Early detection and treatment of hyperlipidemia: physician practices in Canada.

We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient''s age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.     

Positive and negative factors in defensive medicine: a questionnaire study of general practitioners.

OBJECTIVES--(a) To investigate defensive medical practices among general practitioners; (b) to compare any such practices with general practitioners'' understanding of certain aspects of the terms of service and medical negligence and practitioners'' concerns about the risk of being sued or having a complaint lodged. DESIGN--Postal questionnaire survey. Each questionnaire was followed by a reminder. SUBJECTS--500 systematically selected general practitioners on the membership list of the Medical Defence Union. MAIN OUTCOME MEASURES--Answers to questions on defensive medical practices, understanding of certain aspects of the terms of service and medical negligence, and concerns about the risk of being sued or having a complaint lodged. RESULTS--300 general practitioners returned the questionnaire (response rate 60%). 294 (98%) claimed to have made some practice changes as a result of the possibility of a patient complaining. Of the defensive medical practices adopted, the most common (over half of doctors stating likely or very likely) seemed to be increased diagnostic testing, increased referrals, increased follow up, and more detailed patient explanations and note taking. Respondents practised defensive medicine as a possible consequence of concerns about the risks of being sued or having a complaint lodged. This association was particularly strong for negative defensive practices. Defensive medical practice did not correlate with any misunderstanding about the law of negligence or the general practitioners'' terms of service. CONCLUSIONS--General practitioners are practising defensive medicine. Some defensive practices such as increased patient explanations or more detailed note taking are clearly beneficial. However, implementing the findings of the Wilson report may increase negative defensive medical practices.     

Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey.

OBJECTIVES: To assess the health status of patients before and after breast reduction surgery and to make comparisons with the health status of women in the general population. DESIGN: Postal questionnaire survey sent to patients before and six months after surgery. SETTING: The three plastic surgery departments in the Oxford Regional Health Authority, during April to August 1993. SUBJECTS: 166 women (over the age of 16 years) referred for breast reduction; scores from the "short form 36" (SF-36) health questionnaire completed by women in the 1991-2 Oxford healthy life survey. MAIN OUTCOME MEASURES: Health status of breast reduction patients before and after surgery as assessed by the SF-36, the 28 item general health questionnaire, and Rosenberg''s self esteem scale; comparisons between the health status of breast reduction patients and that of women in the general population; outcome of surgery as assessed retrospectively by patients. RESULTS: Differences between the health status of breast reduction patients and that of women in the general population were detected by the SF-36 both before and after surgery. Breast reduction surgery produced substantial change in patients'' physical, social, and psychological function. The proportion of cases of possible psychiatric morbidity according to the general health questionnaire fell from 41% (22/54) before surgery to 11% (6/54) six months after treatment. Eighty six per cent (50/58) of patients expressed great satisfaction with the surgical result postoperatively. CONCLUSION: The study provides empirical evidence that supports the inclusion of breast reduction surgery in NHS purchasing contracts.     

Age-sex registers as a screening tool for general practice: size of the wrong address problem.

Age-sex registers were compiled and updated for the east London general practices participating in a screening study for hypertension. Of 1435 addresses in the registers of two practices that were checked, 228 (16%) were incorrect, according to the return by the post office of the screening invitations and checking the addresses of the non-responders using telephone directories and the medical records. The non-responders to the screening invitation for whom a new address was not found, were visited at the address as recorded on the age-sex register. This showed that the true address error rate from the original age-sex registers was 26% and thus substantially greater than that calculated from returned letters. It is concluded that the non-acceptance rate of screening in general practice might be exaggerated as a result of the lack of a correct address for a substantial proportion of the patients on a general practice list.     

Feasibility of using different approaches for recruiting younger twins to establish a population based twin register in Sri Lanka.

Identifying twins for a population-based register can be achieved through birth records or community surveys. We studied the feasibility and effectiveness of different methods of identifying and recruiting twins to establish a population based register. To trace twins a population survey was carried out using an interviewer administered questionnaire. We also inspected the birth registration certificates at a divisional secretariat reported from a specified hospital between the years of 1985-1997 and compared it to the birth register of this same hospital. To recruit twins a random sample of 75 twin pairs (150 twins) identified at the Divisional Secretariat were contacted through the post and 25 twin pairs (50 twins) were personally visited. The prevalence of twins was 6.5 twins per 1000 people in the area surveyed. The twinning rate at the hospital was 18.92 twins per 1000 births. A discrepancy of 38 multiples births between the hospital labour room records and those registered at the DS was noted. The response from the postal invitation for recruitment was 59% and the response from the personal invitation was 68%. (Difference 9.4% 95% CI; 7.06-11.73). Community survey and systematic inspection of birth records either at the hospital or the birth registration office was an effective method to trace twins. Once traced, personal contact was more effective than the postal invitation for recruitment of younger twins. A cost-effective approach would be to use a postal coverage followed by personal contact for non-responders. The alternative method, community coverage, would have financial implications.     

Alcoholism in the general hospital.

To assess the prevalence of alcoholism among people admitted to hospital 303 patients completed a drinking questionnaire. A total of 59 (19.5%) were found to have a drinking problem, which constituted a sixfold greater prevalence than recorded in a community survey using the same technique. The drinkers were mostly men and tended to be younger than the non-drinkers and to smoke more heavily, live in more crowded conditions, and be of lower social class. Significantly more of the drinkers had at least one parent who was an alcoholic. The results confirm that hospital inpatients comprise a larger proportion of alcoholics than found in the general population. Hence medical staff should be alert to such patients, so that treatment may be initiated at an early stage of social decompensation.     

Prevalence of symptoms of Raynaud's phenomenon in general practice.

OBJECTIVE--To investigate the prevalence of Raynaud''s phenomenon in the populations of five general practices. DESIGN--Two populations studied. A questionnaire was given to all new patients attending five general practices over four weeks, and the same questionnaire was sent by post to a random sample of adults from two of the practices. SETTING--General practices in inner London, Merseyside, and Cheshire. SUBJECTS--1532 Patients who completed questionnaires (1119 who attended the surgeries (response rate unknown) and 413 respondents to the postal survey (response rate 69%)). MAIN OUTCOME MEASURES--Response to questionnaire on symptoms of Raynaud''s phenomenon: patients were regarded as having the disease if they had episodes of blanching of the fingers that were precipitated by cold and accompanied by sensory symptoms (pins and needles or numbness). Subsequent interview and clinical appraisal of patients with the disease according to their responses to the questionnaire. RESULTS--The prevalence of Raynaud''s phenomenon was 11% (26/231) and 19% (34/182) respectively in men and women who completed the postal questionnaire and 16% (56/357) and 21% (157/762) respectively in those who completed the questionnaire when attending their general practice. Thus the overall rates were slightly higher in women, but there was no effect of age even after adjustment of the rates for practice and method of survey. CONCLUSION--The prevalence of Raynaud''s phenomenon is high compared with the low number of patients who seek treatment for the disease.     

Comparison of patient questionnaire,medical record,and audio tape in assessment of health promotion in general practice consultations.

OBJECTIVE--To determine what proportion of health promotion activities reported by the patient is recorded in the general practice notes and to compare these methods of assessing health promotion with audio tape analysis. DESIGN--Secondary analysis of data obtained in a controlled trial of differing appointment lengths. After each consultation the medical record was examined and the patient invited to completed a questionnaire. A subsample of consultations was audio taped. SETTING--Nottinghamshire. SUBJECTS--16 general practitioners from 10 practices. This report includes 3324 consultations with patients aged > or = 17, with data on measurement of blood pressure and advice about smoking and alcohol. RESULTS--Data from questionnaire and medical notes were available for 2281 consultations. Advice on smoking was recorded in the notes in 30.9% of cases in which a patient reported it (for alcohol and measurement of blood pressure, 44.4% and 82.7% of cases respectively). In 516 cases analysis of audio tape and review of records was performed. Advice on smoking was recorded in the patient''s notes in 28.6% of cases in which it was detected on audio tape (for alcohol, 31.1% of cases). In 335 consultations data from audio tape and questionnaire were available. Advice on smoking was reported by patients in 73.9% of cases in which it was detected on audio tape (for alcohol, 75.0% of cases). CONCLUSIONS--Review of the medical record is a reasonably accurate method of assessing measurement of blood pressure in the consultation but would lead to significant underestimation of advice about smoking and alcohol.     

Preliminary results of a district call scheme for cervical screening organised in general practice.

A recognised problem with the cervical screening programme in the United Kingdom is the failure to include women who have never had a cervical smear test, who are a high risk group. The implementation of a district based call scheme in East Berkshire in 1986 is described whereby women aged 20-64 with no record of a cervical smear test who were judged to be eligible for testing by their general practitioner were sent a personal invitation from their general practitioner to attend for a test. A list of high risk unscreened women was kept by each practice, and a duplicate sent to the cytology laboratory to update the central records. Six months after each batch of invitations had been sent the resulting number of women having a smear test was assessed. Forty three of 51 practices approached agreed to participate in the five year scheme. During the first year lists were sent to the 43 participating practices. The first list was returned to the cytology laboratory by 37 practices and the second by 33; practices varied in their responses, however, some needing considerable persuasion to return the lists. Of 972 identified unscreened women from the total 3757 women listed in the lists of the family practitioner committee, 247 (25%) had a cervical smear test in response to the invitation, representing an overall increase of 7% in the screened population. The preliminary findings of the five year study have shown that screening can be improved by a systematic call scheme. Coordinated support from the area health authority in health education, monitoring of screening, and feedback of data from the scheme to practices is required to reduce the proportion of unscreened women.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

Would primary health care workers give appropriate dietary advice after cholesterol screening?

The purpose of this study was to obtain information on the dietary knowledge of primary health care workers and on their ability to apply this knowledge in practice. A total of 128 primary health care workers (53 general practitioners and 61 nurses) in 12 practices and 14 primary care facilitators were surveyed by questionnaire between December 1987 and June 1988. All of the practices were participating in a project to promote prevention in primary care and offered health checks designed to identify and deal with cardiovascular risk factors. The questionnaire focused on issues related to managing patients with moderate hypercholesterolaemia. The results of the study showed some important gaps in the health workers'' knowledge--for example, only 91 understood that dietary intake of polyunsaturated fatty acids as a proportion of total fat intake should be increased in a diet designed to reduce serum lipid concentrations. Appreciable gaps in their ability to give practical and appropriate dietary advice were also identified: 35 gave advice that would have led to the patient losing weight (although his history indicated that he was not overweight), and 27 gave only negative advice, offering no suggestions about substituting healthy foods for unhealthy ones. The demand for primary health care workers to give dietary advice is increasing and is likely to increase further if a national screening programme for hypercholesterolaemia is recommended. The results of this survey point to a need for improved nutritional education and training in dietary counselling for general practitioners, nurses, and primary care facilitators.     

Quality of screening for diabetic retinopathy in the Rijeka region of Croatia

The aim of this study was to compare the quality of screening for diabetic retinopathy in cities of Rijeka and Zagreb, Croatia. Review of a random sample of 500 diabetic patient records and prospective ophthalmologic survey of 466 randomly selected diabetic patients in a secondary level diabetologic service in Rijeka (coastal region of Croatia). The main outcome measures were proportion of diabetic patient records with notes on ophthalmologic examination; rate of diabetic patients involved with screening for diabetic retinopathy; comparison with rates in Zagreb (Croatian capital). A total of 67% patients visited the ophthalmologist at least once after diagnosed with diabetes, and notes on ophthalmologic examination were found in only 28% patient records. Fifty percent of patients underwent an ophthalmologic examination within two years. Only one third of patients diagnosed with DM in last two years visited the ophthalmologist within this time, and 14% of patients older than 50 years never visited the ophthalmologist. Model of screening for diabetic retinopathy in Croatia works better in Zagreb than in Rijeka region, and needs certain improvements. The authors suggested modern methods of screening, the incorporation of the mechanisms of quality control, the obligatory reporting of newly diagnosed diabetic patients to the national registry, and the direct referral from diabetologist to ophthalmologist.     

Medical facilities used by heroin users.

There is little information about the extent of contact between heroin users and medical facilities. In this study of heroin users from general practice we found an increase in the attendance of patients after the onset of heroin use and that a high proportion of appointments were made at general practices compared with hospital departments.     

Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score.

OBJECTIVES: To establish whether a questionnaire incorporating MacKie''s risk factor flow chart can identify patients at high risk for melanoma so that they can be targeted for primary and secondary prevention. To validate the risk score derived from the questionnaire and test the feasibility of self completion by comparing patients'' self reported skin characteristics with a skin examination performed by an experienced general practitioner. DESIGN: Prospective questionnaire survey followed by a comparative study. SETTING: 16 randomly selected group practices in a health district in Cheshire, United Kingdom. SUBJECTS: Questionnaire survey--3105 consecutive patients aged 16 years and over attending for a primary care consultation; comparative study--a self selected subsample of 388 of the 3,105 patients. MAIN OUTCOME MEASURES: MacKie risk group for melanoma. Comparison of high risk skin characteristics reported by patients and those noted during a skin examination by a doctor (kappa statistic). RESULTS: 4.3% of patients (87% women) were in the highest risk group and 4.4% (79% men) were in the second highest risk group, as defined by the MacKie score. Agreement between patients'' self appraisal of skin characteristics and clinical skin examinations was reflected in kappa values of 0.67 for freckles, 0.60 for moles, and 0.43 for atypical naevi. CONCLUSION: This questionnaire helped to identify a group at high risk for melanoma. Furthermore, good agreement was found when the patient''s risk scores were compared with results of the clinical skin examination. This risk score is potentially useful in targeting primary and secondary prevention of melanoma through general practice.     

Cervical screening in Perth and Kinross since introduction of the new contract.

OBJECTIVE--To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. DESIGN--Analysis of computerised records of cervical screening both before and after introduction of the new contract. SETTING--General practices in Perth and Kinross Unit, Tayside. PATIENTS--A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. MAIN OUTCOME MEASURES--Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. RESULTS--Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. CONCLUSION--The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.     

Population based study of fatigue and psychological distress.

OBJECTIVES--To determine the prevalence of fatigue in the general population and the factors associated with fatigue. DESIGN--Postal survey. SETTING--Six general practices in southern England. SUBJECTS--31,651 men and women aged 18-45 years registered with the practices. MAIN OUTCOME MEASURES--Responses to the 12 item general health questionnaire and a fatigue questionnaire which included self reported measures of duration, severity, and causes of fatigue. RESULTS--15,283 valid questionnaires were returned, giving a response rate of 48.3%, (64% after adjustment for inaccuracies in the practice registers). 2798 (18.3%) of respondents reported substantial fatigue lasting six months or longer. Fatigue and psychological morbidity were moderately correlated (r = 0.62). Women were more likely to complain of fatigue than men, even after adjustment for psychological distress. The commonest cited reasons for fatigue were psychosocial (40% of patients). Of 2798 patients with excessive tiredness, only 38 (1.4%) attributed this to the chronic fatigue syndrome. CONCLUSION--Fatigue is distributed as a continuous variable in the community and is closely associated with psychological morbidity.     

Immunisation against influenza among people aged over 65 living at home in Leicestershire during winter 1991-2.

OBJECTIVES--To assess the size of the elderly population for whom influenza vaccine is indicated and how many are vaccinated. DESIGN--Cohort questionnaire study. SETTING--Leicestershire general practices. SUBJECTS--800 elderly subjects selected a random from the Leicestershire family health services authority list who were not living in residential care, 565 of whom returned a questionnaire. MAIN OUTCOME MEASURES--Patient profile, vaccine offers, vaccination status, and reasons for not accepting vaccine. RESULTS--170 of 334 (51%) people aged 65-74 years and 106 of 205 (52%) aged > or = 75 years had one or more medical indications for influenza vaccine. 195 people were offered vaccine, 49 of whom had no risk factor. 152 offers were made opportunistically during visits to the practice and only six were made in writing or by telephone. Overall 113 of 266 patients with known medical indications were immunised. Vaccine was accepted by 148 of 189 (78%) offered it, and, as judged by acceptance in sequential years, influenza vaccine was well tolerated. The main reasons for not being vaccinated were misconception about risk status and inadequate advice from doctors. CONCLUSIONS--The prevalence of medical indications for vaccine is not large enough to justify a policy of universal immunisation. Most patients offered vaccine accept it and tolerate it well. Improved targeting and education is needed to increase immunisation of people at risk.     

Medical students' self-reported typical counseling practices are similar to those assessed with standardized patients

CONTEXT/OBJECTIVES: We surveyed fourth-year medical students in the Class of 2003 at Emory University School of Medicine, Atlanta, Georgia, about various personal and clinical practices. We were especially interested in the frequency that these seniors reported of talking with patients about nutrition, weight, exercise, alcohol, and cigarette smoking. Because the validity of our findings about these counseling practices was limited by our having only self-reported data from seniors' questionnaires, we developed a standardized patient (SP) examination to test the relationship between what students reported on the questionnaires and how they actually performed with SPs. DESIGN/SETTING/MAIN OUTCOME MEASURES: As part of a lengthy questionnaire, 88 senior medical students answered these 5 separated questions: "With a typical general medicine patient, how often do you actually talk to patients about: (1) nutrition; (2) exercise/physical activity; (3) weight; (4) smoking cessation (among smokers); and (5) alcohol? (never/rarely, sometimes, usually/always)." As part of their internal medicine subinternship final exam, students clinically assessed 4 SP cases with predetermined risk factors (poor diet, exercise, alcohol, and/or cigarette-smoking habits). RESULTS: For every risk factor, the proportion of SPs actually counseled was higher for those students who self-reported discussing that risk factor more frequently with their patients. Additionally, the odds of counseling an SP for any risk factor were significantly higher (odds ratio = 1.76-2.80, P < .05) when students reported more frequent counseling. CONCLUSION: Student self-reports regarding patient counseling may be useful when resources are limited, and the purpose is to grossly and anonymously distinguish between higher and lower performers.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.