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.     

How valuable is feedback of information on hospital referral patterns?

OBJECTIVES--To determine general practitioners'' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour. DESIGN--Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice. SETTING--92 general practices in East Anglia. RESULTS--General practitioners judged that access to specialist care, the individual skill of general practitioners, patient demand, and fear of litigation were major determinants of referral behaviour. Because there was widespread scepticism about the accuracy of the data on which the feedback was based and because there is no clear relation between rates of referral and quality of care, it was extremely difficult to encourage doctors to use the feedback as a basis for auditing their own hospital referrals. CONCLUSION--If general practitioners are to contribute meaningfully to monitoring future changes in referral patterns it will be essential to develop reliable information systems in which doctors have confidence. Furthermore, audits need to be based on analysis of clinical cases rather than on rates of referral.     

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.     

General practice postal surveys: a questionnaire too far?

A primary care led NHS, driven by evidence based practice, needs to build on a firm foundation of research in primary care. As researchers are making increasing use of questionnaire surveys to assess general practitioners'' views and attitudes, so response rates to questionnaire surveys among general practitioners are dropping. The reasons include lack of perceived relevance of the research and lack of information and feedback about it, and researchers need to be more aware of the realities of everyday practice. Approaches that might reverse this trend include monitoring all research activities going on in an area to ensure that practices are not overused, giving general practitioners incentives to participate, and improving the relevance of research and the quality of questionnaires.     

Observations on Drug Prescribing in Rheumatoid Arthritis

A total of 125 patients with rheumatoid arthritis were investigated about their drug therapy before referral to a specialist centre. Most referrals were from general practitioners. Only 47 of the patients had received salicylates as the first drug and 18 had never had them at all. Soluble aspirin was the preparation of salicylates most frequently prescribed (for 63 patients). Only 60 patients had been given an adequate dose and only 62 an adequate course of treatment with salicylates. In 28 patients salicylates had been stopped on account of side effects. About one-third of the patients had been prescribed oral corticosteroids.The referral letters were poor in giving details of past and present drug therapy, and there were serious omissions in reporting of previous side effects.Seventy-five general practitioners were asked to rate several currently marketed antirheumatic drugs in terms of effectiveness. Though prednisolone 15 mg daily ranked higher than aspirin 4 g daily the difference was not significant. The study shows the inadequacies of drug prescribing for rheumatoid arthritis in the Glasgow area.     

Urine cytology: appropriate usage maximizes sensitivity and reduces cost

OBJECTIVE: Urine cytology is costly because of the skilled manpower required for analysis. Inappropriate requests are a significant drain both financially and on the cytopathologist's time. The present study aimed at identifying the extent and cause of this misuse and reduce it. METHODS: An audit of urine cytology usage was undertaken using the hospital results reporting system to identify requests. Patient case notes were then obtained to gain further clinical information. Initially a 2-week period was analysed, following which departmental guidelines for requesting urine cytology were produced and circulated. The audit loop was then closed. RESULTS: Over the initial 2-week period, 117 urine cytology requests were received. Thirty-three per cent were inappropriate, either because they were from patients with benign disease or because of duplication. Following the education programme this number fell to 6%. Expenditure on unnecessary samples thus decreased from pounds 2418 to only pounds 310, giving an annual overall saving of pounds 55,000. CONCLUSION: Significant cost and time savings can be made if urine cytology is sent appropriately. Simple guidelines and staff education are the key to reducing inefficiency. Our findings have implications not just for cytopathology costs but for laboratory and radiology requests in general.     

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.     

Diagnosis of urogenital Chlamydia trachomatis infection in women based on mailed samples obtained at home: multipractice comparative study.

OBJECTIVE: To compare urine and vaginal flush samples collected by women at home with endocervical and urethral swabs obtained by general practitioners for their efficacy in the diagnosis of urogenital Chlamydia trachomatis infection. DESIGN: Multipractice comparative study. SETTING: 33 general practices and a central department of clinical microbiology in Aarhus County, Denmark. SUBJECTS: 222 women aged 18-25 years who for any reason had a gynaecological examination. INTERVENTIONS: Endocervical and urethral swabs were obtained by the women''s general practitioners. The same women when at home then collected a first void urine sample, a midstream urine sample, and a vaginal flush sample (using a vaginal pipette) and mailed them to the laboratory. MAIN OUTCOME MEASURES: C trachomatis defected by the polymerase chain reaction and the ligase chain reaction. Eight tests for C trachomatis were performed for every woman. When two of the eight yielded positive results the patient was considered infected. RESULTS: The overall prevalence of C trachomatis infection was 11.2% (23/205 women). Test sensitivities in samples obtained by general practitioners, samples obtained at home subjected to polymerase chain reaction, and samples obtained at home subjected to ligase chain reaction were 91%, 96%, and 100% respectively. The corresponding specificities were 100%, 92.9%, and 99.5%. CONCLUSIONS: The diagnostic efficacy of samples obtained by women at home and mailed to the laboratory was as good as for samples obtained by a general practitioner when using the ligase chain reaction. This may have important implications for the practicability of screening for this common, often asymptomatic, and treatable infection.     

Malaria prophylaxis: postal questionnaire survey of general practitioners in south east Wales.

Postal questionnaires were sent to 494 general practitioners in south east Wales asking about their experience and understanding of antimalarial prophylaxis; 293 were returned, giving a response rate of 59%. Forty eight (16%) of the respondents reported being consulted by immigrants returning home for advice about malaria prophylaxis, of whom 13 (27%) overestimated the time for which their protective immunity might last after leaving the malarious area. Two hundred and eighty respondents (96%) considered that they were responsible for advising travellers and 195 (67%) would always consult a publication before giving chemoprophylactic advice (magazines were particularly popular), but only 18 (6%) would always consult a specialist centre--the Ross Institute in eight cases (3%), a local centre in 39 (13%). Only about half of the doctors were aware of chloroquine resistance in Kenya and Thailand. Over half would withhold chloroquine in pregnancy, and many chose pyrimethamine alone or sulfadoxine-pyrimethamine as suitable chemoprophylactic drugs, though neither is still recommended by the World Health Organisation. One hundred and ninety two respondents (66%) would give advice about protective measures other than chemoprophylaxis. More must be done to encourage general practitioners to contact specialist centres and to educate them in the use of antimalarial chemoprophylactic drugs.     

Are diagnostic tests repeated unnecessarily on hospital admission?

After admission to hospital, patients are often subjected to laboratory tests that may duplicate testing already done. For nearly 2800 patients at three hospitals the numbers and types of tests done in the week before and the week after admission were determined. A team of general practitioners judged the necessity of tests that had been repeated, with only those tests that had yielded normal results at both times being labelled as unjustifiably duplicated. Only 246 patients had had tests done in the week before entering the hospital, but 192 (71%) of them had had tests repeated after admission, 35 (14%) unjustifiably. Of the 743 laboratory tests performed before admission 447 (60%) were subsequently duplicated, but only 85 (11%) of them unjustifiably. Duplication, whether justifiable or unnecessary, was more likely to involve the hemoglobin determinations and urinalyses done routinely in hospitals.     

Efficacy of a Regional Poisoning Treatment Centre in Preventing Further Suicidal Behaviour

A survey of parasuicide (attempted suicide) in general practice in Edinburgh allowed comparison of the rates of further suicidal behaviour in patients treated for their initial episode in the Edinburgh Regional Poisoning Treatment Centre and in those referred to psychiatrists elsewhere or not referred at all. Further suicidal behaviour was only one-third as common among those treated in the treatment centre as among non-admitted patients; patients referred to other psychiatric services did no better than those who were not referred to a psychiatrist at all. The difference in repetition frequencies could not be accounted for in terms of selection of patients in the treatment centre who were less likely to repeat. The tentative conclusion is made that crisis intervention of the kind available at the Edinburgh centre is effective in secondary prevention. The findings add support to Government recommendations that special units like the one in Edinburgh should be set up in other regions.     

Falls in the Elderly: A Clinical Approach

“Topics in the Primary Care Medicine” Presents articles on common diagnostic or therapeutic problems (such as dizziness, pruritus, insomnia, shoulder pain and urinary tract infections) encountered in primary care practice that generally do not fall into well-defined sub-specialty areas and are rarely discussed thoroughly in medical school, house staff training, textbooks and journals. Often the pathophysiology is poorly understood and clinical trials to assess the effectiveness of diagnostic tests or therapies may be lacking. Nevertheless, these problems confront practitioners with practical management questions.The articles in this series discuss new tests and therapies and suggest reasonable approaches even when definitive studies are not available. Each article has several general references for suggested further reading. We hope this series is of interest and we welcome comments, criticisms and suggestions.     

Attitudes to prescribing iron supplements in general practice.

In response to a postal questionnaire general practitioners in the Southampton and New Forest area indicated a considerable understanding of the principles of iron prescribing and use of laboratory tests to determine iron deficiency. Many respondents, however, chose slow release and compound iron preparations as first treatments for iron deficiency. The role of parenteral iron appeared to be poorly understood. The use of and response to laboratory investigations for iron deficiency were generally appropriate, but many practitioners probably do not check for a response to oral iron sufficiently early during treatment or stop prescribing supplements before iron stores have been replenished. There is scope for further education in the biology and management of iron deficiency in general practice.     

Inappropriate use of laboratory services: long term combined approach to modify request patterns.

OBJECTIVE--To see whether changes in request patterns for haematological tests could be influenced in the long term by information released from a haematology department. DESIGN--Analysis of request patterns by hospital divisions before and after intervention and of costs of intervention and savings achieved. SETTING--Haematology laboratory of an inner city district general hospital. INTERVENTIONS--Monthly release of a comparison of clinicians'' workload statistics, issue of on call guidelines, and promulgation of information (by seminars and factsheets) on appropriate use of tests. MAIN OUTCOME MEASURES--Request patterns before and after intervention. RESULTS--During the year after intervention requests fell by at least a fifth, and the reduction persisted over the next two years. The reduction was most pronounced in relation to inpatients within the division of medicine, for whom requests fell from an average of 4.0 per patient in the six months before intervention to 2.9 per patient in the six months after. CONCLUSIONS--A definite and sustained reduction in inappropriate requests for laboratory investigations may be achieved by an ongoing policy of intervention including issuing guidelines and factsheets and holding seminars, but a positive attitude among senior consultant staff is crucial.     

General practitioners' responsibilities to their patients.

The views of general practitioners about their responsibilities for patient care have not been canvassed. A survey of general practitioners was therefore carried out to determine their views. A postal questionnaire, in which general practitioners were asked what they saw as their responsibilities, was sent to 525 principals in Avon and completed by 424, giving a response rate of 81%. The doctors generally agreed that their responsibilities for patient care included problems related to internal medicine, such as managing diabetes and hypertension. Less consensus was found in the replies to questions about technical procedures, such as resection of ingrowing toenails, and gynaecological, orthopaedic, or psychosocial problems. The results supported the view that general practitioners are gradually abandoning technical aspects of medicine to specialists without a compensating role having been defined. In the light of this trend the responsibilities of general practitioners should be clearly defined by the profession.     

Research in general practice. Sources of advice.

Regional advisers, faculty secretaries of the Royal College of General Practitioners, heads of academic departments of general practice and primary care, and heads of RCGP research units were invited to complete a semistructured questionnaire to determine the nature and availability of current sources of advice for general practitioners participating in research activities and the demands placed on the available sources in the United Kingdom. The principal source for research advice was university departments of general practice, yet these have insufficient resources to cope with requests and few have spare capacity to stimulate research. Regional advisers and faculty secretaries do not seem to be kindling a spirit of inquiry and they seem somewhat complacent about both the lack of requests for research advice from general practitioners and the difficulties of academic departments. Proper development of research capability in general practice and primary care is unlikely to occur without more resources to create training posts in academic departments and a greater spirit of inquiry in vocational training programmes, which should lead to both review (audit) and research.     

Effect of NHS walk-in centre on local primary healthcare services: before and after observational study

ObjectiveTo assess the effect of an NHS walk-in centre on local primary and emergency healthcare services.DesignBefore and after observational study.SettingLoughborough, which had an NHS walk-in centre, and Market Harborough, the control town.Participants12 general practices.ResultsThe change between the before and after study periods was not significantly different in the two towns for daily rate of emergency general practice consultations (mean difference −0.02/1000 population, 95% confidence interval −0.75 to 0.71), the time to the sixth bookable routine appointment (−0.24 half-days, −1.85 to 1.37), and daily rate of attendances at out of hours services (0.07/1000 population, −0.06 to 0.19). However, attendance at the local minor injuries unit was significantly higher in Loughborough than Market Harborough (rate ratio 1.22, 1.12 to 1.33). Non-ambulance attendances at accident and emergency departments fell less in Loughborough than Market Harborough (rate ratio 1.17, 1.03 to 1.33).ConclusionsThe NHS walk-in centre did not greatly affect the workload of local general practitioners. However, the workload of the local minor injuries unit increased significantly, probably because it was in the same building as the walk-in centre.

What is already known on this topic

Walk-in centres are well established in North America but differ from NHS centres as they are run by doctors not nurses

What this study adds

Introduction of an NHS walk-in centre did not affect the workload of local general practitionersAttendance increased at the minor injuries unit, which was in the same buildingNon-ambulance attendances at accident and emergency departments decreased but not by as much as in the control area     

Using clinicopathological analysis of general practitioner skin surgery to determine educational requirements and guidelines.

OBJECTIVE--To study the impact of skin surgery in general practice on the workload of a pathology laboratory and to identify what further training might be helpful. DESIGN--Analysis of skin biopsy specimens from general practitioners before and after their new contract to determine numbers of specimens, changes in diagnoses, adequacy of treatment of malignant tumours, and areas of low diagnostic accuracy. SETTING--District general hospital. SUBJECTS--All 1017 skin biopsy specimens from general practice for 15 months before and 12 months after the new general practitioner contract. RESULTS--The number of pathology specimens received increased from 16 to 65 per month (median = 6 submitted by each general practitioner in the post-contract year). The proportion of the more common pathological diagnoses was unchanged between the two periods, but the proportion of correctly diagnosed naevi, cysts, and seborrhoeic keratoses increased in the second. Although few diagnoses were overtly incorrect, accurate diagnosis of dermatofibromas and malignancies decreased after the contract, and the overall correct diagnosis rate for seborrhoeic keratoses, dermatofibromas, rashes, and malignancies was below 30%. Only nine out of 21 squamous cell carcinomas were adequately excised with tumour free margins, and follow up of malignant tumours may have been inadequate. CONCLUSIONS--Skin surgery in general practice has advantages but matters of concern are the increase in laboratory workload, the excision of some benign lesions, and the inappropriateness of biopsy of rashes. Squamous cell carcinoma and other malignant tumours submitted for pathological examination were often unsuspected and inadequately excised, and heightened suspicion is recommended. Pathology request forms may need redesigning to encourage provision of clinical details.     

Epidemiology and Diagnosis of Helicobacter pylori Infection

Medline, PubMed and the Cochrane databases were searched on epidemiology and diagnosis of Helicobacter pylori for the period of April 2011-March 2012. Several studies have shown that the prevalence of H.?pylori infection is decreasing in adults and children in many countries. Various diagnostic tests are available, and most of them have high sensitivity and specificity. The Maastricht IV/Florence consensus report states that the urea breath test using (13) C urea remains the best test to diagnose H.?pylori infection. Among the stool antigen tests, the ELISA monoclonal antibody test is recommended. All these tests were used, either as a single diagnostic test or in combination, to investigate H.?pylori infection among different populations throughout the world. Of particular interest, current improvements in high-resolution endoscopic technologies enable increased diagnostic accuracy for the detection of H.?pylori infection, but none of these techniques, at present, are specific enough for obtaining a real-time diagnosis of H.?pylori infection.