Skip to main content
PMC home page
Quality in Health Care : QHC logoLink to Quality in Health Care : QHC
. 2001 Sep;10(3):152–158. doi: 10.1136/qhc.0100152..

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand

M Seddon 1, M Marshall 1, S Campbell 1, M Roland 1
PMCID: PMC1743427  PMID: 11533422

Abstract

Objectives—Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand.

Design—A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995–9.

Setting—General practice based care in the UK, Australia, and New Zealand.

Main outcome measures—Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study.

Results—Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction.

Conclusions—This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Key Words: quality of care; clinical effectiveness; technical effectiveness; general practice; systematic review

Full Text

The Full Text of this article is available as a PDF (144.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aylett M., Creighton P., Jachuck S., Newrick D., Evans A. Blood pressure control of drug treated hypertension in 18 general practices. J Hum Hypertens. 1996 Aug;10(8):547–550. [PubMed] [Google Scholar]
  2. Bradley F., Morgan S., Smith H., Mant D. Preventive care for patients following myocardial infarction. The Wessex Research Network (WReN). Fam Pract. 1997 Jun;14(3):220–226. doi: 10.1093/fampra/14.3.220. [DOI] [PubMed] [Google Scholar]
  3. Bradshaw C., Steen I. N., Eccles M. Glycated haemoglobin levels in patients with diabetes in one general practice over a 10-year period. Diabet Med. 1995 Jul;12(7):628–631. doi: 10.1111/j.1464-5491.1995.tb00554.x. [DOI] [PubMed] [Google Scholar]
  4. Campbell N. C., Ritchie L. D., Thain J., Deans H. G., Rawles J. M., Squair J. L. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart. 1998 Nov;80(5):447–452. doi: 10.1136/hrt.80.5.447. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Campbell N. C., Thain J., Deans H. G., Ritchie L. D., Rawles J. M. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ. 1998 May 9;316(7142):1430–1434. doi: 10.1136/bmj.316.7142.1430. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Campbell S. M., Roland M. O., Buetow S. A. Defining quality of care. Soc Sci Med. 2000 Dec;51(11):1611–1625. doi: 10.1016/s0277-9536(00)00057-5. [DOI] [PubMed] [Google Scholar]
  7. Chassin M. R., Galvin R. W. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998 Sep 16;280(11):1000–1005. doi: 10.1001/jama.280.11.1000. [DOI] [PubMed] [Google Scholar]
  8. Collins S., Beilby J., Fardy J., Burgess T., Johns R., Booth B. The national asthma audit. Bridging the gap between guidelines and practice. Aust Fam Physician. 1998 Oct;27(10):907–913. [PubMed] [Google Scholar]
  9. Cranney M., Barton S., Walley T. The management of hypertension in the elderly by general practitioners in Merseyside: the rule of halves revisited. Br J Gen Pract. 1998 Apr;48(429):1146–1150. [PMC free article] [PubMed] [Google Scholar]
  10. Dickinson J., Hutton S., Atkin A., Jones K. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respir Med. 1997 Nov;91(10):634–640. doi: 10.1016/s0954-6111(97)90011-1. [DOI] [PubMed] [Google Scholar]
  11. Doyle J. C., Mottram D. R., Stubbs H. Prescribing of ACE inhibitors for cardiovascular disorders in general practice. J Clin Pharm Ther. 1998 Apr;23(2):133–136. doi: 10.1046/j.1365-2710.1998.00144.x. [DOI] [PubMed] [Google Scholar]
  12. Du X., Cruickshank K., McNamee R., Saraee M., Sourbutts J., Summers A., Roberts N., Walton E., Holmes S. Case-control study of stroke and the quality of hypertension control in north west England. BMJ. 1997 Jan 25;314(7076):272–276. doi: 10.1136/bmj.314.7076.272. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Dunn N. R., Bough P. Standards of care of diabetic patients in a typical English community. Br J Gen Pract. 1996 Jul;46(408):401–405. [PMC free article] [PubMed] [Google Scholar]
  14. Fahey T. P., Peters T. J. A general practice-based study examining the absolute risk of cardiovascular disease in treated hypertensive patients. Br J Gen Pract. 1996 Nov;46(412):655–659. [PMC free article] [PubMed] [Google Scholar]
  15. Fahey T., Lancaster T. The detection and management of hypertension in the elderly of Northamptonshire. J Public Health Med. 1995 Mar;17(1):57–62. [PubMed] [Google Scholar]
  16. Fahey T., Peters T. J. Clinical guidelines and the management of hypertension: a between-practice and guideline comparison. Br J Gen Pract. 1997 Nov;47(424):729–730. [PMC free article] [PubMed] [Google Scholar]
  17. Feder G., Griffiths C., Eldridge S., Spence M. Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial. BMJ. 1999 Jun 5;318(7197):1522–1526. doi: 10.1136/bmj.318.7197.1522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Feder G., Griffiths C., Highton C., Eldridge S., Spence M., Southgate L. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ. 1995 Dec 2;311(7018):1473–1478. doi: 10.1136/bmj.311.7018.1473. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Hooker R. C., Cowap N., Newson R., Freeman G. K. Better by half: hypertension in the elderly and the 'rule of halves': a primary care audit of the clinical computer record as a springboard to improving care. Fam Pract. 1999 Apr;16(2):123–128. doi: 10.1093/fampra/16.2.123. [DOI] [PubMed] [Google Scholar]
  20. Hopper S., Pierce M. Aspirin after myocardial infarction: the importance of over-the-counter use. Fam Pract. 1998 Apr;15 (Suppl 1):S10–S13. [PubMed] [Google Scholar]
  21. Hoskins G., Neville R. G., Smith B., Clark R. A. Does participation in distance learning and audit improve the care of patients with acute asthma attacks? The General Practitioners in Asthma Group. Health Bull (Edinb) 1997 May;55(3):150–155. [PubMed] [Google Scholar]
  22. Irvine D. The performance of doctors: the new professionalism. Lancet. 1999 Apr 3;353(9159):1174–1177. doi: 10.1016/S0140-6736(99)91160-1. [DOI] [PubMed] [Google Scholar]
  23. Jacoby A., Graham-Jones S., Baker G., Ratoff L., Heyes J., Dewey M., Chadwick D. A general practice records audit of the process of care for people with epilepsy. Br J Gen Pract. 1996 Oct;46(411):595–599. [PMC free article] [PubMed] [Google Scholar]
  24. Jolly K., Bradley F., Sharp S., Smith H., Thompson S., Kinmonth A. L., Mant D. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ. 1999 Mar 13;318(7185):706–711. doi: 10.1136/bmj.318.7185.706. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Kendall D., Lunt H., Moore M. P., McSweeney W. P. Diabetes complication screening in general practice: a two pass audit with benchmarking. N Z Med J. 1999 Apr 23;112(1086):141–144. [PubMed] [Google Scholar]
  26. Khunti K., Sorrie R., Jennings S., Farooqi A. Improving aspirin prophylaxis after myocardial infarction in primary care: collaboration in multipractice audit between primary care audit group and health authority. BMJ. 1999 Jul 31;319(7205):297–297. doi: 10.1136/bmj.319.7205.297. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Lathlean S. Skin cancer in general practice in South Australia. A five year study. Aust Fam Physician. 1999 Jan;28 (Suppl 1):S28–S31. [PubMed] [Google Scholar]
  28. Leape L. L., Brennan T. A., Laird N., Lawthers A. G., Localio A. R., Barnes B. A., Hebert L., Newhouse J. P., Weiler P. C., Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377–384. doi: 10.1056/NEJM199102073240605. [DOI] [PubMed] [Google Scholar]
  29. Marshall M. N., Shekelle P. G., Leatherman S., Brook R. H. Public disclosure of performance data: learning from the US experience. Qual Health Care. 2000 Mar;9(1):53–57. doi: 10.1136/qhc.9.1.53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Marshall M. N. Time to go public on performance? Br J Gen Pract. 1999 Sep;49(446):691–692. [PMC free article] [PubMed] [Google Scholar]
  31. Mashru M., Lant A. Interpractice audit of diagnosis and management of hypertension in primary care: educational intervention and review of medical records. BMJ. 1997 Mar 29;314(7085):942–946. doi: 10.1136/bmj.314.7085.942. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. McCallum A. K., Whincup P. H., Morris R. W., Thomson A., Walker M., Ebrahim S. Aspirin use in middle-aged men with cardiovascular disease: are opportunities being missed? Br J Gen Pract. 1997 Jul;47(420):417–421. [PMC free article] [PubMed] [Google Scholar]
  33. McCartney P., Macdowall W., Thorogood M. A randomised controlled trial of feedback to general practitioners of their prophylactic aspirin prescribing. BMJ. 1997 Jul 5;315(7099):35–36. doi: 10.1136/bmj.315.7099.35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. McColl A., Roderick P., Gabbay J., Smith H., Moore M. Performance indicators for primary care groups: an evidence based approach. BMJ. 1998 Nov 14;317(7169):1354–1360. doi: 10.1136/bmj.317.7169.1354. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. McDonald P., Friedman E. H., Banks A., Anderson R., Carman V. Pneumococcal vaccine campaign based in general practice. BMJ. 1997 Apr 12;314(7087):1094–1098. doi: 10.1136/bmj.314.7087.1094. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Morgan R., King D., Turnbull C. J. Influenza vaccination: do the aged reap the benefit? Postgrad Med J. 1995 Jan;71(831):22–23. doi: 10.1136/pgmj.71.831.22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Moscovich D. G. Lithium follow-up in general practice. Int J Clin Pract. 1997 Nov-Dec;51(8):491–492. [PubMed] [Google Scholar]
  38. Naylor C. D. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet. 1995 Apr 1;345(8953):840–842. doi: 10.1016/s0140-6736(95)92969-x. [DOI] [PubMed] [Google Scholar]
  39. Neville R. G., Hoskins G., Smith B., Clark R. A. How general practitioners manage acute asthma attacks. Thorax. 1997 Feb;52(2):153–156. doi: 10.1136/thx.52.2.153. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Neville R. G., Hoskins G., Smith B., Clark R. A. Observations on the structure, process and clinical outcomes of asthma care in general practice. Br J Gen Pract. 1996 Oct;46(411):583–587. [PMC free article] [PubMed] [Google Scholar]
  41. Parameswaran K., Hildreth A. J., Chadha D., Keaney N. P., Taylor I. K., Bansal S. K. Asthma in the elderly: underperceived, underdiagnosed and undertreated; a community survey. Respir Med. 1998 Mar;92(3):573–577. doi: 10.1016/s0954-6111(98)90311-0. [DOI] [PubMed] [Google Scholar]
  42. Prasad N., Srikanthan V. S., Wright A., Dunn F. G. Management of suspected myocardial infarction before admission: updated audit. BMJ. 1998 Jan 31;316(7128):353–353. doi: 10.1136/bmj.316.7128.353. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Raman G. V., Neal A., Lewis C. A collaborative audit of the management of hypertension in general practice. Postgrad Med J. 1998 Mar;74(869):165–167. doi: 10.1136/pgmj.74.869.165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Roghmann M. C., Sexton M. Adherence to asthma guidelines in general practices. J Asthma. 1999 Jun;36(4):381–387. doi: 10.3109/02770909909068231. [DOI] [PubMed] [Google Scholar]
  45. Rudiman R., Gilbert F. J., Ritchie L. D. Comparison of uptake of breast screening, cervical screening, and childhood immunisation. BMJ. 1995 Jan 28;310(6974):229–229. doi: 10.1136/bmj.310.6974.229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Sackett D. L., Rosenberg W. M., Gray J. A., Haynes R. B., Richardson W. S. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71–72. doi: 10.1136/bmj.312.7023.71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Salisbury C., Bosanquet N., Wilkinson E., Bosanquet A., Hasler J. The implementation of evidence-based medicine in general practice prescribing. Br J Gen Pract. 1998 Dec;48(437):1849–1852. [PMC free article] [PubMed] [Google Scholar]
  48. Schuster M. A., McGlynn E. A., Brook R. H. How good is the quality of health care in the United States? Milbank Q. 1998;76(4):517-63, 509. doi: 10.1111/1468-0009.00105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Shekelle P. G., Roland M. Measuring quality in the NHS: lessons from across the Atlantic. Lancet. 1998 Jul 18;352(9123):163–164. doi: 10.1016/S0140-6736(05)77801-6. [DOI] [PubMed] [Google Scholar]
  50. Siann T., Duncan E. M., Sullivan F., Matthews D., Cromie D. T. Area-wide diabetes care: the Lanarkshire experience with primary health care teams 1994-1997. Diabet Med. 1998 Nov;15 (Suppl 3):S54–S57. doi: 10.1002/(SICI)1096-9136(1998110)15:3+<S54::AID-DIA732>3.0.CO;2-M. [DOI] [PubMed] [Google Scholar]
  51. Simmons D., Fleming C. E., Cutfield R., Patel A., Innes J., Wellingham J. The Diabetes Care Support Service for general practitioners in Auckland. N Z Med J. 1997 Feb 28;110(1038):48–50. [PubMed] [Google Scholar]
  52. Smith B. H., Vranjkovic V., McEwan S. R., Ritchie L. D. Cholesterol testing by general practitioners in Grampian: patterns and outcomes. Scott Med J. 1996 Jun;41(3):78–82. doi: 10.1177/003693309604100304. [DOI] [PubMed] [Google Scholar]
  53. Steven I. D., Wing L. Control and cardiovascular risk factors of hypertension. An assessment of a sample of patients. Aust Fam Physician. 1999 Jan;28(1):45–48. [PubMed] [Google Scholar]
  54. Sturmberg J. P., Overend D. General practice based diabetes clinics. An integration model. Aust Fam Physician. 1999 Mar;28(3):240–245. [PubMed] [Google Scholar]
  55. Sudlow M., Rodgers H., Kenny R. A., Thomson R. Population based study of use of anticoagulants among patients with atrial fibrillation in the community. BMJ. 1997 May 24;314(7093):1529–1530. doi: 10.1136/bmj.314.7093.1529. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Vaughan N. J., Potts A. Implementation and evaluation of a decision support system for type II diabetes. Comput Methods Programs Biomed. 1996 Aug;50(3):247–251. doi: 10.1016/0169-2607(96)01754-3. [DOI] [PubMed] [Google Scholar]
  57. Ward J., Lin M., Heron G., Lajoie V. Comprehensive audit of quality-of-care and quality-of-life for patients with diabetes. J Qual Clin Pract. 1997 Jun;17(2):91–102. [PubMed] [Google Scholar]
  58. Wheeldon N. M., Tayler D. I., Anagnostou E., Cook D., Wales C., Oakley G. D. Screening for atrial fibrillation in primary care. Heart. 1998 Jan;79(1):50–55. doi: 10.1136/hrt.79.1.50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Wilson R. M., Runciman W. B., Gibberd R. W., Harrison B. T., Newby L., Hamilton J. D. The Quality in Australian Health Care Study. Med J Aust. 1995 Nov 6;163(9):458–471. doi: 10.5694/j.1326-5377.1995.tb124691.x. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

[Web only table]
qualhc_10_3_152__index.html (1,021B, html)
qualhc_10_3_152__internet_table.doc (314.5KB, doc)

Articles from Quality in Health Care : QHC are provided here courtesy of BMJ Publishing Group

RESOURCES