title: Complex consultations in primary care: a tool for assessing the range of health problems and issues addressed in general practice consultations.
abstract: BACKGROUND
  There is an increasing recognition that many consultations in general practice involve several problems covering multiple disease domains. However there is a paucity of reliable tools and techniques to understand and quantify this phenomenon. The objective was to develop a tool that can be used to measure the number and type of problems discussed in primary care consultations.
  
  
  METHODS
  Thirteen consultations between general practitioners and patients were initially videoed and reviewed to identify the problems and issues discussed. An iterative process involving a panel of clinicians and researchers and repeated cycles of testing and development was used to develop a measurement proforma and coding manual for assessment of video recorded consultations. The inter-rater reliability of this tool was assessed in 60 consultations.
  
  
  RESULTS
  The problems requiring action were usually readily identified. However the different dimensions of the problem and how they were addressed required the identification and definition of 'issues'. A coding proforma was developed that allowed quantification of the numbers and types of health problems and issues discussed. Ten categories of issues were identified and defined. At the consultation level, inter-rater agreements for the number of problems discussed (within ± 1), types of problems and issues were 98.3%, 96.5% and 90% respectively. The tool has subsequently been used to analyse 229 consultations.
  
  
  CONCLUSIONS
  The iterative approach to development of the tool reflected the complexity of doctor-patient interactions. A reliable tool has been developed that can be used to analyse the number and range of problems managed in primary care consultations.
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK. Sunita.Procter@bristol.ac.uk.
authors.forename: Sunita
authors.initials: S
authors.lastname: Procter
authors.forename: Kate
authors.initials: K
authors.lastname: Stewart
authors.forename: David
authors.initials: D
authors.lastname: Reeves
authors.forename: Leah
authors.initials: L
authors.lastname: Bowen
authors.forename: Sarah
authors.initials: S
authors.lastname: Purdy
authors.forename: Matthew
authors.initials: M
authors.lastname: Ridd
authors.forename: Chris
authors.initials: C
authors.lastname: Salisbury
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking; D010817:Physician-Patient Relations; D011320:Primary Health Care; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D014741:Video Recording