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.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

Timer: a new objective measure of consultation content and its application to computer assisted consultations.

As part of the research into the effect in the consultation of the use of a computer to prompt opportunistic preventive care a valid, objective, and practical measure of the consultation process was required. After a review of the alternative methods the Time Interval Medical Event Recorder (Timer) was developed, its reliability tested, and applied to 93 control consultations and 49 computer assisted consultations. Timer records, every five seconds, four consultation events: the problems being dealt with, the physical activity, the verbal activity, and the secondary tasks being attempted. Timer showed that control consultations lasted an average of 6 minutes 58 seconds. The doctors spent 35% of their time on administration, and patients and doctors were both conversational for just 33% of the consultation. Giving information was the most common verbal activity (48% of the duration of the consultation) with silence accounting for 21% of the time. When the computer was used the average consultation was longer, at 7 minutes and 46 seconds. The doctor''s contribution to the consultation appeared to have increased. Patient centred speech fell from 36% in controls to 28% of the duration of the consultation when the computer was used, while doctor centred speech rose from 30% to 34.5%. Secondary tasks (exploring patient concepts, education, management sharing, and prevention) were attempted during 28% of the control consultations and 40% of the computer consultations. This was accounted for by the increase in prevention (p less than 0.001). Timer is a reliable and practical tool for researching the consultation, and though it has shown validity in detecting differences between consultations that use a computer and those that do not, further applications are required to establish its full value.     

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.     

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES--To identify those important characteristics of doctors'' and patients'' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners'' performance in their own consultations. DESIGN--Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING--All vocational training schemes for general practice in the Northern region of England. SUBJECTS--First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES--Trainers'' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS--6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION--The instrument produced is reliable for assessing general practitioners'' performance in their own consultations.     

Reactions of patients to video recording of consultations in general practice.

The potential value of video recording for examining medical consultations depends on the extent to which recordings are representative of unfilmed consultations. This paper examines the views of 295 patients in two general practices whose consultations were filmed and compares them with the views of a control group of 185 patients. Most of those who were filmed reported that the consultation was not directly affected, and no overall effect of filming was discovered when patients rated their stress after the consultations, their rapport with the doctor, or other aspects of the consultation. At one practice, however, filming was significantly associated with lower ratings of rapport between doctor and patient among those patients who reported some direct effect of filming. Patient refusal rates from other studies are also examined and shown to vary systematically--the more opportunity patients are given to decline the more likely they are to take it. Consideration of doctors'' responses to being filmed would usefully complement the emphasis on the views of patients.     

Influence of patient characteristics on test ordering in general practice.

Information regarding all consultations was collected in seven general practices for one year. From these data we report on the use of laboratory tests and its association with patient characteristics--including social class, age, sex, and diagnosis--and with which doctor was consulted. Most of the requests were for technically simple tests of low cost. There was a noticeable variation in the use of tests with regard to all patient characteristics. Diagnosis, identity of doctor, age of patient, and social class were each shown by multivariate techniques to be independently related to use of tests. Whereas fewer tests were used per consultation for social classes III-V compared with other social classes, more were used per patient per year for these same groups, reflecting in part the higher consultation rates of social classes III-V. Variation in diagnoses fully accounted for the greater test ordering for women. Nearly two thirds of all tests were ordered for 10% of all patients who consulted and 7% of all registered patients. The results of our analysis suggest that this concentration is determined primarily by those patient characteristics most indicative of medical need and by which doctor is providing care.     

Computer assisted screening: effect on the patient and his consultation.

The initial impact of computer assisted preventive screening in general practice consultations has been monitored. The technology has not been found stressful by patients, and the power of the consultation to alleviate low arousal has been increased by computer use. No appreciable increase in the durations of consultation was detected, despite an average computer initiated input of two minutes eight seconds. The computer has successfully prompted preventive screening and health education with a sixfold increase in the number of potentially relevant procedures being mentioned. The actual information presented by the computer has been shown to be crucial, with the terminal''s mere presence an ineffective reminder. The computer terminal was used in 65% of the consultations for which it was available, which, if sustained, represents an effective screening programme for attending patients.     

Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes

ObjectiveTo determine patients'' preferences for a shared or directed style of consultation in the decision making part of the general practice consultation.DesignStructured interview, with video vignettes of acted consultations.Setting5 practices in Lothian, Scotland.Participants410 patients (adults and adults accompanying children) attending surgery appointments.ResultsPatients varied in their preference for involvement in decision making in the consultation. Under multiple regression analysis, patients'' preference was found to be independently predicted by the problem viewed (patients presented with physical problems preferred a directed approach), patients'' age (patients aged 61 or older were more likely to prefer the directed approach), social class (social classes I and II were more likely to prefer the shared approach), and smoking status (smokers more likely to prefer the shared approach). Those patients who were able to answer (or who thought their doctor''s style similar to those in the vignettes) were more likely to describe their own doctor''s style as similar to their preferred style. No major association in preference was found with sex, frequency of attendance, or perceived chronic ill health.ConclusionPatients may vary in their desire for involvement in decision making in consultations. Although this variation seems to depend on the presenting problem, age, social class, and smoking status, these associations are not absolute, with large minorities in each group. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making.     

Effect of computer use in the consultation on the delivery of care.

The effects of the use of a computer on the delivery of care in consultations in general practice were examined. In this trial a computer system provided for the review and update of patients'' medical histories, notes on doctor-patient contacts, and information on repeat prescribing. Thirty consultations in which the computer system was used and 30 consultations in which no computer was used were matched individually for the doctor consulted, the sex and age of the patient, and the presenting problem(s). Six independent general practitioners blind rated each consultation for the standard of care attained. A minor negative effect of computer use on the doctors'' clinical performance was found. We suggest, however, that this small effect would disappear if a computer system was used routinely.     

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.     

Preoperative Evaluations by an Internist—Are They Worthwhile?

The value of preoperative examinations done by internists on ophthalmology patients was assessed. A retrospective chart review of 258 consultations was conducted and information about surgical risk, as defined by strict criteria, was abstracted. A total of 59 surgical risk conditions and 62 incidental problems were detected. In 65% of the risk conditions internists intervened to lessen the patients'' risk. Most of these benefits were in patients older than 60 years and very few important problems were detected in those younger than 50. The average cost of the consultation and additional laboratory tests was $146.60. It is concluded that significant benefit was derived at a reasonable cost by patients older than 50 years.     

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

OBJECTIVES--To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines. SETTING--Practices within Cambridge Health Authority and Addenbrooke''s Hospital, Cambridge. MAIN OUTCOME MEASURES--Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice. RESULTS--There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral). CONCLUSION--The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.     

Comparison of effects of a self management booklet and audiocassette for patients with asthma.

The effects on self management of asthma of a specially prepared book and audiocassette tape with similar contents were observed in a controlled study of 177 patients with asthma in general practice. After a run in period of six months patients were randomly given the book, the tape, both the book and tape, or neither. Patients'' knowledge of the use of drugs, perceptions of their disability, skill in using an inhaler, consumption of drugs, consultations with their general practitioners, morbidity (from patients'' entries on diary cards), and use of the educational material were measured. Knowledge about the use of drugs was significantly increased in the groups who received the material after three months and persisted after 12 months. Patients who had been given the tape or the book and tape increased their scores of knowledge of drugs more than patients given the book alone. Patients in all groups given the material considered that their disability was reduced. There were no other significant changes. Patients given both the book and the tape preferred the book. Patients with asthma can obtain useful information from such material. The paradoxical result whereby patients learnt more from the tape but preferred the book suggests that a distinction can be made between information that patients need, which may be acquired better from an audiocassette, and information that they want, which may be acquired better from a book.     

List sizes and use of time in general practice.

The claim that list sizes in general practice should continue to fall towards a national average of 1700 patients rests heavily on the assumption that the extra time available to doctors would be used mainly for longer consultations, resulting in better standards of care. Evidence suggests, however, that the time is more likely to be used to increase rates of consultation in surgeries and home visits and to reduce the length of the working week. A national, random sample of 2104 principals in general practice in England and Wales were questioned about their allocation and use of time. The response rate was 67%, and no large biases in response were detected. The smaller their personal list size the less time general practitioners spent on all aspects of their work and the higher their rates of consultation and home visiting. The effects of further reductions in list sizes would be haphazard, being differentially distributed across the range of list sizes. Longer consultations would probably result, but most of the extra time would probably be used in higher rates of consultation in surgeries and home visits and some would be taken as free time.     

Domiciliary consultations: some facts and questions.

The domiciliary consultation scheme introduced at the start of the NHS enables joint consultation between a consultant and general practitioner in a patient''s home when the patient cannot attend hospital on medical grounds. Consultants claim a fee from the NHS, general practitioners do not. Data from the Department of Health and Social Security on domiciliary consultations in England and Wales during 1981-6 were analysed. The number of domiciliary consultations fell during 1981-6 from 429,759 in 1981 to 387,394 in 1986, a fall of 10%, whereas the numbers of consultants and general practitioners increased by 1404 (12%) and 2400 (10%), respectively. The yearly rate of domiciliary consultation per consultant fell by 19% from 36 in 1981 to 29 in 1986 and that per general practitioner by 18% from 18 to 15. In 1986 geriatric medicine had the highest rate of domiciliary consultation per consultant (187) followed by psychiatry (89), general medicine (52), dermatology (49), rheumatology (42), general surgery (36), gastroenterology (35), thoracic medicine (34), and orthopaedics (30). In 1986 all specialties apart from clinical pharmacology and therapeutics and clinical genetics showed a decrease in the yearly rate of domiciliary consultation when compared with the rate for 1981. Domiciliary consultation seems to have become a domiciliary visit by the consultant alone. At an estimated cost of about 20m pounds for 1988 the scheme needs critical evaluation.     

General practice consultations: is there any point in being positive?

A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were randomly selected for one of four consultations: a consultation conducted in a "positive manner," with and without treatment, and a consultation conducted in a "non-positive manner," called a negative consultation, with and without treatment. Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiving a positive consultation got better, compared with 39% of those who received a negative consultation (p = 0.001) and 53% of those treated got better compared with 50% of those not treated (p = 0.5).     

Health promotion in the general practice consultation: a minute makes a difference.

OBJECTIVE--To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations. DESIGN--Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient). SETTING--10 general practices in Nottinghamshire. SUBJECTS--16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length. MAIN OUTCOME MEASURES--Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients. RESULTS--Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity. CONCLUSIONS--Shortage of time is a major factor in general practitioners'' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.