Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.     

The sexual psychopath in California

In California sexual offenders apprehended by the law are examined by court-appointed psychiatrists to determine whether they are "sexual psychopaths" as defined by California law and need treatment in a mental hospital. This paper outlines the criteria to be used as guides in properly selecting the persons for treatment. In general, sexual offenders fall into four categories. The first group consists of persons who cannot maintain proper control over their sexual impulses but whose acts do not constitute them a menace to the health and safety of others. They are not "sexual psychopaths" and their cases should be handled on their legal merits. The second group embraces persons who have committed a sexual offense on only one occasion and while under the influence of abnormal or unusual environmental stress. They are not considered "sexual psychopaths."The third is made up of persons completely out of step with the social culture. They often have long criminal histories or long histories of social maladjustment. They are impulsive in their behavior and not remorseful of their misdeeds. Sexually deviant acts committed by such individuals are often incidental to their general asocial and amoral behavior. They do not suffer from inability to control sexual impulses. Their offenses should be judged according to the legal merits of the case.True "sexual psychopaths" have deviant menaceful sexual impulses and are not able to control them. The vast majority of these persons are those who have committed sexual offenses against children. The California State Department of Mental Hygiene has a maximum security hospital which is charged with the care and treatment of "sexual psychopaths."     

Randomised controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics.

Two hundred patients with type II diabetes were entered into a randomised controlled trial lasting five years to compare routine care of this condition by a hospital diabetic clinic with routine care in general practice. Fewer patients in the group being cared for by their general practitioner (general practice group) were regularly reviewed or had regular estimations of blood glucose concentration. More patients in the general practice group than in the hospital group were admitted to hospital for medical reasons during the study (25 (24%) compared with 17 (18%] and more patients in the general practice group died (18) than did in the hospital group (6). At the end of the study mean concentrations of haemoglobin A1 were higher in the general practice group (10.4%) than in the hospital group (9.5%). Routine care in general practice for patients with type II diabetes was less satisfactory than care by the hospital diabetic clinic.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Healthcare systems and motivation

Despite the fact that most American physicians, at least until around the 1970s, stood in the way of developing a universal healthcare system, most are generally not happy with the current state of healthcare--or its lack thereof--today. The primary reasons for this general unhappiness are that insurance companies and managed care have successfully conspired to remove much of the physician's autonomy (via imposed time constraints, burdensome paperwork, the time-consuming chore of having to defend going against stringent treatment algorithms that are often inappropriate for some patients) and the satisfaction of knowing their patients. Few physicians in managed care organizations (MCOs) are able to practice without constant and blindly algorithmic interference concerning the diagnostic tests and therapeutic interventions they order. As copayments have increased, they often find that patients, even though "covered," cannot afford the therapy they deem necessary. While physicians expect to earn sufficient to pay back their not insignificant educational debts, provide their children with help through college, and assure retirements sufficient for themselves and their spouses, these should not be considered unreasonable expectations. Most physicians today do favor universal healthcare -- to the point of having included such language in their various professional codes of ethics (which, perversely enough, bioethicists as a group have failed to do). Contrary to the claims of our colleagues, Altom and Churchill, physicians seem to be genuinely frustrated as to what else they can do to change the current inequitable system.     

Prospective study of symptoms and signs in acutely ill infants in general practice.

A study was made of all cases of acute illness in infants aged 6 months or less presenting in a Gosport practice over five months. The frequency in these patients of the well defined symptoms and signs suggested to be important by the preliminary report of the Department of Health and Social Security''s multicentre study of postneonatal mortality was recorded. During the study period there were 161 infants of this age in the practice, who gave rise to 69 consultations with acute illness. Thirty eight of these were given drug treatment and five were referred to a paediatric unit, one of them on social grounds. There were no infant deaths in the practice (total population 11,400), but two occurred in the Gosport area (total population 83,000). It would be unrealistic to refer all patients with any one of the symptoms and signs, even when well defined, in the age group 6 months or less. Analysis of the symptoms and signs found in those children who required admission did not show any pattern differentiating them from those who did not. Although the symptoms and signs studied are of value in assessment and should be sought in these patients, they cannot be used singly or in any pattern to indicate referral per se.     

Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices

Background

A tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients’ perceptions of counselling for CVRM.

Methods

A mixed-methods process evaluation was conducted. We assessed practice nurses’ motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data.

Results

Data from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients’ medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options.

Conclusions

The tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all.

     

Diagnosis and treatment of cervical intraepithelial neoplasia in general practice.

OBJECTIVE--To audit the first five years of a colposcopy and treatment service for cervical dysplasia established within a general practice. DESIGN--A cervical smear register was established to determine which women were "at risk" of dysplasia. The results of colposcopy and treatment of dysplasia were analysed. SETTING--A large rural general practice with community hospital facilities in mid-Wales. PATIENTS--4437 Women at risk in a total practice population of 14,100. INTERVENTIONS--Colposcopy of women with dyskaryotic smear results, persistent inflammatory smear results, or vulval warts. Treatment of women with proved dysplasia by electrodiathermy of the cervix or cone biopsy. RESULTS--138 Women with dysplasia were diagnosed over five years: 36 mild, 97 moderate or severe, and five with microinvasion. Despite a 78% smear rate of at risk women over five years, nine invasive cancers still occurred. CONCLUSIONS--The results of treatment are acceptable. Cervical dysplasia has become very common, the risk of a dysplasia in women aged 20-39 who had smear tests being one in 14 over five years.     

Problem drug use in a central London general practice.

OBJECTIVE--To describe the profile of problem drug users presenting in general practice and to determine whether they can be cared for in general practice. DESIGN--Study of consultations by problem drug users. SETTING--Central London general practice. SUBJECTS--150 problem drug users presenting over two years. MAIN OUTCOME MEASURES--Stopping drug use, alterations in lifestyle, obtaining paid work, and stopping drug related crime. RESULTS--Of the 150 patients, 111 were men and 39 women, and 106 were unemployed. 121 patients used heroin, 112 of whom injected. 145 patients accepted a methadone reduction programme and 81 completed it. A further 25 were stabilised on reducing doses of methadone, until places became available for them as inpatients at drug dependency units or rehabilitation projects. CONCLUSION--Withdrawal programmes for patients who misuse drugs can be successfully managed in general practice.     

How much personal care in four group practices?

OBJECTIVE--To establish the degree of continuity of care in general practice. DESIGN--Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING--Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS--776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES--Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS--In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS--Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health''s recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.     

Newly registered elderly patients: who are they and why such delay in the transfer of their medical records?

The time taken to transfer the records of elderly patients registering with a new general practice was investigated. Thirty five (5%) of a total of 671 patients aged 75 and over were entered as new patients on to the age-sex register of an urban group practice during one year. Twenty nine had moved into the area and six had changed their general practitioner for personal and other reasons. An average of 141 (range 71-296) days elapsed before dispatch of their medical records to the new practice. During this period an average of 3·5 (range 0-15) consultations with a general practitioner were recorded, indicating the need of such patients for medical care. The long delays were caused by the processing of medical records at the central register and the transfer of records between family practitioner committees and general practitioners. Delays were most apparent in the time taken for general practitioners to dispatch the necessary documents to the family practitioner committees, and these should be minimised.The use of a summary card written and updated by the general practitioner and retained by the patient would facilitate continuing care should patients change to a new practice. Meanwhile, assessment of elderly patients after registration with a new practice by a member of the primary health care team may identify problems before the records have been transferred and may help the resettlement of these high risk elderly patients.     

Treatment of Depression in General Practice

With the co-operation of the family doctors in five selected urban general practices the general-practitioner treatment of 73 patients suffering from a new episode of depressive illness was evaluated over a period of four months. The purpose was to test the belief that general practitioners are best fitted to manage most psychological ailments, and depression was chosen as the psychiatric illness most commonly seen in general practice. Medication was the principal treatment offered, and this was often inadequate in dosage or the patient defaulted. Drug defaulting was thought to be due partly to failure of supervision and follow-up and to too low a consultation rate. The low consultation rate was also thought to explain why few patients thought there was a therapeutic value in the doctor-patient relationship. The results of the study indicate that patients with depressive illness do not receive the best treatment in general practice. The reasons are several and responsibility must be shared by the medical practitioners, the current system of the general practice, and the patients themselves.     

How informed is signed consent?

The assurance that patients fully understand the information given to them before they sign the consent form for operation has never been validated in this country. One hundred patients were interviewed by an independent medical observer in one surgical unit in a teaching hospital between two and five days after their operation. Although all the patients interviewed were fully aware that they had had an operation, 27 did not know which organ was operated on and 44 were unaware of the exact nature of the surgical procedure. A significantly higher age group was observed in the group of patients who were unaware of the basic facts relating to their operation, and the problem was encountered most commonly in patients over the age of 60. Because of the medical and legal importance the findings of this pilot study warrant further large scale investigations.     

A review of general practice reports: the need for standardisation.

Fifty general practice annual reports were reviewed with a checklist to determine how much information was commonly included and whether they described the patients, the practice, and practice activity. The reports varied widely: important information was sometimes missing, practice activity was measured in different ways, and terms were often not defined. About half the reports reviewed did not draw conclusions or suggest plans for the future. Annual reports should include comparable basic information about patients, the practice, and the practice activity to optimise their usefulness in evaluation, planning, and decision making. Many relevant data are available from family practitioner committees and district health authorities.     

Targeting asthma care in general practice using a morbidity index.

OBJECTIVES--To evaluate a morbidity index as a postal surveillance tool in defining previously diagnosed asthmatic patients needing extra education or management; to determine the accuracy of a computerised asthma register in general practice. DESIGN--Postal questionnaire survey of asthmatic patients identified from a computer register. Questionnaire comprised three morbidity questions, two questions about current asthma status, and one about treatments. SETTING--Urban general practice of 8400 patients linked to academic unit. SUBJECTS--853 asthmatic patients of all ages. MAIN OUTCOME MEASURES--Numbers of patients with low, medium, and high morbidity; associations of these groups with age, asthma status, and drugs taken. RESULTS--Two mailings yielded 621 replies (73%); 28 patients (5%) had moved away, leaving 593 for analysis. Attempts were subsequently made to contact 20% sample of non-respondents. 234 respondents (40%) were in the "low morbidity" group, 149 (25%) in the "medium morbidity" group, and 210 (35%) in the "high morbidity" category. 53% of patients perceiving themselves as currently asthmatic (193/362) were in the high morbidity group, but 7% (11/153) who said they were no longer asthmatic and 8% (6/78) who did not believe they had ever been asthmatic were also in that group. High morbidity was also found in 10% (18/185) of those on no treatment, 38% (59/154) of those on bronchodilators alone, and 54% (119/220) of those on inhaled corticosteroids. 25 patients (4%) were wrongly identified as asthmatic; when combined with returns marked "gone away" this gave a disease register accuracy of 91%. CONCLUSIONS--This exercise identified subgroups of previously diagnosed asthmatic patients with high morbidity in general practice who might benefit from extra education and management and revealed some misclassification on the asthma disease register.     

Medical housing "lines".

General practitioners are often asked for medical certificates (housing "lines") by applicants for council housing who claim to have medical problems requiring housing priority. The results of a survey by questionnaire showed that general practitioners in Edinburgh do not know how the housing system works and that they seem to overestimate their patients'' chances of obtaining suitable council housing. General practitioners need to know how the housing system works, and communication between general practitioners and housing departments should be improved. A comparison was also made between the number of medical points awarded by a community medicine specialist and a group of general practitioners who had written housing "lines" for their patients. The general practitioners tended to award more points than the specialist. Social priority for housing should be recognised as an independent factor and a new category of top social priority added.     

Effect of health visitors working with elderly patients in general practice: a randomised controlled trial.

Health visitors were employed specifically to care for two years for a random sample of patients in general practice who were aged over 70. Independent assessments made at the beginning and end of the study showed that the health visitor in an urban practice had some impact on her caseload of patients; she provided more services for them, their mortality was reduced, and their quality of life improved, though the last measure just failed to be statistically significant. The health visitor working in a rural practice had no such effect.     

Feasibility of contact surveys in general practice.

Surveys to evaluate risk factors for disease in the general population are popular with health authorities for assessing the effectiveness of their preventive measures. A contact survey of the lifestyles of 2000 randomly selected patients aged 25-64 was conducted in five general practices over 18 months; the medical records of the patients selected were tagged, and when the patients first visited the surgery they were given a questionnaire by the receptionists, which they completed in the waiting room. Over the 18 months at least 1400 of these patients visited the practices, of whom 1106 (55%) completed a questionnaire and 20 refused to do so; 896 (81%) completed it within one year. Information on the patients who were not surveyed was obtained by sending the questionnaire by post and by audit of medical records. The population surveyed on contact with the surgeries contained a higher proportion of young women, and possibly a higher proportion of patients from social classes IIIM-V, than the other patients. No important or consistent bias towards unhealthy patients at high risk was identified in the contact survey. A one year contact survey of a random, tagged sample is feasible in estimating the risk factors in a population and may be the method of choice in general practice because of its low cost and adaptability.     

Heroin users in general practice: ascertainment and features

A case-control study of heroin users in general practice showed a prevalence of roughly two per 1000 of the urban population or four per “average” general practice list of patients. A method of studying heroin users who attend general practice was used that has advantages over existing techniques. Thirty six heroin users had a statistically significantly higher yearly doctor-patient consultation rate than a group of matched controls. More heroin users also failed to attend appointments than controls. When consultations directly related to heroin and its effects were excluded, however, the consultation rates in the two groups were similar. The heroin users did not have an excess of psychiatric disorder or disturbed family background compared with controls but had a noticeable history of dishonest and violent behaviour towards medical staff.A high proportion of heroin users in the study were antibody positive for the human immunodeficiency virus. General practitioners should take advantage of their frequent contacts with heroin users and their families to give them support and counselling about the acquired immune deficiency syndrome.     

The rapid transit system for patients with fractures of proximal femur.

The rapid transit system for patients with fractures of the proximal femur consists of immediate internal fixation or replacement of the fractured bone under spinal anaesthesia, without any sedation. Patients are mobilised within hours of surgery and sent home as soon as they can walk. They are supervised at home by both an experienced physiotherapist and a visiting nurse. Sixty nine patients admitted to a metropolitan teaching hospital were considered for the system and 50 were accepted. Their age distribution and level of general ill health were comparable with those in other series. The rapid transit system resulted in 90% of patients accepted being discharged to their homes within the first five days, with a lower morbidity and a mortality at three months of 7%. Using the rapid transit system rehabilitation in the original environment is difficult only if the patient lives alone, and even then temporary support is often enough to allow them to return home.