Long-term outcome of patients with neurotic illness in general practice.

OBJECTIVE--To determine the 11 year outcome of neurotic disorder in general practice. DESIGN--Cohort study over 11 years. SETTING--Two general practices in Warwickshire England. SUBJECTS--100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders. MAIN OUTCOME MEASURES--Mortality, morbidity, and use of health services. RESULTS--At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate. CONCLUSION--These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.     

Endpiece: How to buy gadgets

Objective To assess the effect of additional training of practice nurses and general practitioners in patient centred care on the lifestyle and psychological and physiological status of patients with newly diagnosed type 2 diabetes.Design Pragmatic parallel group design, with randomisation between practice teams to routine care (comparison group) or routine care plus additional training (intervention group); analysis at one year, allowing for practice effects and stratifiers; self reporting by patients on communication with practitioners, satisfaction with treatment, style of care, and lifestyle.Setting 41 practices (21 in intervention group, 20 in comparison group) in a health region in southern England.Subjects 250/360 patients (aged 30-70 years) diagnosed with type 2 diabetes and completing follow up at one year (142 in intervention group, 108 in comparison group).Intervention 1.5 days’ group training for the doctors and nurses—introducing evidence for and skills of patient centred care and a patient held booklet encouraging questions.Main outcome measures Quality of life, wellbeing, haemoglobin A_1c and lipid concentrations, blood pressure, body mass index (kg/m²).Results Compared with patients in the C group, those in the intervention group reported better communication with the doctors (odds ratio 2.8; 95% confidence interval 1.8 to 4.3) and greater treatment satisfaction (1.6; 1.1 to 2.5) and wellbeing (difference in means (d) 2.8; 0.4 to 5.2). However, their body mass index was significantly higher (d=2.0; 0.3 to 3.8), as were triglyceride concentrations (d=0.4 mmol/l; 0.07 to 0.73 mmol/l), whereas knowledge scores were lower (d=−2.74; −0.23 to −5.25). Differences in lifestyle and glycaemic control were not significant.Conclusions The findings suggest greater attention to the consultation process than to preventive care among trained practitioners; those committed to achieving the benefits of patient centred consulting should not lose the focus on disease management.

Key messages

• A training programme in patient centred care for practitioners led to patients with newly diagnosed diabetes reporting better communication with doctors, greater wellbeing, and greater treatment satisfaction at one year, without loss of glycaemic control
• Knowledge scores were lower and weight and other cardiovascular risk factors higher among patients attending trained practice teams
• Trained practitioners may have found it difficult to integrate attention to wellbeing with management of disease risk
• Professionals using patient centred consulting should not lose the focus on disease

     

Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

Computer assisted shared care in hypertension.

A computer assisted shared care scheme for the long term management and follow up of hypertensive patients has been developed in the Grampian Region. The scheme aims at facilitating the exchange of clinically important information between doctors and at achieving target levels of blood pressure with treatment in patients at highest risk of cardiovascular events. The shared care scheme has been well received by the local practitioners. Two hundred and fifty seven patients (18%) of 1426 patients under current long term follow up are assigned to follow up in the hospital aspect of the scheme. At the most recent visit 32% of patients in the hospital aspect and 10% of 1169 patients in the general practice aspect had blood pressure recordings above the target levels of 160/95 mm Hg. The stratification of patients formerly attending hospital clinics into grades of risk has rationalised our follow up procedures to allow the specialist resources to be freed and concentrated on those patients at highest risk and with the most complex problems. This computer assisted patient records system could be applied to other groups of high risk patients in whom long term follow up and surveillance are necessary--for example, patients with diabetes mellitus--and has implications for optimising and monitoring the delivery and outcome of care without overwhelming limited hospital resources.     

Audit of terminal care in a general practice.

OBJECTIVE--To determine satisfaction of relatives and general practitioners with care of patients during terminal illness and make recommendations on improving terminal care in general practice. DESIGN--Interviews with available relatives of patients who had had terminal illnesses and died in 1987, supplemented by questionnaires; questionnaire survey of general practitioners after review of case notes of all their patients who had died of terminal illnesses in 1987. SETTING--One urban general practice. SUBJECTS--34 Relatives of patients with terminal illnesses who died in 1987; five general practitioners from one practice. RESULTS--In six cases relatives were dissatisfied, mainly because of lack of communication; in eight cases doctors were dissatisfied because of communication, poor symptom control, and inadequate care. IMPLICATIONS--There is a need for improved communication between relatives and the health professionals involved in terminal care as well as better advice on services and benefits available to both patients and relatives. Bereavement counselling should be better organised.     

Mental health,job satisfaction,and job stress among general practitioners.

OBJECTIVE--To identify sources of job stress associated with high levels of job dissatisfaction and negative mental wellbeing among general practitioners in England. DESIGN--Multivariate analysis of large database of general practitioners compiled from results of confidential questionnaire survey. Data obtained on independent variables of job stress, demographic factors, and personality. Dependent variables were mental health, job satisfaction, alcohol consumption, and smoking. SETTING--National sample of general practitioners studied by university department of organisational psychology. SUBJECTS--One thousand eight hundred seventeen general practitioners selected at random by 20 family practitioner committees in England. INTERVENTIONS--None. END POINT--Determination of the combination of independent variables that were predictive of mental health and job satisfaction. MEASUREMENTS AND MAIN RESULTS--Women general practitioners both had job satisfaction and showed positive signs of mental wellbeing in contrast with other normative groups. Conversely, male doctors showed significantly higher anxiety scores than the norms, had less job satisfaction, and drank more alcohol than their women counterparts. Multivariate analysis disclosed four job stressors that were predictive of high levels of job dissatisfaction and lack of mental wellbeing; these were demands of the job and patients'' expectations, interference with family life, constant interruptions at work and home, and practice administration. CONCLUSIONS--There may be substantial benefit in providing a counselling service for general practitioners and other health care workers who suffer psychological pressure from their work.     

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients'' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.     

Patients' assessment of out of hours care in general practice

A sample of 177 patients drawn from 13 north London practices were interviewed shortly after they had sought help from their practice outside normal surgery hours. Patients were asked to describe the process and outcome of their out of hours call, to comment on specific aspects of the consultation, and to access their overall satisfaction with the encounter.Parents seeking consultations for children were least satisfied with the consultation; those aged over 60 responded most positively. Visits from general practitioners were more acceptable than visits from deputising doctors for patients aged under 60, but for patients aged over 60 visits from general practitioners and deputising doctors were equally acceptable.Monitoring of patients'' views of out of hours consultations is feasible, and the findings of this study suggest that practices should regularly review the organisation of their out of hours care and discuss strategies for minimising conflict in out of hours calls—particularly those concerning children.     

Decision making by general practitioners in diagnosis and management of lower urinary tract symptoms in women.

OBJECTIVE--To identify factors influencing decision making by general practitioners in the diagnosis and treatment of lower urinary tract symptoms in women. SETTING--Two suburban London general practices. SUBJECTS--Women presenting to their family doctor with lower urinary tract symptoms. DESIGN--After each consultation the doctor completed a questionnaire on presenting symptoms; clinical examination; investigations undertaken; presence of psychological, social, and menstrual problems; patients'' requests for antibiotics; antibiotic prescribing; knowledge of the patient; attitude towards the consultation; and any other factors assisting in diagnosis and management. Finally, doctors predicted the presence or absence of clinically important bacteriuria. Each woman completed a demographic questionnaire, the 12 item general health questionnaire, and the modified menstrual distress questionnaire, after which each provided a clean catch midstream urine sample. Case notes were examined for information on previous reports of results of urine analysis. RESULTS--When the general practitioners did not know the patients well they were 4.5 times more likely to assume that there was a clinically important infection. When they knew the patient well, they were four times more likely to make a correct prediction of the test result and 12 times less likely to prescribe antibiotics. Doctors were five times more likely to predict the test result correctly in patients from social classes 1 and 2 and were six times more likely to prescribe antibiotics for the older women in the sample. CONCLUSIONS--In women presenting with urinary tract symptoms, these family practitioners seemed to take no particular regard of physical, psychological, or menstrual factors in making their assessments. They were most accurate in their prediction of the result of urine analysis and least likely to prescribe antibiotics when they had a good general knowledge of the patient. Which came first, the diagnosis or prescribing, is difficult to say and probably differed in individual cases. Doctors tended to be more conservative in their management of older women and those whom they knew less well.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

Measuring outcomes in primary care: a patient generated measure,MYMOP, compared with the SF-36 health survey.

OBJECTIVE--To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness. DESIGN--Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with'' practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed. SETTING--Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre. SUBJECTS--Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days. OUTCOME MEASURES--Standardised response mean and index of responsiveness; view of practitioners. RESULTS--The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.4 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with < 0.45 for SF-36. MYMOP''s validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients'' priorities. CONCLUSION--MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.     

Long-term digoxin treatment in general practice.

A questionnaire was sent to several general practitioners and specialists in an attempt to obtain a consensus on standards of care for patients receiving long-term digoxin treatment. The consultants'' suggested standards were slightly more stringent than those of the general practitioners. The records of 42 patients taking digoxin under the care of two general practitioners were studied to see how far their actual care matched up to the suggested standards. The models of management proposed by these patients'' doctors were only slightly different from those suggested by other practitioners, but measured against these models the patients'' care was in some cases inadequate. Nevertheless, there was little relationship between the recorded levels of care and the health of the patient, and it may have been the standard of recording rather than the care that was inadequate. Measuring plasma digoxin levels in these patients proved to be of little value. Medical audit is thus a useful tool in helping the general practitioner to review his work and improve his knowledge, but it may not be a practical or true way of measuring the quality of care.     

The Influences of Group and Independent General Practice on Patient Care: A Comparative Study in Ontario

When the practices of four general practitioners, members of multispecialist-general practitioner salaried groups (clinic doctors) were compared with those of four independent general practitioners (solo practitioners), it was noted that: group practice patients had more office laboratory investigation and greater in-hospital consultation and referral. On the other hand, independent practitioners'' patients seemed to receive more personal attention from the doctor, a fuller explanation of diagnosis and treatment during office hours, more drug samples and more laboratory investigation in hospital.Group and independent practices are similar with respect to the rate of follow-up visits, the volume of preventive medicine, the number of radiographs and special procedures, the total number of drugs ordered, and the in-hospital formal written consultation rate and office consultation rate.The similarities between two types of practice may be a result of the interaction of group and independent practice in the same community.It is concluded that the team approach to medical care is not incompatible with independent practice.     

Use of thermometers in general practice.

OBJECTIVE--To identify the attitudes of general practitioners towards the use of thermometers in general practice. DESIGN--Postal questionnaire survey. SETTING--All general practitioners in the catchment area of Frimley Park Hospital, Surrey. SUBJECTS--145 general practitioners. MAIN OUTCOME MEASURES--Answers to questions covering a variety of aspects concerning the use of thermometers in general practice. RESULTS--116 (80%) doctors replied. Seven doctors did not have any method of taking a patient''s temperature; up to 12 more doctors did not use their thermometers and 56 doctors used them infrequently, less than once a fortnight. Mercury glass thermometers were most commonly used (80 doctors; 69%), but only 8% of doctors used them correctly. Six doctors failed to clean their thermometers between patients. The study failed to identify the roles of axillary and rectal temperature readings. CONCLUSION--There is a wide variation in attitudes towards the use of thermometers in general practice.     

Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme

ObjectivesTo establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.DesignRandomised controlled trial with 1 year follow up.SettingMetropolitan general practices in Melbourne, Australia.Subjects42 general practitioners and 267 of their patients aged over 65 years.InterventionEducational and clinical practice audit programme for general practitioners on health promotion for elderly people.ResultsPatients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.ConclusionsEducation of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients.

Key messages

• Few educational interventions for doctors have shown benefit to the health of patients
• Elderly people were identified in the UK health initiatives as in need of additional attention, and levels of health protective behaviours were low in community surveys
• A multifaceted educational intervention for general practitioners was effective in improving walking behaviour, self rated health status, and the frequency of social contacts in elderly patients
• General practitioners are effective in improving health and health behaviours in their elderly patients

     

Patients with fatigue in general practice: a prospective study.

OBJECTIVE--To describe the characteristics of patients attending their general practitioners and complaining of fatigue or being "tired all the time." DESIGN--Prospective study of cohort aged 16 years and older with follow up at two weeks and by questionnaires at two and six months. SUBJECTS--220 patients (164 women) with mean age 43 years and an age-sex matched comparison group. SETTINGS--Doctors and patients in four practices in Lancashire, Mid Glamorgan, Suffolk, and Surrey. MAIN OUTCOME MEASURES--General clinical data, results from standard group of laboratory tests, fatigue questionnaire, and 12 item general health questionnaire. RESULTS--Over twice as many patients with fatigue had high scores on the health questionnaire compared with the comparison group (156 (75%) v 69 (34%)). Results of laboratory tests were abnormal and contributed to the diagnosis in 19 patients. 59 out of 102 patients who responded had high fatigue scores six months later. Patients with persistent fatigue were more likely to have a history of anxiety or depression and to have had fatigue for more than three months on entry to the study. CONCLUSIONS--Women are particularly at risk of fatigue. The outcome is better if patients have had symptoms for three months or less or there is no history of emotional illness.     

HIV and measures to control infection in general practice.

OBJECTIVE--To assess the impact of HIV on procedures to control infection in general practices. DESIGN--A postal questionnaire survey. SETTING--General practices throughout Britain. SUBJECTS--5359 General practitioners, 3429 (63.9%) of whom returned the questionnaire. MAIN OUTCOME MEASURE--Response to questionnaire on knowledge about HIV and policies for controlling infection. RESULTS--Most doctors (2018) had started to wear gloves when taking blood. Almost half (1510) had not resheathed needles previously but a further 776 had adopted this policy because of HIV. Over half of the doctors did not know or were unsure about the risk of infection from needlestick injuries, and 1759 had no practice policy for controlling infection. CONCLUSIONS--Many doctors are uncertain about measures to control infection in general practice. More information and advice are needed to help doctors develop policies to protect patients and staff.     

Paediatric Care in General Practice: an Experiment in Collaboration

A project of joint consultation between a paediatrician and several general practitioners serving a group practice of 15,000 patients has shown that outpatient clinics held at a group-practice centre (when 36 children were seen at 78 consultations over 18 months) reduced the overall work-load, eliminated dual care, and directly benefited the doctors, the children, and their families.