Is histological examination of tissue removed by general practitioners always necessary? Before and after comparison of detection rates of serious skin lesions.

OBJECTIVES: To examine whether histological examination of all tissue removed by general practitioners in minor surgery increases the rate of detection of clinically important skin lesions, and to assess the impact of such a policy on pathologists'' workload. DESIGN: Before and after comparison. SETTING: Stratified random sample of 257 general practitioner partnerships from the catchment areas of 19 English pathology laboratories. SUBJECTS: Tissue removed in minor surgery by general practitioners during the control period (September 1992 to February 1993) and intervention period (September 1993 to February 1994). INTERVENTION: General practitioners referred to their local pathology laboratory all solid tissue removed in all minor surgery, irrespective of their previous policy. MAIN OUTCOME MEASURES: Numbers of specimens referred for histology by general practitioners during intervention and control periods; numbers of primary malignant melanomas, non-melanoma malignancies, premalignant lesions, and benign lesions. RESULTS: 257/330 partnerships participated (response rate 78%). During the intervention period 5723 specimens were sent, compared with 4430 during the control period. The referral rate increased by an estimated 1.34 specimens per 1000 patient years (95% confidence interval 0.93 to 1.76, P < 0.0001). General practitioners sent 204 specimens that were malignant (including 16 malignant melanomas) in the control period and 188 that were malignant (including 15 malignant melanomas) during the intervention period (change in total number of malignancies, -1.0 per 100,000 patient years (-5.9 to 3.8, non-significant). CONCLUSIONS: The intervention was associated with a substantial increase in laboratory workload, all of which was accounted for by increases in non-serious lesions. This observation should be taken into account when considering the merits of a policy requiring histological examination in every case.     

Using information from asthma patients: a trial of information feedback in primary care.

OBJECTIVE--To test the effects of feedback of information about patients'' asthma to primary care teams. DESIGN--Patients'' reports of morbidity, use of health services, and drug use on questionnaire was given to primary care teams. Randomised controlled trial with general practices as the subject of the intervention was used to test effectiveness of supplying information. SETTING--Primary care in district health authority, London. SUBJECTS--23 general practices, each of which notified at least 20 asthmatic patients aged 15-60 years for each principal. Practices were randomly allocated to an invention group (receiving feedback of information on control of asthma) or a control group (no feedback). INTERVENTION--Information on cards inserted in patients'' medical records; booklet copies of information for team members; formal presentation to primary care teams; poster displays of data on patients in each practice. MAIN OUTCOME MEASURES--Type and frequency of asthma symptoms, use of health services, use of asthma drugs. RESULTS--Reported morbidity at entry to the study was substantial: 45% (818) patients reported breathlessness at least once a week. Less than half these patients were using inhaled steroids regularly. Intervention and control groups did not differ in practice or patient characteristics on entry to the study. In spite of the potential for improvement no differences were observed between the two practice groups at the end of the study--for example, breathlessness at least once a week in last six months was experienced by 36% in intervention group v 35% in control group (t = -0.27, P < 0.79); surgery attendance in last six months by 48% v 48% (t = -0.05, P < 0.96); regular use of inhaled steroids by 60% v 58% (t = 0.51, P < 0.62). CONCLUSION--Feedback to general practitioners of information about patients'' asthma does not on its own lead to change in the outcome of clinical care.     

Home visiting by general practitioners in England and Wales.

OBJECTIVE--To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients'' characteristics. DESIGN--Survey of diagnostic data on all home visits by general practitioners. SETTING--60 general practices in England and Wales. SUBJECTS--502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES--Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS--10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients'' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS--Home visits remain an important component of general practitioners'' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.     

Do clinical guidelines improve general practice management and referral of infertile couples?

OBJECTIVE--To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple). DESIGN--Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group. SETTING--82 general practices in Grampian region. SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners. MAIN OUTCOME MEASURES--Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately. RESULTS--Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples'' use of fertile period, 85% v 69%, p < 0.01); examine both partners (female partner, 68% v 52%, p < 0.05; male partner 39% v 13%, p < 0.01); and investigate both partners (day 21 progesterone, 72% v 41%, p < 0.001; semen analysis, 51% v 41%, p > 0.05). Improvements were greater when general practitioners used the disease specific reminder. CONCLUSION--Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple.     

Workload of general practitioners before and after the new contract.

OBJECTIVE--To assess changes in general practitioners'' workload associated with the new contract introduced in April 1990. DESIGN--Weekly workload diary completed during four weeks in February-March 1990 and during the same period in 1991. SETTING--Sheffield, United Kingdom. SUBJECTS--All 300 general practitioners on Sheffield Family Health Services Authority list as principals in 1990 and 1991. MAIN OUTCOME MEASURES--Mean number of hours worked per week, number of patients seen each week, and mean time spent per patient. RESULTS--181 (60%) general practitioners responded in 1990 and 163 (54%) in 1991. Of these, 18 (10%) were not working in 1990 and 14 (7%) in 1991. General medical service work increased during a "normal working week" from a mean of 38.6 hours a week in 1990 to 40.6 hours in 1991, and non-general medical service work decreased from 5.4 hours a week to 4.5 hours. Hours spent on call were similar before and after the contract. For the 99 general practitioners who responded in both years, time spent on general medical service duties increased significantly (40.5 h in 1990 v 42.5 h [corrected] in 1991; p = 0.033), mainly due to more time being spent in clinics. Significantly more patients were being seen in clinics (9 v 14; p = 0.001); the average time spent per patient remained at about 8 1/2 minutes during surgeries and 16 minutes for a home visit, and rose from 13 to 14 minutes for patients seen in clinics. The time spent on practice administration fell but not significantly. CONCLUSION--Since the new contract there has been a significant increase in general medical services work, mainly due to more patients being seen in clinics, with no reduction in the time spent per patient.     

Opinions of general practitioners in Nottinghamshire about provision of intrapartum care.

OBJECTIVE--To examine the beliefs of general practitioners concerning intrapartum care. DESIGN--Postal questionnaire survey. SUBJECTS--All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES--General practitioners'' current involvement in maternity care, and beliefs on intrapartum care. RESULTS--Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women''s choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS--The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.     

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

ObjectivesTo determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease.DesignRandomised controlled trial.Setting52 general practices in east London, 44 of which had received facilitation of local guidelines for coronary heart disease.Participants328 patients admitted to hospital for myocardial infarction or unstable angina.InterventionsPostal prompts sent 2 weeks and 3 months after discharge from hospital. The prompts contained recommendations for lowering the risk of another coronary event, including changes to lifestyle, drug treatment, and making an appointment to discuss these issues with the general practitioner or practice nurse.ResultsPrescribing of β bockers (odds ratio 1.7, 95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol lowering drugs (1.7, 0.8 to 3.4, P>0.05) did not differ between intervention and control groups. A higher proportion of patients in the intervention group (64%) than in the control group (38%) had their serum cholesterol concentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondary outcomes were significantly improved for consultations for coronary heart disease, the recording of risk factors, and advice given. There were no significant differences in patients’ self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event.ConclusionsPostal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle. The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practices. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines.

Key messages

• Postal prompts to patients and their general practitioners about effective secondary prevention after a myocardial infarction did not improve the prescribing of cholesterol lowering drugs and β blockers
• The prompts did improve general practice recording of cardiovascular risk factors and lifestyle advice given to patients, but they made no difference to patients’ reports of changes to lifestyle
• Other methods are needed to improve the quality of secondary prevention of coronary heart disease in general practice

     

Effects of an educational intervention for general practitioners in adolescent health care principles: a randomized controlled study

Objective To evaluate the effectiveness of an educational intervention in adolescent health designed for general practitioners, in accordance with evidence-based practice in continuing medical education. Design Randomized, controlled trial with baseline testing and 7- and 13-month follow-ups. Setting The intervention was delivered in local community settings to general practitioners in metropolitan Melbourne, Australia. Participants A total of 108 self-selected general practitioners. Intervention A multifaceted educational program (2.5 hours per week for 6 weeks) in the principles of adolescent health care, followed 6 weeks later by a 2-hour session of case discussion and debriefing. Outcome measures Objective ratings of videotaped consultations with standardized adolescent patients and self-completion questionnaires were used to measure general practitioners' knowledge, skill, and self-perceived competency; satisfaction with the program; and self-reported change in practice. Results 103 of 108 physicians (95%) completed all phases of the intervention and evaluation protocol. The intervention group showed significantly greater improvements than the control group in all outcomes at the 7-month follow-up (all subjects P<0.03), except for the standardized patients' rating of rapport and satisfaction (P=0.12). 104 participants (96%) found the program appropriate and relevant. At the 13-month follow-up, most improvements were sustained, the standardized patients' rating of confidentiality fell slightly, and the objective assessment of competence further improved. 106 physicians (98%) reported a change in practice attributable to the intervention. Conclusions General practitioners were willing to complete continuing medical education in adolescent health and its evaluation. The design of the intervention, using evidence-based educational strategies, proved effective and expeditious in achieving sustainable and large improvements in knowledge, skill, and self-perceived competency.     

Analysis of the bureaucratic unsolicited mountainous paper heap (BUMPH) that general practitioners received in 1994.

OBJECTIVES--To record and analyse the bureaucratic unsolicited mountainous paper heap (BUMPH) received by general practitioners; to make some suggestions for coping with the ensuing workload. DESIGN--Daily record of all BUMPH landing on the desk of a general practitioner in one year. SETTING--Mixed practice with one full time and two job sharing principals. RESULTS--5100 pages of BUMPH arrived during the year. The most prolific source of origin was health authorities (1549 pages). Fridays, Mondays, and the day after a holiday were the days BUMPH was most frequently seen. CONCLUSIONS--BUMPH is a major source of workload. One way of avoiding it is not to work on the day after a day off.     

New roles for general practitioners.

General practice is likely to change greatly over the next few years. Increases in care in the community and day surgery will lead to more work, and the demand for better data on practice activity will mean the development of audit and epidemiological work. To make time general practitioners will have to learn to delegate work that does not require a doctor. Fundholding has already stimulated some practices to bring services to patients rather than send patients to hospital, and this trend seems set to continue. It is important to pool resources, not only within practices but among other practices in the area--joint action will increase the ability to improve the services for patients. If general practitioners take the opportunity to gain control of the changes the morale of the profession should improve.     

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE--To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN--Multicentre randomised controlled trial. SETTING--51 general practices linked to nine Scottish maternity hospitals. SUBJECTS--1765 women at low risk of antenatal complications. INTERVENTION--Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES--Comparisons of health service use, indicators of quality of care, and women''s satisfaction. RESULTS--Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION--Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.     

The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial

Background

Diabetes is a major challenge for the health care system and especially for the primary care provider. The Chronic Care Model represents an evidence-based framework for the care for chronically ill. An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters. However, most of these findings have been performed in settings different from the Swiss health care system which is dominated by single handed practices.

Methods/Design

CARAT is a cluster randomized controlled trial with general practitioners as the unit of randomization (trial registration: ISRCTN05947538). The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year (primary outcome). Furthermore, we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure (<130/80), HbA1c (=<6.5%) and low-density lipoprotein-cholesterol (<2.6 mmol/l), increases patients' quality of life (SF-36) and several evidence-based quality indicators for diabetes care. These improvements in care will be experienced by the patients (PACIC-5A) as well as by the practice team (ACIC). According to the power calculation, 28 general practitioners will be randomized either to the intervention group or to the control group. Each general practitioner will include 12 patients suffering from diabetes type II. In the intervention group the general practitioner as well as the practice nurse will be trained to perform care for diabetes patients according to the Chronic Care Model in teamwork. In the control group no intervention will be applied at all and patients will be treated as usual. Measurements (pre-data-collection) will take place in months II-IV, starting in February 2010. Follow-up data will be collected after 1 year.

Discussion

This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach. If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to redesign care in Switzerland.

     

Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice

Objectives To determine whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice.Design Controlled trial randomised by practice.Setting General practices in Perth, Western Australia.Participants 468 general practitioners in 223 practices.Interventions Intervention practices were given an algorithm and instant camera to assist with the diagnosis of pigmented skin lesions. All practices were given national guidelines on managing melanoma.Main outcome measures Ratio of benign pigmented lesions to melanomas excised. Analyses conducted with and without inclusion of seborrhoeic keratoses.Results At baseline the ratios of benign to malignant lesions were lower in the intervention group than in the control group. During the trial period the ratios were higher in the intervention group (19:1 v 17:1 without seborrhoeic keratoses and 29:1 v 26:1 with seborrhoeic keratoses). After adjustment for patients'' age, sex, and socioeconomic status, the ratio was 1.02 times higher (95% confidence interval 0.68 to 1.51, P = 0.94) in the intervention group when seborrhoeic keratoses were not included and 1.03 times higher (0.71 to 1.50, P = 0.88) when seborrhoeic keratoses were included. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% v 48%, P < 0.001) and to refer the patient to a specialist (16% v 27%, P = 0.06).Conclusions Provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.     

Deputising services: the portsmouth experience.

An analysis of the deputising service in the city of Portsmouth showed that the workload of doctors was not excessive and there was no evidence that the number of calls was higher than in areas where no deputising service exists. Sixty seven per cent of patients were seen within one hour of requesting a call and 93% within two hours. Seven per cent of patients were admitted to hospital and 88% of these were seen within one hour of requesting medical care. Drugs were prescribed at 65% of all contacts between doctor and patient which compares favourably with prescribing rates for consultations in general practice. A notable feature of the Portsmouth scheme is that all subscribers who use the deputising service have to agree to participate as a deputy, with 90% of deputies being practising general practitioners or eligible to be principals in general practice. This has probably conserved costs and hospital resources.     

Aid to diagnosis of melanoma in primary medical care.

OBJECTIVE--To evaluate an intervention designed to reduce the number of benign melanocytic lesions excised from the skin. DESIGN--A randomised controlled field trial based in the medical practices of two cities. Examination of histopathological reports of 5823 melanocytic skin lesions excised over the intervention period and in the preceding six months. INTERVENTION--Medical practitioners were offered an algorithm and use of an instant developing camera. SETTING AND SUBJECTS--Over 50 medical practitioners, mostly in general practice, in each of two cities in tropical Queensland, Australia. MAIN OUTCOME MEASURES--Percentages of benign (neither malignant nor potentially malignant) melanocytic lesions excised during the two year intervention period. RESULTS--There were no significant differences in the percentages of benign lesions reported in the intervention and control cities before the intervention started (93.6% and 94.0%, respectively), but there was a significant difference afterwards (88.8% and 93.8%, P < 0.001). There was no difference in the percentage of invasive melanomas excised per month in the intervention city (3.4%) compared with control city (3.4%). CONCLUSION--Clinical diagnostic accuracy may be enhanced by offering to clinicians managing suspicious melanocytic skin lesions a simple algorithm and a camera with which to record the appearance of lesions objectively.     

Organisation of telephone services and patients' access to doctors by telephone in general practice.

OBJECTIVES--To assess how accessible general practitioners are to patients by telephone and to examine the relations between organisation, number of lines, and number of patient-doctor calls. DESIGN--Postal survey of a random sample of general practitioners stratified by rural and urban practice areas, with differential sampling fractions. SETTING--General practices in England and Wales. SUBJECTS--2000 general practitioners, of whom 1459 (74%) responded. MAIN OUTCOME MEASURES--Number of calls received by general practitioner a day, time reserved for patients'' calls, and communication of availability of telephone contact. RESULTS--1421 general practitioners said that they accepted non-emergency calls from patients during the day and 285 reported reserving specific times of the day for this purpose. 848 estimated that they received four or fewer patient calls a day. The number of calls was significantly related to reserving time for calls (p less than 0.001), informing patients that the doctor was accessible by telephone (p less than 0.00001), and the number of periods when calls were accepted (p less than 0.00001). On average there were 3659 patients per incoming line; the number of patients per incoming line rose significantly as practice size increased (p less than 0.00001). CONCLUSIONS--The apparent willingness of general practitioners to accept calls was not reflected in the number of calls received. Reserving time, increasing periods of availability, and publicising telephone access increased the number of doctor-patient telephone contacts. Line congestion may be a problem, and impartial advice and guidance on telephone organisation and line requirements would be helpful.     

Do general practitioners act consistently in real practice when they meet the same patient twice? Examination of intradoctor variation using standardised (simulated) patients.

OBJECTIVE: To assess the variation within individual general practitioners facing the same problem twice in actual practice under unbiased conditions. DESIGN: General practitioners were consulted during normal surgery hours by a standardised patient portraying a patient with angina pectoris. Six weeks later the same general practitioners were consulted again by a similar standardised patient portraying a similar case. The patients reported on the consultations. SETTING: Trondheim, Norway. SUBJECTS: Of 87 general practitioners invited by letter, 28 (32%) agreed to participate without hesitation; nine others (10%) wanted more information before consenting. From these 24 were selected and visited. MAIN OUTCOME MEASURES: Number of actions undertaken from a guideline in both rounds of consultations. Duration of consultations. RESULTS: The mean (range, interquartile range) guideline score, total score, and duration of consultation were not significantly different between the first and second patient encounters for the group as a whole. For individual doctors the mean (SD) difference was -0.09 (3.36) for the guideline score, 0.30 (8.1) for the total score, and -0.87 (9.01) for consultation time. CONCLUSIONS: The study shows that assessment of performance in real practice for a group of general practitioners is consistent from the first round of consultations to the second round. However, significant variation occurs in performance of individual physicians.