Computerisation of primary care in Wales.

OBJECTIVE--To obtain information about the computerisation of general practice in Wales, and to enable more effective planning of educational provision for doctors and other primary health care workers. DESIGN--Postal questionnaire sent to all general practices in Wales. SUBJECTS--553 general practices, of which 401 (73% replied). RESULTS--The level of computerisation varied from 11 (85%) of practices in Powys Family Health Services Authority to 22 (40%) in Mid Glamorgan. Less than half of practices had a computer in only two authorities. The commonest uses of the computer were for patient registration (208 practices), repeat prescribing (180), call and recall of patients (165), and partial clinical records (122). The main suppliers were VAMP (78 practices), AAH Meditel (46), and AMC (23). 102 of 226 practices with a computer had a terminal on each doctor''s desk. Just 33 practices had full patient notes on computer and 51 had modems for electronic communication. CONCLUSION--Mechanisms to encourage greater and more sophisticated use of computers and information technology need to be explored.     

Survey of equipment in general practice.

Partners in general practice have to buy any equipment they want themselves. As a result partners in high investing practices have lower net incomes. Of the 297 practices in Devon and Cornwall, 265 responded to a questionnaire listing 115 possible items of practice equipment. Overall, practices seemed to be fairly well equipped. Key findings were that 193 of those who responded had an electrocardiograph, 206 had a kit for minor operations, 119 owned a computer, and less than one third owned a microscope. Most of these practices were high investors. There seems to be a shift away from some traditional instruments towards expensive information technology. Government policies are encouraging the use of computers and such equipment, though funds are not necessarily being made available for this purpose.     

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.     

Information systems for general practitioners for quality assessment: I. Responses of the doctors.

A questionnaire was sent to all general practitioner principals in Leicestershire and Lincolnshire (n = 669) to determine (a) the extent to which they would participate in quality assessment activities based on objective evidence of performance and (b) the personal and professional characteristics of interested doctors. The overall response rate to the questionnaire was 76% (508 replies). The highest response rates were recorded by trainers (100%), principals in training practices (94%), and younger doctors (80-86%), the lowest by overseas graduates (59%) and older doctors (65%). Distinctive patterns of interest and participation in three types of audit activities were clearly evident. Overall, 61% (310) of respondents wished to be provided with profiles of practice activity from their family practitioner committees, 36% (183) volunteered to participate in a prescribing study, and 34% (172) expressed interest in carrying out an audit in depth. Proportionately, the most enthusiastic and active groups were trainers 88%, 70%, 62%), principals in training practices (74%, 49%, 47%), and members or fellows of the Royal College of General Practitioners (71%, 50%, 45%). Also active were younger doctors, vocationally trained doctors, and principals in large group practices. These figures suggest that roughly 15 000 general practitioners in the United Kingdom would be prepared to participate in performance review activities using information provided by external agencies, 10 000 would if they had to generate some of the information, and 7500 would if they had to produce all the information themselves.     

Factors influencing the response to advertisements for general practice vacancies.

OBJECTIVES: To investigate the extent of problems in recruiting general practitioners and to determine which practice characteristics affect recruitment--in particular, to see if practices with deprived patients have more recruitment problems. DESIGN: Postal questionnaire survey in August 1995. SUBJECTS: 489 consecutive practices that had advertised for a partner in the BMJ from January to April 1995. MAIN OUTCOME MEASURES: The number of applicants, the practices, satisfaction with their quantity and quality, and whether a successful appointment was made. RESULTS: 442 (90%) practices replied. 262 practices (60%) were not very satisfied or very dissatisfied with the number of applications they received; 15 (3%) received no applications. There was a significant difference in the number of applications received by practices in different NHS regions. The 32 practices with the highest proportions of patients eligible for deprivation payments received a median of five applicants compared with 10 for practices without deprivation. CONCLUSION: There is a widespread problem in recruiting general practitioners. Recruitment is hardest in areas with the greatest health needs.     

Quality of care in managing hypertension by case finding in north west London.

The records of patients who were registered with general practice in inner London and outer London (both training and non-training practices) were examined for details of blood pressure recordings. A blood pressure recording was found in the past five years in only 22% of the notes of inner London practices but in 43% of notes in outer London practices, there being no difference between training and non-training practices. In 31% of the notes with a blood pressure recording the blood pressure had been raised (greater than or equal to 160/90) at some time: in 62% of these notes for patients aged 65 or more and in 52% of these notes for patients aged under 65 treatment had been given at some time. Thirty eight per cent of patients in the older group and 33% in the younger group were being treated at the time of the survey, thiazides being the most commonly used drugs. Thirty four per cent of all those with a raised blood pressure at some time had a latest recording of under 90 mm Hg diastolic. There seems to be a continuing need for general practitioners to detect and treat hypertension, and it is suggested that general practitioners should consider using systematic case finding for hypertension in their practices.     

Diabetes registers: a grassroots approach.

OBJECTIVES--To compile a register of diabetic patients within the catchment area of a district general hospital and evaluate the characteristics of the population using aggregated data from a general practice audit. DESIGN--Cross sectional study. Practices identified all known diabetics and completed a questionnaire from information in each patient''s medical record. SETTING--Practices affiliated to a district audit group in south east England. MAIN OUTCOME MEASURES--Number of participating practices; prevalence of diabetes and its complications; and sex distribution of patients, age at diagnosis and review, treatment, and metabolic control. Comparisons with similar data from other studies. RESULTS--41 out of 43 practices participated, and 2574 diabetic patients were identified (prevalence 1.18%). 52.4% of patients were male. The mean age was 61.6 years. 32% of patients were treated with insulin, 51.5% with oral hypoglycaemic agents, 16.5% with diet alone. The mean random blood glucose concentration was 10.4 mmol/l and glycosylated haemoglobin 10.1%. 8% had proteinuria, 7% a history of myocardial infarction, 5% a history of stroke, and 2% a diabetes related amputation. These proportions were not significantly different from those found in studies performed by different methods in Poole, Islington, Powys, Trowbridge, and Southall. CONCLUSION--It is feasible to compile a register of diabetic patients in a district and evaluate their characteristics by using only general practice sources.     

General practitioners' referrals to specialist outpatient clinics. II. Locations of specialist outpatient clinics to which general practitioners refer patients.

Although linkage by computer of hospital administration systems across all clinics in a health district is becoming a practical possibility, complete records of general practitioners'' referrals to outpatient clinics will be difficult to achieve. Data from a large study of general practitioners'' referrals to such clinics were used to calculate the proportion of referrals that crossed district boundaries, the proportion that were made to the private sector; and the number of locations that each practice referred patients to. Of the 17,601 referrals from practices in Oxford Regional Health Authority, 13,857 (78.7%) were made to NHS outpatient clinics within practices'' own districts, 1524 (8.7%) to clinics in other districts in the same region, 420 (2.4%) to NHS clinics in other regions, and 1800 (10.2%) to the private sector; but these proportions varied considerably among the practices. The mean number of different NHS hospitals or clinics that each practice referred patients to was 15.8 (range 4-42).     

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.     

Current management of hypertension in general practice.

An examination of the notes of 697 patients in a random sample of seven general practices in one part of inner London showed that 164 (24%) of 669 had had a blood-pressure recording in a five-year period. Proportions varied between 4% and 36% in the different practices. The blood pressure was raised (systolic greater than or equal to 160 mm Hg or diastolic greater than or equal to 100 mm Hg or both) in 74 patients (45%) whose blood pressure had been recorded, and another recording had subsequently been made in 45 (61%) of these patients. Fifteen (21%) of those with hypertension had not had a blood-pressure recording during the five years before the study. Tranquillisers or sedatives were the commonest drugs used in the treatment of hypertension. As in a study of the management of hypertension in hospital, opportunities provided by visits to the general practitioner were not commonly used for blood-pressure screening, and the discovery of hypertension often did not lead to further action.     

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.     

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.     

Laboratory and radiological investigations in general practice. I-Type requested and rate of use.

The use that 30 general practitioners in four group practices made of open access laboratory and radiological facilities was studied for one year. We were particularly interested in whether general practitioners hoped to exclude rather than confirm abnormality when requesting investigations. All but two of the general practitioners studied used investigations to exclude abnormality to a greater extent than to confirm it. The rate at which the practices investigated patients and the number of investigations requested were appreciably different and were different for individual general practitioners, part time general practitioners requesting more investigations than trainees and full time general practitioners. Haematological investigations accounted for over 30% of requests for investigations in all but one practice, biochemical investigations being requested as often as bacteriological investigations in two of the four practices. The ratio of expected to unexpected results varied among general practitioners; no general practitioner had more unexpected results and the range of ratios was similar for full time and part time general practitioners and for trainees. The proportion of patients with abnormalities uncovered by each practice increased disproportionately as the use of investigations increased, supporting a higher rather than lower rate of investigation among general practitioners. Compared with the results of other studies the use of the radiological facilities available was low. X ray examinations of the skeleton were requested more than chest and contrast media examinations by three of the four practices. Most x ray examinations were used to exclude rather than confirm abnormality by all the practices, with over 85% of results confirming the general practitioner''s initial diagnosis.     

Pneumococcal vaccine campaign based in general practice.

OBJECTIVE: To show whether a general practice setting is a practical and effective medium for increasing uptake of pneumococcal vaccine. DESIGN: Follow up study of responses of general practices (debriefing by questionnaire or small group session) and patients (questionnaire sent to 429 patients vaccinated in a two week period) to vaccination campaign. SETTING AND SUBJECTS: Patients registered with general practices of one family health services authority. INTERVENTIONS: Pneumococcal vaccination campaign including clinical guidelines and support materials. MAIN OUTCOME MEASURES: Proportion of general practitioners offering pneumococcal vaccine; proportion of patients at risk who were vaccinated between 1 May and 31 December 1995; number of splenectomised patients identified and vaccinated in same period; views of patients who were vaccinated. RESULTS: Proportion of general practitioners offering pneumococcal vaccine increased from 17% to 89% during the campaign. Estimated number of patients at risk who were vaccinated increased from 656 (4%) to 5982 (33%) during campaign. Of 61 splenectomised patients identified, 30 had been vaccinated previously and 27 were vaccinated during campaign. Practices in which a general practitioner took or shared the lead had higher vaccination rates and used vaccine up faster. Of the 384 patients whose questionnaires were used in analysis, only 35 had heard of pneumococcal vaccine before the campaign, 198 reported side effects (mostly minor and local, but systemic and severe local reactions were more common than expected), and 337 were pleased they had been vaccinated (only five expressed dissatisfaction). CONCLUSION: A practice based campaign is an effective method of increasing uptake of pneumococcal vaccine by high risk groups.     

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.     

Effect of NHS reforms on general practitioners' referral patterns.

OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners'' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners'' referral behaviour.