05–1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

The authors investigated the importance of psychological distress and somatization among patients with musculoskeletal illness in general practice. The authors used the Hopkins Symptom Check List (SCL-8) and the Whiteley Index to rate 1,720 patients with musculoskeletal illness referred to physiotherapy from general practice. General practitioners (GPs), patients, and physiotherapists often noted stress or psychological distress to be a possible cause of the patient’s musculoskeletal illness, but agreement between them was low. If the GP included the patient’s own view on psychological distress, the result of the SCL-8 did not add much to the detection of distress. The results emphasize the importance of discussing psychological distress when dealing with patients with musculoskeletal illness.

Objective - To demonstrate whether standardization of practice populations by age and sex changes the internal prescription ranking order of a group of practices.Design - Data on the prescribing of cardiovascular drugs in a group of practices were obtained from a county-based database. Information on the age, sex, and numbers of patients per practice was also obtained. The direct standardization method was used to adjust practice populations for age and sex.Setting - The town of Randers, Aarhus County, Denmark.Subjects - 35 practices, 41 GPs.Main outcome measures - Ranking of the 35 practices with respect to number of prescribed daily doses of cardiovascular drugs in crude utilization index and standardized utilization index. The slope of the regression curve of variation between the practices.Results - The change from crude to standardized utilization index gave an entirely new ranking order of the practices. Only four practices did not change ranking position, while four moved more than ten places. The slope between highest and lowest ranked practice did not diminish after standardization.Conclusion - Care should be taken when comparing peer prescribing patterns from crude utilization data, and we recommend prior age and sex standardization. Our results are of value in creating a more reliable basis for a debate on variation in prescribing patterns between peers.

Documentation and evaluation of medical care are attracting increasing interest in most health care services. The strategies used in this context are clinical research, technology assessment, and quality assurance, including clinical audit. The important questions are how these strategies are defined and how they interrelate with each other. Clinical research is defined as the process through which new knowledge is produced. Technology assessment is a systematic assessment of diagnostic and therapeutic procedures in advance of their introduction into medical practice or reconsideration of their place in clinical practice. Quality assurance continuously documents whether goals defined by the results of the technology assessment have been reached. Three important concepts should be understood in utilising quality assurance. Criteria define good clinical practice, which a doctor aims to achieve. Standard specifies the acceptable range of variation from the ideal, while the indicator is the tools to measure the standard achieved in comparison to the criteria set. It is stressed that clinical research, technology assessment, and quality assurance are interdependent, mutually driving the quality process forward.

Systems of Quality Assurance are necessary, partly to advance service and professional development, and partly to provide accountability. Such systems require criteria and standards on the basis of which to conduct evaluation, but these are not easy to establish. Not only is there a tension between measurability and relevance, there is also variation in the appropriateness of different criteria between localities and countries. With increasing involvement of external evaluation, and increasing interest in international comparisons, there is concern over the validity of many criteria and standards, and over their inappropriate use.The literature has been reviewed, and a series of consensus meetings held by representatives of eleven European countries.Since criteria and standards are so difficult to agree and vary so widely with different contexts of care, it is necessary first to define and identify indicators of care which are likely to be valid across varying localities and countries. Criteria and standards can then be derived from these indicators.

Objective –Several studies have compared attenders and non-attenders in organised cervical screening programmes but few have analysed subgroups of at-tenders and non-attenders. This study presents social and other characteristics of such subgroups. Setting—Aarhus County, Denmark.Methods –A case-control study in a cohort of 133 500 women, aged 23–60, included in the programme from 1 October 1990 to 1 April 1994. The participation rate was 75%, and those taking part comprised women with opportunistic screening or who had had a smear owing to symptoms in the previous three years (“active” attenders), and women who were invited for screening because they had not been otherwise tested (“passive” attenders). “Passive” (n = 708) and “active” attenders (n = 692) were compared. Women who had never had a smear test (“never” attenders, n = 287) were then compared with “ever” attenders (n = 1215)—that is, women who had not had a smear test during the previous 42 months, but had had at least one previous test. Data were collected by mailed questionnaires.Results –The response rate was 81% and 53% for attenders and non-attenders, respectively. After correction for age, there was no difference between the “active” and “passive” attenders for cancer risk factors (smoking, age of first intercourse, number of sexual partners, and social group), or in the degree of responsibility for close relatives, but “active” attenders seemed to have more frequent contact with their general practitioner. “Never” attenders had less frequent contact with their general practitioner than “ever” attenders. They were more often living alone and nullipara, but had no overrepresentation of cancer risk factors.Conclusions –Increased effect cannot be obtained by focusing on the described groups, but by increasing the participation rate. “Never” attenders do not belong to a special risk group.

To evaluate the risk of addiction after prescription of a strong analgesic, we followed 90 patients during the year after they had received a prescription for a strong analgesic for the first time in September 1989 in North Jutland County, Denmark. The study was based on copies of all prescriptions of strong analgesics; these are sent to the National Health Service, which is responsible for the control of the prescribing of strong analgesics. Seven patients were excluded because the data registration was incomplete, while there was valid data on the remaining 83 patients, 12 of whom had cancer. All the cancer patients and 14 other patients died during the follow-up period. Of the remaining 57 patients, seven were still being treated (12.3%; 95 confidence limits: 5.1–23.7%) with strong analgesics. Addiction was not suspected by their general practitioners in any of these seven as the main reason for continued treatment with strong analgesics. We therefore conclude that addiction is rare after a first prescription of strong analgesics.

Objective-We carried out two studies (a and b) to assess general practitioners' attitudes towards a) regionally developed guidelines and b) guidelines developed by the Danish College of General Practitioners.Design-a) A randomized study among all GPs in Aarhus county comparing their attitudes towards guidelines in general and towards regional multidisciplinary developed guidelines on Pap-testing for cervical cancer, and b) a survey among all Danish GPs on attitudes towards earlier submitted guidelines for diabetes Type 2.Setting-GPs in Aarhus county and in all Denmark.Subjects-a) Questionnaires sent to 370 doctors in Aarhus county, and b) to 3471 GPs in all Denmark. Main outcome measures-a) Attitudes to the known Pap guidelines compared with general attitudes. Themes in question were acceptance of guidelines, acceptance of multidisciplinary involvement, especially from the administrative staff, perceived effect on the consultation and the quality of care. In study b) remembrance of receiving, having read and used previous guidelines. Wishes with respect to future updates.Results-a) GPs were very positive towards the Pap guidelines they knew, and only few resisted. The number of positive answers was significantly fewer when doctors were asked about guidelines in general, b) There was an overwhelmingly positive attitude towards guidelines from the College on diabetes care and other topics relevant to GP work.Conclusion-Danish GPs reported a very positive attitude towards the presented well-known guidelines on Pap testing and diabetes Type 2, and a fairly positive attitude towards hypothetical questions on guidelines in general.

During one week in 1985, 227 general practitioners (GPs) in the county of Aarhus, Denmark, recorded all their prescriptions of psychotropic drugs, amounting to 4180 prescriptions for 3756 patients. There was great variation in the rate of prescribing among the GPs. The median number of prescribed defined daily doses per 1000 registered patients per day was 84, and the corresponding median number of prescriptions per 1000 patients per week was 14. There was a significantly lower rate of prescribing of psychotropic drugs by rural/small town GPs, compared with GPs in major cities (odds ratio, 0.84;99% confidence limits, 0.77-0.91), after correction for differences in patients' age and sex. There were no differences in rate of prescribing among GPs in relation to size and type of practice, nor to the age and sex of the GP.

The study concerned a nation-wide Danish investigation of 519 women who received the diagnosis of cancer of the cervix uteri in 1983. Data on doctor-contact patterns during the single year, and for the 3 years pre-diagnosis were obtained on 428 of the women (82%), and a comparison was made with an age- and practice-matched control group. Significantly more patients than controls had had no doctor contact, and their odds rate for cancer development was higher than that of the patients who had had at least one contact with their general practitioner during the previous one or three years. Those patients with more advanced stages of cancer, those who had never had a cytological examination, and those living in counties without organized screening programmes were in general the ones with fewest doctor-contacts, and the odds rates for cancer development among the no-contact patients were highest in these groups. No doctor-contact was more common among patients living in counties without organized screening programmes, and these women represented a relatively higher risk group than those living in counties with organized screening. More women are thus caught in the organized screening net, compared with unsystematized screening. The findings support systematic rather than opportunistic unsystematic screening for cancer of the cervix.

Two different organizational methods of Pap smear examination in prevention of cancer colli uteri are compared in two Danish counties. In one county the method was planned as a pure case finding model; in the other county a modified screening approach was used. Resources were measured as the number of Pap smear examinations per 1000 women of risk age (25-54 years). They were nearly identical in the two counties. The number of sufficiently investigated women, defined as examined by a Pap smear at least once within a 3-year period, was much larger in the county using the screening model than in the other county. Furthermore the proportion of women sufficiently investigated varied greatly in the county using the case finding model. Even the most active one-fourth of the doctors in this county did not obtain the same percentage of examined women as the average in percentage of examined women in the county with a regular screening programme, even though this active group of doctors had a resource consumption about twice the average for this county.It is concluded that the Pap smear method when aiming at a maximum interval between smears in individual women of 3 years, can be conveniently carried out in general practice by using a case finding model in combination with a screening programme together with a systematized, centrally computer-surveyed procedure, in order to avoid overlapping and exclude women not examined as well as possible.

Do various General Practice factors influence the participation rate (PR) in the cytological investigation for preventing cancer of the cervix uteri in counties without systematized screening? This was studied in the county of Aarhus, Denmark, where there are no systematic cytological examinations (CE). We studied a random sample of 2023 women aged 27.5 years to 47.5 years. Essential differences in PR depended on various practice characteristics. Practices with the highest average use of CE services, as counted by the Regional Health Authorities, also had the best PR. The relative chance of being sufficiently examined was almost twice as great among patients in active practices compared with other practices. Furthermore, practices with at least one female practitioner and practices that wanted the introduction of systematic screening had a significantly higher PR. There was a slightly higher PR for patients in large practices. Type of practice, i.e. whether single or partnership, and the individual practitioner's attitude to the efficiency of the present opportunistic screening were not related to the PR. Finally, a slightly lower PR was found among patients in the city of Aarhus, whereas the PR in the major cities of the county as a whole did not differ from the coverage rate in the county in general.It is concluded that the Health Authorities' average figure for CE-use/1000 women in the individual practice is the most significant factor that determines the CE rate for any given patient. Variation in the PR in different practices is unacceptably large if all the women are to receive a uniform CE screening offer.

Objective - To describe a method to handle data in qualitative research.Design - Description of the data handling process in a personal computer database.Setting - The method was used in a Danish qualitative study with more than 100 interviews on quality of care.Outcome measures - The author's own description and assessment of the system.Results - Storing information in a database makes it possible to store and retrieve information from qualitative research divided in themes and subthemes. The themes and subthemes are based on an interview guide and the succeeding development of theory and new themes. The comprehensive sorting systems in a database enable the researcher to keep an overview of his data while analysing and reporting.Conclusion - Storing, analysing, and retrieving data from qualitative research demands careful planning. A computer database may be a good help in this process if the researcher will not use more complex and comprehensive software for his analysis.

This article summarises presentations made by the authors to an expert group of the World Health Organisation (Europe) meeting to consider a framework for general practice in Europe, held in Copenhagen on 6th and 7th February 1998.

Sir, - Practice activity analyses and a subsequent small group discussion of result are often used as tool for quality assessment and quality assurance in general practice. The method is quite intensively used in Denmark, as in many other countries. It is often referred to as 'medical audit' in Denmark, although this concept also covers other quality assurance activities (1,2). Audits in general practice in Denmark are mostly carried out by an institution called APO (1).