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A reproduceable method has been developed for measuring the quality of clinical care provided by physicians and nurse practitioners. The distinctive features of the method are the extended use of the tracer disease concepts, the evaluation of referrals, new procedures for probing the clinical operation of practices, a single blind design, emphasis on the use of the untouched medical record, the ability to compare results with measurements of concurrent outcome, and a relatively low cost. Three simultaneous approaches used in the method are described: surveillance of the management of indicator conditions, evaluation of clinical use drugs, and the assessment of referral decisions. The three approaches gave consistently similar results about the relative performances of the practices compared and were in agreement with concurrent outcome studies. The method was successfully implemented in a health care experiment. [ABSTRACT FROM AUTHOR]

A review of a typical Canadian urban family practice over a ten year period, 1965-1974, has revealed that control of hypertension was achieved in 67% of cases. A statistically significant fall in mortality from stroke and congestive heart failure resulted. From these favorable results we suggest that the family physician is the ideal clinician to detect, evaluate, manage and control hypertension, and that he/she could use some assistance from secondary and tertiary care consultants, lay groups and the Ministry of Health in dealing with this problem.

Core content in family medicine has been difficult to define, given that family practice has differed widely from physician to physician, according to locale and availability of resources. Since family medicine has been taught, educators have been attempting to define its core content-and find ways of teaching it. At the McMaster University Medical Centre Family Practice Unit we have put the problems first: residents present a problem in patient care and the group discusses the problem in relation to a precirculated article on the topic. Lecturing is kept to a minimum, and articles are chosen according to the principles of critical appraisal. An attempt at evaluation generated a positive response.

In March 1972 a private family practice in Hamilton, Canada, became a teaching practice of McMaster University. Subsequently a before-and-after study was conducted to compare characteristics of the patients and the impact of the change on the practice. There was a 34 percent reduction in practice size. There was a shift to younger patients and a substantial drop in mean patient income. Utilization rates of health services rose, particularly hospitalization, even though the average length of stay decreased. Profiles of complaints and diagnoses remained very similar. Quality of care scores were comparable with those of community controls before and after the change. Gross income from clinical earnings dropped, but the amounts per person per year were very similar in the two periods. It is concluded that the "transplanted private practice" which becomes part of a school of medicine is a realistic teaching resource in primary care.

The performance of an urban Canadian family practice in the detection, evaluation, treatment, control and follow-up of hypertension for a 10-year period 1965-74 was reviewed. Vigorous case-finding and treatment were followed by good control of hypertension in 67% of cases and a significant decrease in mortality from stroke and congestive heart failure. It is strongly suggested that the proper location for dealing with hypertension is the primary-care practice and that the general practitioner deserves greater assistance from clinical specialists, health foundations and ministries of health in attacking this problem.

To determine whether continuing medical education affects the quality of clinical care, we randomly allocated 16 Ontario family physicians to receive or not receive continuing-education packages covering clinical problems commonly confronted in general practice. Over 4500 episodes of care, provided before and after study physicians received continuing education, were compared with preset clinical criteria and classified according to quality. Although objective tests confirmed that the study physicians learned from the packages, there was little effect on the overall quality of care. When the topics were of relatively great interest to the physicians, the control group (who did not receive the packages) showed as much improvement as did the study group. When the topics were not preferred, however, the documented quality of care provided by study physicians rose (P less than 0.05) and differed from that provided by control physicians (P = 0.01). Finally, there was no spillover effect on clinical problems not directly covered by the program. In view of the trend toward mandatory continuing education and the resources expended, it is time to reconsider whether it works.

We randomly allocated family physicians meeting explicit entry criteria to experimental and control groups to determine whether CME affects the quality of patient care. The experimental group received educational packages, the control group did not. These educational packages were closely matched with explicit criteria used in the indicator condition-our method of measuring the quality of care. The indicator conditions were divided into elective, mandatory and hidden categories. We compared over 4,500 patient encounters, before and after the educational maneuver, with explicit clinical criteria in the indicator condition. These episodes of care were then classified according to quality of care. Though knowledge increased from the educational packages, overall quality of care improved very little. If the topics were elective, quality of care improved equally in both the experimental and control groups. When the topics were mandatory, quality of care provided by the experimental group improved (P < 0.05). Topics covered by the hidden indicator conditions showed no spillover effect.

FAMILY PHYSICIANS ARE MIRED IN A HOPELESS FLOOD OF INFORMATION UNLESS THEY UNDERTAKE REGULAR CONTINUING MEDICAL EDUCATION BASED ON ANSWERS TO THE QUESTIONS: What do I need to learn? How do I learn best? What format is best suited to me? How can I evaluate my learning? This paper examines answers to these questions, and looks ahead to methods which may become the preferred choices in future.

A 13 year review of a Hamilton, Ontario, family practice resulted in the detection of 607 hypertensive patients through case finding. By using a series of simple strategies, the measurement and recording of patients' blood pressures increased from 41% in 1965 to 98% in 1977. Team members now consistently measure and record the blood pressures at virtually all encounters of patients at risk and are convinced that case finding is the only method of detection of hypertension which is at all logical, economical and practical.