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Technical clinical procedures constitute an important part of the work of general practitioners. Assessment of competence in the relevant skills is important from the perspective of quality assurance. In this study, the psychometric characteristics of three different methods for assessment of competence in technical clinical skills in general practice were evaluated. A performance-based test (8 stations), a written knowledge test of skills (125 items) and a self-assessment questionnaire (41 items) on technical clinical skills were administered to 49 GPs and 47 trainees in general practice. The mean scores on the performance-based test and the written knowledge test of skills showed no substantial differences between GPs and trainees, whereas the GPs scored higher on the self-assessment questionnaire. While the correlation of the score on the knowledge test of skills with the score on the performance-based test was moderately high, the score on the self-assessment questionnaire showed a rather low correlation with the performance-based test. Although performance-based testing is obviously the best method to assess proficiency in hands-on skills, a written test can serve as a reasonable alternative, particularly for screening and research purposes.

Feedback can be described as a way to provide information on doctors' performance to enable changes in future behaviour. Feedback is used with the aim of changing test-ordering behaviour. It can lead to reductions in test usage and cost savings. It is not sufficiently clear, however, whether feedback leads to more appropriate test use. Since 1985, the Diagnostic Coordinating Center Maastricht has been giving feedback on diagnostic tests as a routine health care activity to all family doctors in its region. Both quantity and quality of requests are discussed. In a randomised, controlled trial over 2.5 years, discussion of tests not included previously was added to the existing routine feedback. One group of family doctors (n = 39) received feedback on test-group A (electrocardiography, endoscopy, cervical smears, and allergy tests), the other (n = 40) on test-group B (radiographic and ultrasonographic tests). Thus, each group of doctors acted as a control group for the other. Changes in volume and rationality of requests were analysed. The number of requests decreased during the trial (p = 0.036). Request numbers decreased particularly for test-group A (p = 0.04). The proportion of requests that were non-rational decreased more in the intervention than in the control groups (p = 0.009). Rationality improved predominantly for test-group B (p = 0.043). Thus, routine feedback can change the quantity and quality of requests.

Objective: To examine cholesterol diagnosis and treatment by Dutch general practitioners (GPs) in the period before publication of national guidelines, in order to develop implementation strategies based on discrepancies found between daily practice and the guidelines., Design: Data of the 'Dutch National Survey of General Practice', in which GPs were involved in extensive consultation registration, were used. Patients were included for analysis if serum cholesterol, or the ICPC-code lipid metabolism disorder, or cholesterol-lowering treatment was registered., Setting: General practice., Participants: 161 GPs, 177 practice-nurses., Outcome Measures: Reasons for consultation, diagnoses, therapy, inter-doctor variation., Results: The main discrepancies between daily practice and the guidelines concerned indications for cholesterol measurement, repeated measurements to diagnose hypercholesterolaemia, and attention for diet advice. A remarkable inter-doctor variation in diagnosis, and less so in treatment, was also found., Conclusion: The inter-doctor variation justifies the publication of the standard guidelines. Implementation strategies should aim at indications for cholesterol testing, repeating measurements for diagnosis, and advice on diet.

Quality assurance' (QA) is an important new development in general practice. In order to describe the state of the art in this field a preliminary survey was performed by the WONCA European Working Party on Quality in General Practice (EQuiP) in 17 European countries. The results revealed considerable differences in the systems and organization of general practice care [such as practice form, list size, the role of the general practitioner (GP), remuneration], which will have an impact on setting up QA. The preliminary findings demonstrated that most countries are only just beginning the implementation of QA. Nevertheless, there are many valuable developments and experiments concerned with the methodology, procedures and structures for it. In order to accelerate the speed of adoption of QA and to avoid the repetition of mistakes, policy makers and GPs from different parts of Europe should study examples in their fellow countries. A clearing house of QA projects in general practice can help to inform them on valuable developments.

A postal questionnaire was sent to a random sample of 495 Dutch general practitioners (GPs) and 278 midwives to evaluate the use of the 'imminent miscarriage' standard used by the Dutch College of General Practitioners. The response rates were 63 and 87% respectively. The first questions asked related to the respondents' routine management of an imminent miscarriage. The second part of the questionnaire addressed the respondents' attitude to the 17 most important guidelines in the standard. Finally, the respondents were invited to describe problems arising in adhering to the standard. Midwives and GPs differed in their management of an imminent miscarriage. Midwives used more 'technology' such as ultrasound scans or a doptone to trace complications or see if the fetus was still viable, whereas the GPs more often carried out vaginal and speculum examinations. Midwives also paid more attention to care following a miscarriage. The guidelines that many respondents did not adhere to involved the period of 10 days for the follow-up appointment and counselling after 6 weeks. Guidelines restricting ultrasound scans and the decision only to refer the patients to an obstetrician after three consecutive miscarriages were also not accepted by all respondents. Respondents mentioned several practical problems or obstacles in adhering to the standard, including women's requests for ultrasound scans or referrals and also the attitude of obstetricians who sometimes simply assumed control. The results will serve as a starting point for updating the standard.

Doubts have been raised about the effectiveness of traditional types of continuing medical education. Different strategies or combinations of strategies could prove to be more effective for improving the care provided by the general practitioner. For this reason a systematic literature analysis was carried out involving 75 studies of different strategies applied in primary health care. The strategies most often studied were feedback, reminders and group education. Educational material or group education combined with feedback was the combination most frequently studied. One third of all studies could be characterized as randomized controlled trials. Individual instruction, feedback and reminders seem to be the most effective single strategies. The most effective combined strategies appeared to be all combinations with individual instruction and the combination of peer review and feedback.

Patient report seems to be a workable method for quality assurance. For the purpose of the development of such a method, a review was made of 40 studies into patient judgements on general practice care. Apparently, many aspects of care are only rarely included in patient report and the patients themselves are hardly ever involved in selecting these aspects. Furthermore, there appears to be a large variety in the methods that are used. The conclusion must be that in the field of general practice care only little progress has been made in the development of patient report as a method for quality assurance.

Objective: To establish to which degree the guidelines of the Otitis media acuta standard of the Netherlands college of general practitioners (NHG) are followed in practice and what is GPs' opinion of them., Design: Survey., Setting: 65 general practitioners settled throughout the Netherlands., Method: The GPs were recruited for the study by means of an advertisement and a personal approach. Opinions and performances were inventoried using a questionnaire and self-completion forms for successive doctor-patient contacts, respectively., Results: Virtually all participants were familiar with the NHG standard and most were familiar with three central guidelines. Of these three, the recommendation of an active follow-up policy for children up to the age of 2 was known to the fewest GPs, and this recommendation also received the least support. In the 327 consultations recorded there was good agreement between actual performance and the guidelines, especially as regards history-taking, physical examination and diagnosing. Regarding management and patient information the agreement was less. Concerning the follow-up policy for young children and the prescribing of antibiotics, actual performance clearly differed from the NHG standard, possibly because the relevant guidelines were less well known., Conclusion: The results of this study are relevant to the planning of GP education and the evaluation of the guidelines themselves.

The number of good quality studies on the effect of feedback and reminders on diagnostic and preventive activities in ambulant practice is still low. The interventions and procedures studied differ widely, and the reporting of the results is insufficiently precise. This makes comparison difficult and quantitative pooling impossible. Nevertheless, the literature supports the contention that feedback reduces the use of diagnostic tests and the costs thereby engendered. It also discloses a positive effect of feedback on the adherence of medical practice to guidelines or standards. In this respect, the effect of reminders seems to exceed that of classical methods of feedback. There is still a need for research on the effect of feedback, reminders and other instruments for quality assurance on various aspects of medical performance in different settings.

The setting of standards for general practice care is receiving increasing attention in many countries. However, various problems have been noted in the procedures used for the development of guidelines. In this paper, a model for developing guidelines that fit into the specific general practice situation is presented. This model attempts to integrate current experiences in this area. Ideally, the development of guidelines should take place on various levels (central, local, practice and individual), each level involving different aims and methods. Thorough procedures must be used, in which attention is paid to the scientific validity of the guidelines, the reliability of the results, the clinical applicability, and in particular, the acceptance and adoption of the guidelines in practice.

The extent to which computerized medical administration facilitates quality control was studied using as an example the quality of blood glucose regulation in diabetics supervised by general practitioners in 11 computerized practices. Systematic use of the general practice computer rapidly provided an unequivocal answer that 37% of such patients were not regulated in accordance with the guidelines for type 2 diabetes mellitus of the Dutch College of General Practitioners. The extra workload for the participating general practitioners was minimal. Automated recording of problem lists, as applied in the general practices belonging to the Registration Network, facilitates access to data on chronic diseases and risk factors for purposes of research, quality control and quality assessment.

Objective: To assess the effect of feedback on the test ordering behaviour of general practitioners., Design: Comparison of requests at two diagnostic centres, and internal comparison between tests which were discussed in feedback and tests which were not., Setting: A diagnostic centre in Maastricht giving feedback and another elsewhere in the Netherlands (laboratory A) not giving feedback., Subjects: All 85 general practitioners in the region of Maastricht, and all general practitioners in the region of laboratory A., Main Outcome Measures: Numbers of tests requested by general practitioners., Results: Requests at the Maastricht diagnostic centre decreased soon after the onset of feedback whereas there was a persistent increase in requests at laboratory A. Tests that were discussed showed the strongest decrease (maximum 40%), though tests that were not discussed decreased as well (maximum 27%)., Conclusions: Feedback on diagnostic requests may exert a strong influence on request behaviour. Four years after the onset of feedback the effects were still noticeable.

Patient education is a central aspect of the GP's work, but it is not clear what type of information and guidance should be given to patients during consultations. As the existing literature did not offer any clear solutions to this problem, a consensus study was carried out using a panel of GPs, patients and experts/policymakers in the field of health education. After three cycles of questioning involving written questionnaires and written feedback, the panel reached a consensus on 35 priorities and recommendations concerning patient education carried out by the GP. A consensus method of this type is a valuable tool for setting standards when scientific findings are not available, and contrasting views play a role in the definition of what constitutes adequate performance.

The Nederlands Huisartsen Genootschap (NHG), the college of general practitioners in the Netherlands, has begun a national programme of standard setting for the quality of care in general practice. When the standards have been drawn up and assessed they are disseminated via the journal Huisarts en Wetenschap. In a survey, carried out among a randomized sample of 10% of all general practitioners, attitudes towards national standard setting in general and to the first set of standards (diabetes care) were studied. The response was 70% (453 doctors). A majority of the respondents said they were well informed about the national standard setting initiatives instigated by the NHG (71%) and about the content of the first standards (77%). The general practitioners had a positive attitude towards the setting of national standards for quality of care, and this was particularly true for doctors who were members of the NHG. Although a large majority of doctors said they agreed with most of the guidelines in the diabetes standards fewer respondents were actually working to the guidelines and some of the standards are certain to meet with a lot of resistance. A better knowledge of the standards and a more positive attitude to the process of national standard setting correlated with a more positive attitude to the guidelines formulated in the diabetes standards. The results could serve as a starting point for an exchange of views about standard setting in general practice in other countries.

The attitudes of general practitioners in Belgium, Britain and the Netherlands have been sought to determine if they are patient-centred or disease-centred (that is, doctor-centred). The results indicated that many of the doctors held disease-centred attitudes, which in previous studies in the Netherlands and Belgium had correlated with increased prescribing of symptomatic medication, shorter consultation time, inadequate patient records and poorer standards of care within the consultation. Doctors in Belgium had the highest level of disease-centred attitudes, Dutch doctors the lowest. Possible explanations for these differences include differences in the doctor-patient relationship that exist between these countries. Although the results must be interpreted with some care, they should form a basis for discussions about doctor-patient relations and medical education in each country.

The attitudes of groups of general practitioners in Belgium, the UK and the Netherlands to risk taking in medical decision making have been determined. The results indicate that many doctors seek to minimize the risks that they take when treating patients. Doctors in Belgium had the highest levels of 'no risk-taking' attitudes with 60% preferring not to take risks; Dutch doctors had the lowest levels with only 24% preferring not to take risks. Possible explanations for this difference include the differences in doctor-patient relationship and the systems of medical education in these two countries.

In a district of the town of Nijmegen in the Netherlands, 322 family physicians were approached to take part in an intensive peer review programme: 73% agreed to take part. The problems doctors experienced at the start of the programme were: a dislike of being criticized and doubts about such an investment of time. As the programme got going most of the problems shrank in size whilst the problem of changing their practice routines to meet certain guidelines for quality of care imposed by the programme grew. Nevertheless, for the large majority participation was a very valuable experience. By means of a gradual and personal approach towards doctors, systematic procedures for assessment and feedback, variation in topics and methods, and good organization and guidance it is possible to make quality assurance by means of peer review into a valuable aspect of the daily work of many care providers.

This paper describes the effects of an intensive, structured programme of peer review on the behaviour of general practitioners. Trained assessors evaluated 43 doctors before and after participating in the programme. Both the medical and non-medical performance of the general practitioners was assessed using a previously tested measuring instrument. In addition, the prescribing behaviour of the participants was compared with that of a control group. After taking part in the programme, the work of the general practitioners conformed more closely to a number of criteria for good general practice care. This was particularly true for clarifying the questions and expectations of the patients, active stimulation of patient involvement, history taking and providing information and advice to patients. The greatest change occurred among general practitioners who had previously conformed least with the established criteria. During peer review participants in the project prescribed fewer drugs, such as analgesics, tranquillizers and antibiotics, than before peer review while non-participants prescribed more. The value of these changes is discussed.