Referrals from general practice to hospital outpatient departments: a strategy for improvement.

OBJECTIVE--To determine the appropriateness of referrals from general practice to hospital outpatient departments. DESIGN--Prospective audit of referrals from a group practice over one year. SETTING--Six handed practice in a southern coastal town. SUBJECTS--All patients referred during the study period for whom a copy of the referral letter was available. MAIN OUTCOME MEASURES--The investigations carried out by the consultant that led to the diagnosis; the diagnosis reached; and the management. RESULTS--Of roughly 3000 patients referred during the year, 277 with various skin and soft tissue disorders could probably have been managed solely by the general practitioner. Referrals for cryotherapy (96 in this series) and diabetes (19) could probably also have been avoided by specialist training of the general practitioner. In addition, in cases of haematuria and prostatic hypertrophy (34 and 22 referrals) substantial time could have been saved for both the patient and the consultant had the general practitioner supplied the results of relevant investigations. Probably the most important outcome was the model that the study offered for other general practitioners to improve the appropriateness of referrals. CONCLUSION--This approach to determining the appropriateness of referrals benefits the general practitioners, the consultant, and the patient.     

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care.

OBJECTIVE--To determine appropriateness of referrals from primary care to secondary care. DESIGN--Retrospective evaluation of appropriateness of referrals from a single-handed general practice: evaluations carried out independently by referring doctor and by second general practitioner who worked in same area and had access to similar secondary care services. SUBJECTS--168 referrals made between 1 October 1990 and 31 March 1991 and followed up for up to 12 months by matching with available information on outcome of episode of care. MAIN OUTCOME MEASURES--Appropriateness of referral and reasons for inappropriate referrals. RESULTS--110 referrals were agreed to be appropriate and 58 were considered avoidable. The reason for 32 of the inappropriate referrals was lack of resources: 10 were due to lack of information (mainly failure of hospitals to pass on information to general practitioner), nine were due to a deficient primary health care team; five were due to insufficient use of home care nurses, three were due to absence of direct access to day hospital, and five were due to lack of access to general practitioner beds or other facilities. Most of the remaining 26 avoidable referrals were because available resources had not been fully used, because recognised management plans had not been followed, or because of lack of skills to perform certain procedures. CONCLUSIONS--Many theoretically avoidable referrals were due to managers'' and politicians'' decisions about allocation of resources, but some inappropriate referrals could be avoided by assessment of general practitioners'' needs for further knowledge and skills.     

Influence of Royal College of Radiologists' guidelines on referral from general practice. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on general practitioner referrals for radiography of introducing guidelines of good practice together with monitoring and peer review. DESIGN--Collection of referral data during 1 January 1989 to 31 December 1990. Guidelines were introduced on 1 January 1990. SETTING--Open access radiology services provided by one non-teaching district in England. SUBJECTS--144614 registered patients from 22 practices. MAIN OUTCOME MEASURES--Number of referrals per 1000 registered patients for radiography of the chest, skull, spine, abdomen, limbs, and joints and for barium investigation and excretion urography. RESULTS--Overall referrals fell from 88.4/1000 registered patients to 77.2/1000 after the guidelines were introduced. The commonest reasons for referral were for examination of the chest, spine, and limbs and joints and referrals for these fell by 9.4%, 17.5%, and 13.5% respectively. Referrals for skull radiography fell by 30% (from 241 to 168). CONCLUSIONS--By helping general practitioners to be more selective in their use of diagnostic radiology, the guidelines reduced the rate of referral and thus patients'' exposure to radiation.     

Chromosomal instability parameters in the population affected by nuclear explosions at the Semipalatinsk nuclear test site

A population genetic survey of 149 persons who were born and have permanently lived in the contaminated zones of the Semipalatinsk region has been performed. A cytogenetic study has demonstrated that the frequency of aberrant cells is 1.7-3 times higher than control parameters. The total frequencies of chromosome aberrations are 3.43 +/- 0.48, 3.1 +/- 0.3, 1.8 +/- 0.2, and 1.15 +/- 0.17 aberrations per 100 cells in the populations of the extreme radiation risk (ERR), maximum radiation risk (MaxRR), minimum radiation risk (MinRR), and control zones, respectively. The high chromosome aberration rate in all three zones of radiation risk has been detected mainly due to radiation-induced chromosome markers, including paired fragments (1.2 +/- 0.2, 0.94 +/- 0.13, and 0.43 +/- 0.06 per 100 cells, respectively), dicentric and ring chromosomes (0.44 +/- 0.04, 0.45 +/- 0.07, and 0.11 +/- 0.02 per 100 cells, respectively), and stable chromosome aberrations (0.74 +/- 0.16, 0.8 +/- 0.1, and 0.63 +/- 0.13 per 100 cells, respectively). The qualitative spectra of the cytogenetic lesions observed in these groups indicate a mutagenic effect of ionizing radiation on chromosomes in the populations studied.     

Indications for total parenteral nutrition in the hospitalized patient: a prospective review of evolving practice

The indications for initiating total parenteral nutrition (TPN) were prospectively evaluated in 100 consecutive patients at a tertiary referral hospital with a long-standing Nutritional Support Service to illustrate the reasons why the parenteral route was chosen at this unique institution in terms of patient population. Sixty male and 40 female patients, average age 59 +/- 17 years (range 22-86 years), were classified a priori as to the underlying reasons for initiation of TPN. The study was conducted by a Nutrition Support Service at this hospital without pediatric, trauma, or burn services specializing in the care of patients with diabetes mellitus. Of the 100 patients, 63% were from the surgical service; 24% had diabetes mellitus. Their mean weight (118 +/- 29% of ideal), body mass index (25 +/- 6 kg/m(2)), and serum albumin (2.8 +/- 0.7 g/dL) indicated a reasonable body composition with a moderate systemic inflammatory response. Six patients received preoperative TPN for an average of 5 +/- 3 days with a variety of diagnoses including malignancy, Crohn's disease, bowel obstruction, and gastrointestinal bleeding. The underlying reasons for initiating nutritional support were related to three factors that largely determine the need for involuntary feeding: preexisting protein calorie malnutrition, actual or anticipated semistarvation for a prolonged period, and the presence of a systemic inflammatory response. The choice of TPN was based on anticipated or proven intolerance to full enteral feeding. The duration of time before initiation of TPN postoperatively was 6 +/- 5 days, which reflects our policy that initially well-nourished patients who are experiencing a systemic inflammatory response should not undergo more than 5 to 7 days of inadequate feeding. The duration of TPN overall was 11 +/- 10 days, which primarily illustrates the dramatic reduction in length of hospital stay that has occurred throughout the health care system and the willingness to provide TPN in alternative settings including transitional care units, rehabilitation hospitals, and for short-term care, the patient's home. The most common specific reasons identified for initiating TPN rather than enteral nutrition were ileus (25%), an underlying acid-base or electrolyte/mineral disorder (13%) requiring correction, and the convenience of TPN because a central venous catheter was in place (12%). The usual indication for nutritional support at this tertiary referral and specialty hospital was actual or impending protein calorie malnutrition. TPN was chosen for a variety of reasons related to actual or anticipated tolerance to enteral feeding. This audit demonstrates that our TPN practice has evolved in relation to time of initiation and duration of feeding, which reflect a clearer appreciation of the risks and benefits of TPN.     

General practitioners' referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics.

There has been much concern about the wide variations in general practitioners'' referral rates and the consequent implications for cost and quality of care. This has led to a call to evaluate the appropriateness and effectiveness of referrals. A collaborative audit of referrals to outpatient clinics was conducted by 127 general practitioners in 33 practices in the Oxford region. Records were kept of 18,754 referrals, which included data on diagnoses and reasons for referral. Overall, 6553 (35.4%) of the referrals were for particular treatments or operations and a further 6475 (34.9%) were for specific investigation or diagnosis. Advice on management was the main reason for referral in 2656 (14.3%) cases, and in 1719 (9.3%) cases the general practitioners wanted the consultants to take over managing their patients. Reassurance of either the general practitioner or the patient was recorded as the main reason in only 762 (4.1%) referrals. There seems to be scope for rationalising the referral process. A programme with three stages for evaluating referrals to outpatient clinics is recommended.     

Successful gamete intrafallopian transfer (GIFT) in the porcine

Gamete intrafallopian transfer (GIFT) was successfully established in the pig. In Experiment 1 (6 replicates) 234 oocytes (39 +/- 5.5 per recipient) plus spermatozoa (4000 to 8000 per oocyte) were transferred bilaterally into the oviducts of synchronized gilts, and embryos were recovered 48 h thereafter. The recovery rate was 50.4% and 50% of the recovered oocytes were fertilized. A total of 55 embryos was cultured in vitro in NCSU-medium for 48 h and 63.6% developed to morula or blastocyst stages. In Experiment 2 (5 replicates) 220 oocytes (44 +/- 4.9 per recipient) plus spermatozoa (4000 per oocyte) were transferred to 5 recipients which were allowed to go to term. Three gilts delivered 16 (n = 3, 5, 8) piglets. In Experiment 3 (5 replicates) 183 oocytes (36.6 +/- 1.2 per recipient) plus flow cytometry gender sorted spermatozoa (4000 per oocyte) were transferred to 5 recipients. The recovery rate was 47.8%, and 27.6% of the oocytes were fertilized. From all cleaved oocytes 45.8% developed to expanded blastocysts, with the number of blastomeres varying from 20 to 85 (38.3 +/- 22.5). These results indicate that the GIFT procedure can be used successfully in pigs, and can be a valuable tool for the study of gamete interaction as well as in the continued development of biotechnological procedures such as sex pre-determination.     

A role for membrane transport in modulation of intramuscular free glutamine turnover in streptozotocin diabetic rats.

We wished to examine the effects of diabetes on muscle glutamine kinetics. Accordingly, female Wistar rats (200 g) were made diabetic by a single injection of streptozotocin (85 mg/kg) and studied 4 days later; control rats received saline. In diabetic rats, glutamine concentration of gastrocnemius muscle was 33% less than in control rats: 2.60 +/- 0.06 mumol/g vs. 3.84 +/- 0.13 mumol/g (P < 0.001). In gastrocnemius muscle, glutamine synthetase activity (Vmax) was unaltered by diabetes (approx. 235 nmol/min per g) but glutaminase Vmax increased from 146 +/- 29 to 401 +/- 94 nmol/min per g; substrate Km values of neither enzyme were affected by diabetes. Net glutamine efflux (A-V concentration difference x blood flow) from hindlimbs of diabetic rats in vivo was greater than control values (-30.0 +/- 3.2 vs. -1.9 +/- 2.6 nmol/min per g (P < 0.001)) and hindlimb NH3 uptake was concomitantly greater (about 27 nmol/min per g). The glutamine transport capacity (Vmax) of the Na-dependent System Nm in perfused hindlimb muscle was 29% lower in diabetic rats than in controls (820 +/- 50 vs. 1160 +/- 80 nmol/min per g (P < 0.01)), but transporter Km was the same in both groups (9.2 +/- 0.5 mM). The difference between inward and net glutamine fluxes indicated that glutamine efflux in perfused hindlimbs was stimulated in diabetes at physiological perfusate glutamine (0.5 mM); ammonia (1 mM in perfusate) had little effect on net glutamine flux in control and diabetic muscles. Intramuscular Na+ was 26% greater in diabetic (13.2 mumol/g) than control muscle, but muscle K+ (100 mumol/g) was similar. The accelerated rate of glutamine release from skeletal muscle and the lower muscle free glutamine concentration observed in diabetes may result from a combination of: (i), a diminished Na+ electrochemical gradient (i.e., the net driving force for glutamine accrual in muscle falls); (ii), a faster turnover of glutamine in muscle and (iii), an increased Vmax/Km for sarcolemmal glutamine efflux.     

Converting Predation Cues into Conservation Tools: The Effect of Light on Mouse Foraging Behaviour

Prey face a conflict between acquiring energy and avoiding predators and use both direct and indirect cues to assess predation risk. Illumination, an indirect cue, influences nocturnal rodent foraging behaviour. New Zealand holds no native rodent species but has introduced mice (Mus musculus) that severely impair native biodiversity. We used Giving-Up Densities (GUDs) and observations of foraging frequency and duration to assess if artificial light induces risk avoidance behaviour in mice and could limit their activity. We found both captive (wild strain) mice in outdoor pens and wild mice within a pest fenced sanctuary (Maungatautari, New Zealand) displayed avoidance behaviour in response to illumination. In captivity, total foraging effort was similar across lit and unlit pens but mice displayed a strong preference for removing seeds from dark control areas (mean: 15.33 SD: +/-11.64 per 3.5 hours) over illuminated areas (2.00 +/-3.44). Wild mice also removed fewer seeds from illuminated areas (0.42 +/-1.00 per 12 hours) compared to controls (6.67 +/-9.20). Captive mice spent less than 1.0% of available time at illuminated areas, versus 11.3% at controls; visited the lit areas less than control areas (12.00 +/- 9.77 versus 29.00 +/-21.58 visits respectively); and spent less time per visit at illuminated versus control areas (8.17 +/-7.83 versus 44.83 +/-87.52 seconds per visit respectively). Illumination could provide protection at ecologically sensitive sites, damaged exclusion fences awaiting repair, fence terminus zones of peninsula sanctuaries and shipping docks that service offshore islands. We promote the hypothesis that the tendency of mice to avoid illumination could be a useful conservation tool, and advance knowledge of risk assessment and foraging under perceived danger.     

Fundholding in general practice and financial risk.

OBJECTIVE--To estimate the financial effect of random yearly variations in need for services on fundholding practices with various list sizes. DESIGN--A simulation model was derived using historical data on general practitioner referrals for the 113 surgical procedures covered by the general practitioner fund, combined with data on the hospital prices for those procedures. PATIENTS--Resident population of Central Birmingham Health Authority. MAIN OUTCOME MEASURES--Expected expenditure on the relevant surgical procedures for the whole district and for practices with list sizes of 9000, 12,000, 15,000, 18,000, 21,000, or 24,000 for each of 100 simulated years. RESULTS--By using average hospital prices for the West Midlands region the mean (SD) annual expenditure for the 179,400 residents was 4,832,471 pounds (87,149 pounds); the random variation between the 5th and 95th most expensive years was 5.7% of the mean cost. For a practice with a list size of 9000 the values were 244,891 pounds (18,349 pounds), with a variation of 27.5%. With a list size of 24,000 the values were 652,762 pounds (32,512 pounds), with a variation of 15.3%. CONCLUSIONS--Random variations in need for inpatient services will have a significant financial impact on the practice fund. The problem will be particularly great for smaller practices. Additional measures are required to ensure that the scheme is not undermined and that the potential benefits are secured.     

Microvascular versus macrovascular dysfunction in type 2 diabetes: differences in contractile responses to endothelin-1

Vascular dysfunction characterized by a hyperreactivity to vasoconstrictors and/or impaired vascular relaxation contributes to increased incidence of cardiovascular disease in diabetes. Endothelin (ET)-1, a potent vasoconstrictor, is chronically elevated in diabetes. However, the role of ET-1 in resistance versus larger vessel function in mild diabetes remains unknown. Accordingly, this study investigated vascular function of third-order mesenteric arteries and basilar arteries in control Wistar and Goto-Kakizaki (GK) rats, a model of mild Type 2 diabetes. Six weeks after the onset of diabetes, contractile responses to 0.1-100 nM ET-1 and relaxation responses to 1 nM-10 microM acetylcholine (ACh) in vessels preconstricted (baseline + 60%) with serotonin (5-HT) were assessed by myograph studies in the presence or absence of a nitric oxide synthase (NOS) inhibitor, N-nitro-L-arginine (L-NNA). Maximum contractile response to ET-1 was augmented in mesenteric vessels (155 +/- 18% in GK vs. 81 +/- 6% in control; n = 5-7) but not in the basilar artery (134 +/- 29% in GK vs. 107 +/- 17% in control; n = 4 per group). However, vascular relaxation was impaired in the basilar arteries (22 +/- 4% in GK vs. 53 +/- 7% in control; n = 4 per group) but not in mesenteric arteries of GK rats. Inhibition of NOS decreased the relaxation response of basilar arteries to 15 +/- 8% and 42 +/- 5% in GK and control rats, respectively; whereas, in resistance vessels, corresponding values were 56 +/- 7% and 89 +/- 3% (vs. 109 +/- 2% and 112 +/- 3% without NOS blockade), indicating the involvement of different vasorelaxation-promoting pathways in these vascular beds. These findings provide evidence that the ET system is activated even under mild hyperglycemia and that it contributes to the hyperreactivity of resistance vessels, therefore, the ET system may play an important role in elevated blood pressure in Type 2 diabetes.     

Nutritional and pharmacologic support in patients with pancreatic cancer

The aim of our study was to assess whether the influence of nutritional support, consisting of counseling, enteral liquids support and pharmacologic support, can slow down weight loss and whether the change in weight has the impact on the performance status in our patients. In our study 44 patients with pancreatic cancer were included--26 males (mean age 69 years +/- 2.4 years) and 18 females (mean age 63 +/- 3.2 years). Metastatic disease was found in 21 patients, 15 patients had liver metastasis. Locally advanced disease was found in 24 patients and metastatic and locally advanced disease in 17 patients. Surgery was performed in 34 patients. Forty four (100%) patients underwent nutritional counseling, 33 of them (75%) took supplemental enteral feeding and 44 (100%) took megestrol acetate 400 mg per a day. The patients were followed up during 8 weeks during 5 visits. At first visit we took initial nutritional status of patients. Appetite loss, weight gain and Karnofsky performance status were monitored at every visit. All patients were treated with gemcitabin for a 7 week period. Results: NTS score at initial visit in 44 patients (100%) was > or = 5. Using nutritional counseling, enteral food substitution and pharmacological support, weight gain was observed in 61.1% patients and appetite improved. Average KPS mostly improved after first month of therapy while after two months was again at the basal level. With nutritional counseling, supplemental feeding and pharmacologic support weight loss in our patients slowed down and appetite improved. Despite of that, Karnofsky Performance Status didn't change significantly, reflecting the impact of the disease itself and chemotherapy procedures to the patient's condition. We can conclude that nutritional and pharmacological support can temporarily stop weight loss and improve appetite, social life and quality of life in those groups of patients but have no implications on patients KPS and course of their disease.     

A decade of diabetes: keeping children out of hospital.

OBJECTIVES--To document the number of children aged less than 15 years who developed diabetes and were managed within one large health district, and to evaluate the outcome of those children managed without hospital admission at diagnosis. DESIGN--A retrospective study over 1979-88, when a paediatrician and a physician with special interests in childhood diabetes initiated joint clinics. Data collected from the district diabetes register and files of consultants and health visitors specialising in diabetes. SETTING--Referral of children to consultants in Leicestershire (total population 863,000). MAIN OUTCOME MEASURES--The proportion of children managed without hospital admission, comparison of readmission rates and glycated haemoglobin concentrations between children admitted and those not admitted. RESULTS--Over 10 years 236 children aged 10-14 years developed diabetes (annual incidence rate 12.8/100,000 child population (95% confidence interval 11.3 to 14.7)). In total 138 were not admitted to hospital but received supervised management based at home. Admitted children were younger or acidotic or their family doctors did not contact the diabetes team. Duration of admission declined from seven days in 1979-80 to three days in 1987-8. Ninety two were not admitted to hospital during the 10 years for any reason. Significantly fewer children who received management at home were readmitted for reasons related to diabetes than the group treated in hospital (30 (22%) v 40 (41%); p = 0.004). Concentrations of glycated haemoglobin were no different between the two groups. CONCLUSIONS--Children with newly diagnosed diabetes may be safely and effectively managed out of hospital. Domiciliary or community based management depends on the commitment of consultants specialising in diabetes working in close cooperation with general practitioners, specialist nurses in diabetes, and dietitians.     

Effect of Baseline Glycosylated Hemoglobin A1C on Glycemic Control and Diabetes Management following Initiation of Once-daily Insulin Detemir in Real-Life Clinical Practice

ObjectiveThe SOLVE study investigated the initiation of basal insulin in patients with type 2 diabetes on oral antidiabetic (OAD) treatment and outcomes in patients with varying levels of glycemic control at baseline.MethodsThis was an observational cohort study conducted in 10 countries using insulin detemir. Data were collected at 3 clinic visits (baseline, 12-week interim, and 24-week final visit).ResultsA total of 13,526 (77.9%) patients were included in the glycosylated hemoglobin A1c (HbA1c) subset analysis. Patients were grouped according to pre-insulin HbA1c values as follows: HbA1c <7.6% (n = 2,797); HbA1c 7.6-9% (n = 5,366), and HbA1c >9% (n = 5,363). A total of 27 patients experienced serious adverse drug reactions (SADRs) and/or severe hypoglycemia (3, 10, and 11 patients with pre-insulin HbA1c <7.6%, 7.6-9.0%, and >9.0%, respectively). All patient subgroups realized improvements in HbA1c, with the pre-insulin HbA1c >9% subgroup having the largest HbA1c reduction (-2.4% versus -0.9% and -0.2% for HbA1c subgroups 7.6-9% and <7.6%, respectively). In the total cohort (n = 17,374), the incidence of severe hypoglycemia decreased from 4 events per 100 person years to <1 event per 100 person years by final visit; the incidence of minor hypoglycemia increased from 1.6 to 1.8 events per person year.ConclusionsIn this study, insulin initiation was delayed until late in disease course, and overall concordance with internationally recognized guidelines was low. The initiation of once-daily insulin detemir was associated with substantial improvements in glycemic control and was not associated with an increase in severe hypoglycemia or weight gain. (Endocr Pract. 2013;19:462-470)     

Use of Structured Templates to Improve Completeness of Endocrinology Referrals

ObjectiveEndocrinology referrals frequently lack important clinical information, which may increase the risk of inefficiency and adverse outcomes. This quality improvement project aimed to improve the completeness of new referrals by utilizing structured referral templates for common endocrine conditions at a large Veterans Health Administration medical center. Our target was of at least a 30% improvement in referral completeness for each condition after the intervention.MethodsElectronic structured referral templates were designed utilizing existing resources and input from primary care providers and endocrinologists. Essential elements were identified and included in the templates. We conducted a retrospective chart review to compare referrals for 125 patients referred between January 1, 2021 and September 1, 2021 (preintervention) and 125 patients referred between October 1, 2021 and September 30, 2022 (postintervention). Each referral was rated using a scoring system derived from the criteria in the data abstraction tool formulated by the investigators.ResultsOn average, preintervention referrals included 52% of the essential elements and postintervention referrals included 93%. Improvements in referral scores for each condition all met the prespecified 30% improvement target. The greatest improvement was for the element “type of visit preference.” A separate analysis excluding that element showed an average improvement from 64% of essential elements preintervention to 92% postintervention.ConclusionStructured referral templates, designed with the input of primary care providers and endocrinologists and embedded into an electronic referral system, can improve the availability of essential information and increase the quality of referrals. Future work should examine the effect of structured referral templates on efficiency, specialist experience, patient experience of care, and clinical outcomes.     

Tertiary cancer services in Britain: benchmarking study of activity and facilities at 12 specialist centres.

OBJECTIVE--To collate information on current activity and facilities in British hospitals to assist the planning of future cancer services. DESIGN--12 hospitals delivering specialist cancer services provided information on the size of population served, activity levels related to non-surgical oncology for 1994-5, and facilities available. Inconsistencies in the recording of data were resolved through meetings of all participants. SETTING--Five single specialty NHS trusts and seven specialist cancer facilities within multispecialty trusts, serving a combined population of 24.3 million. MAIN OUTCOME MEASURES--Activity levels and facilities per million population served. RESULTS--The facilities available per million population served varied widely between centres. In contrast, the range in the number of new referrals per million population (seen either at the centre or in peripheral clinics) was relatively small. Considerable variations were observed in the number of attendances per patient and amount of radiotherapy and chemotherapy delivered. Overall it was estimated that 40-45% of all new cases of cancer are currently being referred to non-surgical oncologists. For the seven hospitals which could provide data on trends in activity, the average increase in chemotherapy day case episodes between 1992-3 and 1994-5 was 83%. CONCLUSIONS--The results of this study provide a benchmark both for purchasers and providers of cancer care. The increase in the use of chemotherapy points to an urgent need for a unified system for monitoring both activity and outcomes of treatment.     

Costs of paediatric diabetes care in Germany: current situation and comparison with the year 2000

Diabet. Med. 29, 1327-1334 (2012) ABSTRACT: Aims To estimate direct costs of paediatric Type 1 diabetes care and associated factors in Germany for the year 2007 and to compare results with the costs for the year 2000. Methods Our study includes clinical data and charges for any diabetes-related health care service of 14?185 continually treated subjects with paediatric diabetes aged 相似文献