Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease.

Case notes of 1113 consecutive new patients referred to a consultant ophthalmologist at a district general hospital were reviewed to determine the source and efficacy of referrals and the current screening practices of general practitioners and ophthalmic opticians. General practitioners initiated referral in 546 cases (49%) and ophthalmic opticians referral in 439 (39%). Visual loss or visual disturbance was the most important single reason for referral (345 cases; 31%), followed by suspected glaucoma (145 cases; 13%), abnormalities of binocular vision (140; 12.5%), disorders of eyelids or ocular adnexa (127; 11%), and red eye (86; 8%). General practitioners referred many more patients with disorders of the eyelids and adnexa and ophthalmic opticians many more patients with suspected glaucoma. Ophthalmic opticians were far more likely than general practitioners to refer patients with suspected glaucoma correctly. A total of 180 patients (16%) were referred from ocular screening, in 149 cases by ophthalmic opticians and in 10 by general practitioners. Seventy patients had glaucoma or incomplete features of glaucoma, all of them referred by ophthalmic opticians. Of eight diabetic patients referred by ophthalmic opticians, three had asymptomatic disease and in two diabetes was diagnosed as a result of ocular screening. No patient was referred for asymptomatic diabetic retinopathy from screening by general practitioners. Ophthalmic opticians were more likely than general practitioners to diagnose retinopathy requiring photocoagulation. Use of a community based service to screen for glaucoma could save unnecessary consultant outpatient appointments. A similar service could facilitate detection of diabetic retinopathy at a stage when treatment is most effective.     

Demand incidence and episode rates of ophthalmic disease in a defined urban population.

OBJECTIVES--To estimate demand incidence and episode rates of ophthalmic disease in a defined urban population over one year. DESIGN--Study of patients presenting with eye problems to general practice and eye casualty department. SETTING--General practice and ophthalmic services in west Nottingham. SUBJECTS--36,018 people from the combined practice lists of 17 Nottingham general practitioners. MAIN OUTCOME MEASURES--Ophthalmic disorder, age and sex of patient, and where presented. RESULTS--587 consultations were recorded for ophthalmic problems, 1771 with general practitioners and 816 with eye casualty. Most consultations to general practice were by females (1066 (60%)), whereas men aged 15-44 accounted for most work in eye casualty. These men commonly presented with trauma. Infective conjunctivitis, the commonest condition, had an episode rate of 13.5/1000 population/year. Demand incidence for cataracts was 1.9/1000 population/year. Demand incidence for chronic conditions increased with age. CONCLUSIONS--As the average age of the population increases demand for ophthalmic services will rise. Planning and provision of resources to meet this increased demand should be considered now.     

Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice.

OBJECTIVE--To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice. DESIGN--Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients'' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not. SETTING--Inner city health district. PATIENTS--133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up. MAIN OUTCOME MEASURES--Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment. RESULTS--Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients'' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists. CONCLUSIONS--Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients'' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.     

Assessment of psychological care in general practice.

OBJECTIVE--To pilot a method of assessing psychological care by general practitioners. DESIGN--Prospective examination of psychological care given in general practice by using general health questionnaire with predetermined quantifiable and case specific indices of outcome established at the original consultation. SETTING--Rural general practice in Clwyd, North Wales. SUBJECTS--447 consecutive adult general practice attenders. MAIN OUTCOME MEASURES--Three month follow up consultation rates, one year retrospective consultation rates, continuity of care, changes in general health questionnaire scores at follow up, general satisfaction, and acceptability of outcome measures. RESULTS--The principal and trainee identified 72 patients with psychological problems, 46 of whom had new conditions. 133 patients scored over 6 on the 28 item general health questionnaire, 33 of whom were identified as new cases by the general practitioners. 62 patients were seen at follow up, including 23 patients identified by the questionnaire but not by the doctor. The doctors used diagnostic terms to describe the presenting condition in 38 cases. At three month follow up the general health questionnaire scores had fallen by more than 5 points in 22/39 patients identified and managed by doctors and 11/23 identified by the questionnaire. The agreed index of good outcome was almost or completely achieved by 20 of the 39 patients managed by doctors. CONCLUSION--Quantifiable methods of evaluating the quality of the structure, process, and outcome of psychological care can be achieved in general practice.     

Diabetes,driving, and the general practitioner.

The medical fitness of drivers who have diabetes is assessed primarily by general practitioners. A survey was made of the knowledge of driving and diabetes of 105 general practitioners in Glasgow. Ninety four (90%) knew that people who were insulin dependent were required by law to declare their condition to the Driver and Vehicle Licensing Centre in Swansea, but most were unaware that people with diabetes should not hold a "till 70" driving licence. Seventy one doctors (69%) claimed that patients were recalled individually for fitness to drive. The minimum visual acuity for driving was stated correctly by 37 (35%). Only eight respondents knew that a hypoglycaemic diabetic driver can be charged with driving under the influence of a drug (Road Traffic Act 1972), and the practical advice that was given to patients about hypoglycaemia and driving was unsatisfactory. As a group the general practitioners showed deficiencies in knowledge regarding diabetes and driving, suggesting a need for further postgraduate education.     

Approval of trainers and training practices in the Oxford region: criteria.

New criteria for approving practices for training general practitioners have been accepted by the Oxford regional postgraduate subcommittee for general practice. These criteria cover the trainer, the practice, and the training. Two further papers will discuss new methods of assessment and their evaluation.     

Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care.

OBJECTIVE--To evaluate whether adding retinal photography improved community screening for diabetic retinopathy. SETTING--Mobile screening unit at rural and urban general practices in south west England. SUBJECTS--1010 diabetic patients from primary care. DESIGN--Prospective study; patients were examined by ophthalmoscopy by general practitioners or opticians without fundal photographs and again with photographs, and assessments were compared to those of an ophthalmologist. MAIN OUTCOME MEASURES--Whether fundal photography improved the sensitivity of detection of retinopathy and referrable diabetic retinopathy, and whether this sensitivity could be improved by including a review of the films by the specialist. RESULTS--Diabetic retinopathy was detected by the ophthalmologist in 205 patients (20.5%) and referrable retinopathy in 49 (4.9%). The sensitivity of the general practitioners and opticians for referrable retinopathy with ophthalmoscopy was 65%, and improved to 84% with retinal photographs. General practitioners'' sensitivity in detecting background retinopathy improved with photographs from 22% to 65%; opticians'' sensitivity in detecting background retinopathy improved from 43% to 71%. The sensitivity of detecting referrable retinopathy by general practitioners improved from 56% to 80% with photographs; for opticians it improved from 75% to 88%. CONCLUSIONS--Combining modalities of screening by providing photography with specialist review of all films in addition to direct ophthalmoscopy through dilated pupils improves assessment and referral for diabetic retinopathy by general practitioners and opticians. With further training and experience, primary care screeners should be able to achieve a sensitivity that will achieve an effective, acceptable, and economical community based screening programme for this condition.     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

Sigmoidoscopy/proctoscopy service with open access to general practitioners.

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.     

Building morale through personal development.

Once general practitioners have established themselves as principals it may seem there is little else to work for. Lack of stimulation may lead to demoralisation, and it is essential that they have other ways to continue to develop their careers. Meeting other doctors to discuss cases and problems and postgraduate education often help but many doctors want to take on extra roles. The options available include undergraduate teacher, tutor for postgraduate education, and participation in medical audit advisory groups, local medical committees, or royal college faculties. Some general practitioners work part time to allow them to fit in these activities. It may also be possible to obtain extended study leave or a sabbatical to broaden experience. Others even more practice to provide new challenges.     

Attitudes of general practitioners to prehospital thrombolysis.

OBJECTIVE--To investigate reasons for general practitioners not giving thrombolytic treatment to eligible patients with acute myocardial infarction. DESIGN--Postal questionnaires were sent to 424 general practitioners. SUBJECTS--97 general practitioners who had taken part in the Grampian region early anistreplase trial, 185 whose practices in Scotland were at least 24 km from a district general hospital, and 142 who had attended postgraduate conferences at which thrombolysis had been discussed; 87, 158, and 125 respectively responded. MAIN OUTCOME MEASURES--Answers to questions about readiness to use thrombolytic treatment. RESULTS--Response rate was 87% (370/424). Almost all respondents (350) were convinced of benefits of thrombolysis for acute myocardial infarction, and 277 were convinced that there were additional benefits from its administration in the community at first opportunity. Most doctors working 16 km or more from hospital thought that giving treatment at home would appreciably save time (200/274). Most doctors agreed that they could make time to give thrombolytic treatment (278), and would be willing to record an electrocardiogram (284), and would be able to interpret it (280). Sixty four respondents (17%) reported using thrombolytic treatment in previous year. Among non-users, 150 (49%) were unwilling to use thrombolytic treatment without further training. While many non-users (210 (69%)) were willing to use thrombolytic treatment without encouragement from Department of Health, 184 (60%) were unwilling to use it unless encouraged to do so by their local cardiologist. CONCLUSIONS--The need to become better informed about thrombolysis and lack of encouragement from local cardiologists were important factors preventing wider use of thrombolytic treatment in the community by general practitioners.     

Making the internal market work: a case for managed change.

The internal market in the NHS is meant to ensure that provider units compete on the basis of price and quality and that money follows patients into efficient units. But the example of what happened to one local ophthalmology unit suggests what may go wrong when entrepreneurial activity is applied in a market that does not work perfectly. In 1991-2 the unit had a high workload but also comparatively high prices (because of crude pricing in the local hospital); because of pressure of work the waiting times lengthened and general practitioners increasingly complained about the service. The staff in the unit reopened a longstanding debate about the need for a third consultant ophthalmologist, but neither the purchasers (including fundholders) nor the provider unit were able to fund the post. Fundholders in a neighbouring district, however, together with that district health authority, decided to place their contracts elsewhere for the following year. Although the withdrawal of contracts jeopardised the clinical and financial viability of the ophthalmic unit, patients continued to use the service. When general practitioners in the district realised that their local service might collapse they pressed to keep the service open. The fundholders and the host purchaser finally agreed to fund a third consultant and drew up standards for the service. As a result the waiting times fell and the service is now described as "excellent." Short term market decisions may have unforseen long term implications for services to patients. This needs to be addressed as part of the evolution of the reformed NHS.     

CANCER OF THE LUNG IN TUBERCULOUS PATIENTS

Of all tuberculous patients over 45 years of age admitted to Olive View Sanatorium in the five-year period ended July, 1958, 1.4 per cent had cancer of the lung. This is a much higher incidence than in a comparable segment of the general population.Careful examination of serial roentgenographic studies in all cases of suspected pulmonary lesions was found to increase diagnostic acuity. Scalene node biopsy, cytologic study and bronchoscopy were of less help. Diagnostic thoracotomy was the single most useful procedure for diagnosis.As to operability, the results in patients with both cancer and tuberculosis compared very well with those in patients who had only cancer. Patients who have inactive pulmonary tuberculosis and cancer have much poorer results than patients with active tuberculosis and cancer. There are difficulties in accurately diagnosing cancer in the presence of tuberculosis; and there are special problems in patients with inactive tuberculosis and cancer.     

Referral routes to hospital of patients with chronic open-angle glaucoma.

An analysis of the referral routes of Southampton Eye Hospital of 191 patients who had been diagnosed as having chronic open-angle glaucoma showed that 121 patients (63.4%) were diagnosed as a result of the patient seeking advice for ocular symptoms (118) or because they had a family history of glaucoma (3). Advice had been sought from general practitioners (48), ophthalmic medical practitioners (19), and ophthalmic opticians (46). The remaining eight patients had gone directly to the casualty department. Seventy patients had been identified by chance, the majority of ophthalmic medical practitioners (26) or ophthalmic opticians (32).     

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91.

OBJECTIVE--To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this. DESIGN--A retrospective case-control study. SETTING--South east Scotland. SUBJECTS--All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91. OUTCOME MEASURES--Demographic details of patients; Breslow thickness, clearance of excision. RESULTS--42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis. CONCLUSIONS--General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.     

General practitioner training in paediatrics in the Trent region.

A total of 259 postal questionnaires were sent to all final year vocational trainees and new principals in general practice in the Trent region to find out how much training in paediatrics they had had. Questionnaires were returned by 105 trainees and 139 principals (244; 94%). Overall 72% (175) had taken up a hospital post in paediatrics during training, but among the 138 doctors who were on or had completed a three year vocational training scheme the proportion was slightly higher (82%; 115) (p = 0.01). Among the 175 who had had a post in paediatrics 108 (62%) had been given teaching sessions every week, and for half of these doctors the sessions lasted over one hour a week. Seventy five (54%) of the 139 principals reported that in their training in a general practice they had received no teaching about child health and a fifth said that they had not attended a clinic for children; 47 (34%) had received no training on procedures for dealing with cases of child abuse. The doctors who had held posts as senior house officers in paediatrics were more likely to report that they had adequate skills in paediatrics than those who had not, but overall only 62 (44%) reported that they could run a preschool child health surveillance programme. Extra paediatric posts in hospital are needed, but in the mean time improvements can be made to the teaching content in hospital and in the general practice attachment and postgraduate training in paediatrics provided for all general practitioners.     

Patients' and general practitioners' satisfaction with information given on discharge from hospital: audit of a new information card.

OBJECTIVE--To determine the attitudes of patients discharged from hospital and their general practitioners to a new information card giving details about admission, diagnosis, and treatment and to assess the completeness of the information on the card. DESIGN--Consecutive patients discharged from the care of three consultant physicians over 16 weeks. SETTING--One general medical ward in a large teaching hospital. PATIENTS--A total of 275 consecutive discharges of 258 patients were studied. The mean age of patients was 60 years and mean duration of admission five days. INTERVENTION--At discharge from the ward all study patients received an information card and a copy of the card in the form of an interim discharge letter to be delivered to their general practitioner. Patients and general practitioners were asked to complete a questionnaire giving their views on the legibility, helpfulness, quality, and quantity of the information they received. Copies of all the information cards were scrutinised for completeness. MAIN RESULTS--The results were based on 208 (76%) forms returned by patients and 214 (78%) forms returned by general practitioners. Information was considered very helpful or quite helpful according to 170 (83%) forms from patients and 197 (92%) forms from general practitioners; sufficient information was provided according to 160 and 182 forms. Most patients and nearly all general practitioners thought it was a good idea to provide this information for patients at discharge. According to 125 forms from patients and 188 from general practitioners the information card was very easy or quite easy to read; 155 patients had read it at least twice and 149 were likely to refer to it again. OTHER RESULTS--The written information about the patient, the diagnosis, and what the patient had been told was generally well completed, although the date of discharge was omitted from 42 (15%) cards. Details of drugs prescribed at discharge were generally thorough. CONCLUSIONS--Giving an information card to all patients at discharge was feasible and favoured by most patients and their general practitioners. Having made minor changes in design, we think that we have produced an information card that is a convenient size and will improve communication between patients, their general practitioners, and hospital doctors. We now issue this card routinely to all patients discharged from our ward and hope that it might be widely adopted.     

Overweight and Obesity: Knowledge,Attitudes, and Practices of General Practitioners in France

Objective: To describe the current knowledge, attitudes, and practices of French general practitioners (GPs) in the field of adult overweight and obesity management. Research Methods and Procedures: A cross‐sectional telephone survey interviewed a sample of 600 GPs, representative of the private GPs in southeastern France. A four‐part questionnaire assessed personal and professional characteristics, attitudes and opinions about overweight and obesity, relevant knowledge and training, and practices (diagnostic methods, clinical assessments, weight loss objectives, types of counseling). Results: Most GPs knew that weight problems are health‐threatening, and 79% agreed that managing these problems is part of their role. Nevertheless, 58% did not feel they perform this role effectively, and one‐third did not find it professionally gratifying. Approximately 30% had negative attitudes toward overweight and obese patients; 57% were pessimistic about patients’ ability to lose weight; 64% often set weight loss objectives more demanding than guidelines call for; and neither food diaries nor nutritional education were used systematically. GPs’ feelings of effectiveness and attitudes toward obese patients were associated with some professional (training) and personal (BMI, personal diet experience) characteristics. Discussion: GPs’ feelings of ineffectiveness may stem from an underlying conflict between practitioners’ and patients’ representations of weight problems and the relationship problems this causes. Inadequate practices and health care system organization may also play a role.     

胆囊结石患者超声诊断结果漏诊及误诊分析

目的:探讨我院胆囊结石患者超声诊断漏诊、误诊的超声诊断结果,并分析出现漏诊、误诊的原因。方法:选取我院肝胆外科经彩色多普勒超声诊断确诊并实施手术治疗的胆囊结石患者260例,结合临床资料分析患者彩色多普勒超声图的特点,并在术后一周进行随访,对彩色多普勒超声诊断的漏诊率及误诊率并分析原因。结果:1、胆囊结石分型:典型胆囊结石167例(64.3%)、充满型胆囊结石50例(19.2%)、多发性胆囊结石28例(10.8%)、泥沙样胆囊结石10例(3.8%),另外5例患者属非胆囊结石(1.9%);2、彩色多普勒超声确诊的260例胆囊结石患者经手术病理证实其中255例为胆囊结石,5例为非胆囊结石(2例为误诊,3例为漏诊),超声诊断的准确率98.1%。误诊、漏诊的发生与病灶部位、患者肥胖程度、仪器操作及医师经验等因素有关。结论:虽然彩色多普勒超声对胆囊结石的诊断率较高,但仍需完善,以减少或避免临床误诊和漏诊的发生。     

Incidence of Neuralgic Amyotrophy (Parsonage Turner Syndrome) in a Primary Care Setting - A Prospective Cohort Study

Objective

Neuralgic amyotrophy is considered a rare peripheral nervous system disorder but in practice seems grossly under recognized, which negatively affects care for these patients. In this study we prospectively counted the one-year incidence rate of classic neuralgic amyotrophy in a primary care setting.

Methods

In a prospective cohort study during the year 2012 we registered all new cases of neck, shoulder or arm complaints from two large primary care centers serving a population of 14,118. Prior to study, general practitioners received a short training on how to diagnose classic neuralgic amyotrophy. Neuralgic amyotrophy was defined according to published criteria irrespective of family history. Only patients with a classic phenotype were counted as definite cases. After inclusion, patients with suspected neuralgic amyotrophy who had not yet seen a neurologist were offered neurologic evaluation for diagnostic confirmation.

Results

Of the 492 patients identified with new onset neck, shoulder or arm complaints, 34 were suspected of having neuralgic amyotrophy. After neurologic evaluation the diagnosis was confirmed in 14 patients. This amounts to a one-year incidence rate for classic neuralgic amyotrophy of 1 per 1000.

Conclusions

Our findings suggest that neuralgic amyotrophy is 30-50 times more common than previously thought. Unawareness of the disorder and its clinical presentation seems the most likely explanation for this difference. An incidence rate of 1 per 1000 and the long-term sequelae many patients suffer warrant more vigilance in diagnosing the disorder, to pave the way for timely treatment and prevent complications.