Outcome of low back pain in general practice: a prospective study

Objectives: To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Design: Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Setting: Two general practices in south Manchester. Subjects: 490 subjects (203 men, 287 women) aged 18-75 years. Main outcome measures: Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Results: Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

Key messages

• It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
• In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
• While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
• Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
• Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

     

Establishing a minor illness nurse in a busy general practice.

OBJECTIVE--To study the feasibility of a practice nurse caring for patients with minor illnesses. DESIGN--Nurse given training in dealing with patients with minor illnesses. Patients requesting a same day appointment were offered a nurse consultation. SETTING--Group practice in Stockton on Tees. MAIN OUTCOME MEASURES--Number of consultations which required a doctor contact, treatment, and rate of reconsultation. RESULTS--Of 696 consultations in six months, 602 (86%) required no doctor contact. 549 (79%) patients did not reconsult about the episode of illness, and 343 (50%) patients were given advice on self care only. CONCLUSION--Trained nurses could diagnose and treat a large proportion of patients currently consulting general practitioners about minor illness provided that the nurse has immediate access to a doctor.     

The Influences of Group and Independent General Practice on Patient Care: A Comparative Study in Ontario

When the practices of four general practitioners, members of multispecialist-general practitioner salaried groups (clinic doctors) were compared with those of four independent general practitioners (solo practitioners), it was noted that: group practice patients had more office laboratory investigation and greater in-hospital consultation and referral. On the other hand, independent practitioners'' patients seemed to receive more personal attention from the doctor, a fuller explanation of diagnosis and treatment during office hours, more drug samples and more laboratory investigation in hospital.Group and independent practices are similar with respect to the rate of follow-up visits, the volume of preventive medicine, the number of radiographs and special procedures, the total number of drugs ordered, and the in-hospital formal written consultation rate and office consultation rate.The similarities between two types of practice may be a result of the interaction of group and independent practice in the same community.It is concluded that the team approach to medical care is not incompatible with independent practice.     

Depressive Illness in a General Practice. A Demographic Study and a Controlled Trial of Imipramine

The distribution of 93 consecutive cases of depressive illness in a Surrey general practice was found to be non-random. Married women were at risk, while men and unmarried women were largely spared. Married women were prone to the disorder at any time in their lives, and relapse was frequent. There was some suggestion that divorced wives and wives of low social class were particularly predisposed to the disorder.Sixty of the patients took part in a double-blind controlled trial of imipramine. There was no evidence that the drug was superior to a placebo in inducing a remission. It is suggested that imipramine has become established in clinical practice on inadequate evidence and that there is a need for further trials.     

Long-term outcome of patients with neurotic illness in general practice.

OBJECTIVE--To determine the 11 year outcome of neurotic disorder in general practice. DESIGN--Cohort study over 11 years. SETTING--Two general practices in Warwickshire England. SUBJECTS--100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders. MAIN OUTCOME MEASURES--Mortality, morbidity, and use of health services. RESULTS--At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate. CONCLUSION--These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.     

Edinburgh primary care depression study: treatment outcome,patient satisfaction,and cost after 16 weeks.

OBJECTIVE--To compare the clinical efficacy, patient satisfaction, and cost of three specialist treatments for depressive illness with routine care by general practitioners in primary care. DESIGN--Prospective, randomised allocation to amitriptyline prescribed by a psychiatrist, cognitive behaviour therapy from a clinical psychologist, counselling and case work by a social worker, or routine care by a general practitioner. SUBJECTS AND SETTING--121 patients aged between 18 and 65 years suffering depressive illness (without psychotic features) meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition for major depressive episode in 14 primary care practices in southern Edinburgh. MAIN OUTCOME MEASURES--Standard observer rating of depression at outset and after four and 16 weeks. Numbers of patients recovered at four and 16 weeks. Total length and cost of therapist contact. Structured evaluation of treatment by patients at 16 weeks. RESULTS--Marked improvement in depressive symptoms occurred in all treatment groups over 16 weeks. Any clinical advantages of specialist treatments over routine general practitioner care were small, but specialist treatment involved at least four times as much therapist contact and cost at least twice as much as routine general practitioner care. Psychological treatments, especially social work counselling, were most positively evaluated by patients. CONCLUSIONS--The additional costs associated with specialist treatments of new episodes of mild to moderate depressive illness presenting in primary care were not commensurate with their clinical superiority over routine general practitioner care. A proper cost-benefit analysis requires information about the ability of specialist treatment to prevent future episodes of depression.     

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patient''s daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.     

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.     

Assessing the consultation: method for measuring changes in patient stress and arousal.

A method has been developed to assess anxiety levels in terms of stress and arousal in patients before and after a consultation with a general practitioner. The MACL self report mood scale has been used in hospital outpatient studies. An adaptation of the scale using 26 items of low vocabulary was applied to general practice patients in a novel way to show appreciable reductions in stress and increases in arousal after consultations. Since arousal is related to efficiency of performance and stress has been inversely related to recall of information given in the consultation factors that affect stress and arousal in patients could usefully be identified.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

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.     

Unrecognised depression in general practice.

Patients attending their general practitioner were screened and a group with unrecognised major depressive disorder identified. This group was interviewed and the findings compared with those in a group of patients recognised correctly as depressed by their general practitioners. Half of the patients with severe depression screened in their doctors'' waiting rooms went unrecognised, and they differed in few ways from those who were recognised. The differences found were that the patients with unrecognised depression were less obviously depressed and their illness had lasted longer. Physical illness was present in nearly 30% of patients in the unrecognised group, and the depression seemed related to it. Patients with unrecognised depression were more likely to have feelings other than those of normal sadness and more likely to respond with change of mood to intercurrent events. These data suggest that patients might benefit if general practitioners were better trained to recognise depression, although it is not known whether treatment would be effective.     

Factors affecting early unplanned readmission of elderly patients to hospital.

A random sample of 133 elderly patients who had an unplanned readmission to a district general hospital within 28 days of discharge from hospital was studied and compared with a matched control sample of patients who were not readmitted. The total group was drawn from all specialties in the hospital, and by interviewing the patients, their carers, the ward sisters, and the patients'' general practitioners the factors causing early unplanned readmission for each patient were identified. Seven possible principal reasons were found: relapse of original condition, development of a new problem, carer problems, complications of the initial illness, need for terminal care, problems with medication, and problems with services. There were also contributory reasons, and it was usual for several of these to be present in each case. The unplanned readmission rate was 6%; the planned readmission rate was 3%. It was thought that unplanned readmission was avoidable for 78 (59%) patients. Patients in the study group and in the control group showed significant differences in certain characteristics--such as low income, previous hospital admission, already having nursing care, and admission by general practitioners--and this might help to identify patients who are likely to be readmitted in an emergency.     

Comparison of medical care in prison and in general practice.

The medical care of prisoners "declaring sick" to the medical officer and hospital officers in Bedford Prison was surveyed and compared with the medical care given to the medical officer''s patients in general practice. The consultation rate of prisoners was higher than that of patients in the practice. Part of this increase was because household remedies were not available to prisoners except through the prison medical service and part may also have been due to the stresses of life in prison. Few psychoactive drugs were prescribed in prison. The problems that prisoners presented reflected the problems of violence and poor hygiene in prison. Some problems that more commonly present in prison than in general practice may be related to stress.     

Evaluation of the development of psychosomatic medicine in a large university hospital in Turkey

The purpose of this study was to evaluate the development of psychosomatic medicine at our university hospital in Istanbul, which has an inpatient capacity of 3,000. Changing patterns of utilization of psychiatric service were analyzed in two 1-year surveys five-year intervals (1998, n=888) - (2003, n=1609). Psychiatric referrals were analyzed with regard to rate of consultation, demographic characteristics, departments making referrals, reasons for referral, psychiatric diagnoses and patterns of psychiatric intervention. Psychiatric consultation request, consultation reply and medical psychiatric examination forms were used. In evaluating the data, consultation rate was seen to have doubled over the five intervening years. Significant changes were also noted in the demographic characteristics of patients (e.g., more men, older mean age). The most prevalent disorders in both groups were depressive disorder and adjustment disorders. Alcohol and substance abuse remained as a small group. The gradual increase in the utilization of psychiatric services can be attributed to service and education-related variables.     

SUICIDE PROBLEMS IN MEDICAL PRACTICE

Increasing awareness by physicians in general medical practice of the possibility of suicide in nonpsychiatric patients is indispensable for the evaluation of suicide risk and for a practical approach to the problem of prevention.An analysis was made of the records of 11 cases of suicide by medical and surgical patients who were in a general nonpsychiatric Veterans Administration hospital for evaluation and treatment of physical disease.It was noted that the general hospital staff had a low index of suspicion of the possibility of suicide in general hospital patients.It appeared from this study that there is a definite suicide risk in older persons hospitalized for physical illness who develop psychotic reactions during the course of their illness and hospitalization. The signs and symptoms of toxic and organic psychosis in these older patients were not recognized and their significance relative to suicide risk was not appreciated. Although psychiatric signs of severe emotional disturbance appeared clinically obvious at least 24 hours before suicide in ten of the eleven patients, no suicide risk was considered present, nor were adequate precautions taken by the hospital staff. This was owing to the lack of psychiatric orientation among the nonpsychiatric physicians.     

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.