Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.

OBJECTIVE: To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams. DESIGN: One year retrospective and a 2 1/2 year prospective study. SETTING: Two hospitals in West London and 88 general practitioners in 72 general hospitals. SUBJECTS: 209 adults with HIV infection. INTERVENTION: General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced. MAIN OUTCOME MEASURES: Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners. RESULTS: The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved. CONCLUSIONS: This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.     

Attitudes of doctors to the Alma Ata recommendations in Sri Lanka.

A detailed postal questionnaire was sent to 400 general practitioners, hospital doctors, and Ayurvedic practitioners in Sri Lanka as part of a wider study to investigate the delivery of primary medical care. The responses to questions that were related to the Alma Ata recommendations, which aim at providing "health for all by the year 2000," and the perceived health needs of the population are reported. Basic sanitation, clean water, adequate nutrition, and improved health education were considered to be the most important needs. When asked to suggest one change in health care 30% of the doctors recommended the integration of primary and secondary care services.     

Night workload in one health district.

The night work (11 pm-7 am) in primary care in one health district (population 195 212 with 93 general practitioners) was studied over a three month period, starting 1 January 1983. The workload proved to be small (15% of all "out of hours" work for general practitioners). An average of three night visits was done a night in the whole health district, and 26 general practitioners were available for these. On average, over seven doctors were available each night for each patient who required a visit in primary care in the health district. It is concluded that there is only sufficient work for (at maximum) two doctors, and a system is proposed to make more efficient use of the general practitioner''s time.     

Gallop rhythm.

Seventy-five percent of family practitioners in Ventura County, California, responded to a seven-page mailed questionnaire. One third of the practitioners do no obstetrics. The physicians counsel seven patients to every delivery performed and to every surgical procedure performed. Family practice consists of medicine and pediatrics, rather than surgery, obstetrics and psychiatry. Family practitioners use referrals to community health care services in a limited fashion. Lack of information about availability of community resources may be the reason.     

Training Physicians for Primary Care: Trends and Hazards

Programs to train physicians more effectively for careers in primary care are being organized within academic departments in internal medicine and pediatrics, while the number of training programs in family practice continues to grow rapidly. However, the field of primary care training is expanding without a common vocabulary and with inadequate communication between the specialties involved.If decisions concerning health care policy are to be made rationally, the development of multiple distinct models for primary health care delivery must be encouraged and these models must then be evaluated.The distinction between family practice and family medicine must be made clear if the latter discipline is to realize its potential application to all specialties.The relative exclusion of family practice from universities and the absence of experienced practitioners in university primary care programs are conditions that threaten the future of both types of programs and deserve thoughtful attention from medical educators.     

Feasibility and effects of nurse run clinics for patients with epilepsy in general practice: randomised controlled trial. Epilepsy Care Evaluation Group.

OBJECTIVE: To test the feasibility and effect of nurse run epilepsy clinics in primary care. DESIGN: A randomised controlled trial of nurse run clinics versus "usual care." SETTING: Six general practices in the South Thames region. SUBJECTS: 251 patients aged over 15 years who were taking anti-epileptic drugs or had a diagnosis of epilepsy and an attack in the past two years who met specified inclusion criteria and had responded to a questionnaire. MAIN OUTCOME MEASURES: Questionnaire responses and recording of key variables extracted from the clinical records before and after the intervention. RESULTS: 127 patients were randomised to a nurse run clinic, of whom 106 (83%) attended. The nurse wrote 28 letters to the general practitioners suggesting changes in epilepsy management. For this intervention group compared with the usual care group there was a highly significant improvement in the level of advice recorded as having been given on drug compliance, adverse drug effects, driving, alcohol intake, and self help groups. CONCLUSIONS: Nurse run clinics for patients with epilepsy were feasible and well attended. Such clinics can significantly improve the level of advice and drug management recorded.     

Empowering GPs as purchasers.

FHSAs have defined their role in purchasing primary care FHSAs have also found themselves intermediaries between district health authorities and general practitioners All of the purchasing authorities recognise the need to educate general practitioners on how to use their influence in the purchasing process General practitioners should be involved in the purchasing process as they purchase the bulk of health care; are the first point of contact for the users of the health service; need to have input on what is purchased; and need to be able to manage the changes resulting from the shift in the balance of power towards primary care The involvement of general practitioners in the purchasing process at present varies considerably among health authorities. Several district health authorities have developed models of purchasing that enable different levels of involvement     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

The General Practitioner in a Changing World

Throughout the world there is need for physicians to render primary and continuing health care to individuals, families, and communities; and there is growing concern over the deficiency in the numbers of such doctors. In the U.S.A. there has been a decrease in the number of general practitioners and others who are in the best position to render this kind of service, and the number of medical graduates entering this field continues to decline. Many reasons for this state of affairs have been offered, but one fact stands out above all others: the majority of medical students wish to engage in a career of service and significance but are unwilling to become second-class physicians. If young men are to be recruited into family practice we must build for them a clinical and academic specialty in which research is being done, and in which they can obtain significant qualifications.     

Would primary health care workers give appropriate dietary advice after cholesterol screening?

The purpose of this study was to obtain information on the dietary knowledge of primary health care workers and on their ability to apply this knowledge in practice. A total of 128 primary health care workers (53 general practitioners and 61 nurses) in 12 practices and 14 primary care facilitators were surveyed by questionnaire between December 1987 and June 1988. All of the practices were participating in a project to promote prevention in primary care and offered health checks designed to identify and deal with cardiovascular risk factors. The questionnaire focused on issues related to managing patients with moderate hypercholesterolaemia. The results of the study showed some important gaps in the health workers'' knowledge--for example, only 91 understood that dietary intake of polyunsaturated fatty acids as a proportion of total fat intake should be increased in a diet designed to reduce serum lipid concentrations. Appreciable gaps in their ability to give practical and appropriate dietary advice were also identified: 35 gave advice that would have led to the patient losing weight (although his history indicated that he was not overweight), and 27 gave only negative advice, offering no suggestions about substituting healthy foods for unhealthy ones. The demand for primary health care workers to give dietary advice is increasing and is likely to increase further if a national screening programme for hypercholesterolaemia is recommended. The results of this survey point to a need for improved nutritional education and training in dietary counselling for general practitioners, nurses, and primary care facilitators.     

General practitioners in partnership with management: an organisational model for debate.

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community.     

Need for primary health care: an objective indicator.

The allocation of resources for primary health care should be based on the community''s needs and not only on the workload of general practitioners. I therefore present an objective indicator that may be used to assess the need for primary health care.     

Meningococcal infections: reducing the case fatality rate by giving penicillin before admission to hospital.

OBJECTIVE--To determine whether parenteral penicillin given before admission to hospital reduces the case fatality rate in patients with meningococcal disease. DESIGN--Retrospective analysis of 46 consecutive patients admitted to hospital with meningococcal disease from January 1986 to March 1991. SETTING--District general hospital. MAIN OUTCOME MEASURE--Hospital case fatality rate. RESULTS--None of the 13 patients given parenteral penicillin by the referring doctor before admission died, compared with eight deaths (24%) in 33 patients admitted without such treatment. CONCLUSION--Parenteral penicillin given before admission probably contributed to a reduction in the case fatality rate from meningococcal disease, and primary care physicians should be encouraged to give such treatment immediately on suspicion of the diagnosis before transferring the patient to hospital. Public health physicians are well placed to inform and alert general practitioners of the potential benefit of this action.     

Sources of primary health care for women in an urban centre.

Family or general practitioners and obstetrician-gynecologists have the opportunity to provide primary health care to women. Who actually gives this care in a large urban setting was the focus of this study. In the Montreal area 297 women were asked by telephone whether they had an obstetrician-gynecologist and whether they would see another type of doctor for a cold that was not getting better. Overall, 88% of all the women indicated that they would go to a family or general practitioner for such a problem, and of the women who reported receiving some care from an obstetrician-gynecologist 78% also received care from another physician. Of the respondents seeking health care from only one type of doctor, women with English as the mother tongue were significantly more likely to attend an obstetrician-gynecologist, whereas French-speaking women much more often were cared for by family or general practitioners.     

Measles immunisation rates and the good practice allowance.

The recent discussion document on primary health care proposes that a good practice allowance is paid to general practitioners based in part on the uptake of immunisation by patients. The variation between and the validity of practice immunisation rates for measles as determined by one district health authority''s child health computer are assessed. In areas of low population mobility district health authority rates may be sufficiently accurate to base a good practice allowance on but should not be used until the social environment of each practice can also be characterised. In areas of high mobility intermittent surveys may be a preferable method of auditing performance.     

Economic Burden of Hypoglycemia in Patients with Type 2 Diabetes Mellitus from Korea

Background

Hypoglycemia is a very serious complication in patients with type 2 diabetes mellitus (T2DM) and affects the economic burden of treatment. This study aims to create models of the cost of treating hypoglycemia in patients with T2DM based upon physician estimates of medical resource usage.

Methods

Using a literature review and personal advice from endocrinologists and emergency physicians, we developed several models for managing patients with hypoglycemia. The final model was approved by the consulting experts. We also developed 3 unique surveys to allow endocrinologists, emergency room (ER) physicians, and primary care physicians to evaluate the resource usage of patients with hypoglycemia. Medical costs were calculated by multiplying the estimated medical resource usage by the corresponding health insurance medical care costs reported in 2014.

Results

In total, 40 endocrinologists, 20 ER physicians, and 30 primary care physicians completed the survey. We identified 12 types of standard medical models for secondary or tertiary hospitals and 4 for primary care clinics based on the use of ER, general ward, or intensive care unit (ICU) and patients’ status of consciousness and self-respiration. Estimated medical costs per person per hypoglycemic event ranged from $17.28 to $1,857.09 for secondary and tertiary hospitals. These costs were higher for patients who were unconscious and for those requiring ICU admission.

Conclusion

Hypoglycemia has a substantial impact on the medical costs and its prevention will result in economic benefits for T2DM patients and society.     

EDWIN L. BRUCK,M.D

The progressive fall in the status and numbers of general practitioners has produced a dangerous void in the field of comprehensive medical care. The Millis Commission and other national study committees have recommended that family practice be made a board-certified specialty in order to restore the status and numbers of family physicians. The scope of family practice that is envisioned, however, would be so restricted in depth as to raise serious doubts that sufficient medical graduates would be attracted to careers in this new specialty. Better training in broadly-based general or family practice—rather than a specialty board, per se—is the only realistic way to elevate status and attract more medical students to this field.     

Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.