Annual visits to patients over the age of 75-- who is missed?

BACKGROUND: In the UK, the GP contract requires annual consultations andoffers of home visits to the elderly. However, as many as 50%of elderly people refuse the offer of a health screen. OBJECTIVE: To describe the characteristics of elderly people who declinedthe offer of an annual home visit. METHOD: All elderly people aged 75 years and over, registered with ageneral practice of 13 full time and 3 part time doctors witha list size of 33,000 people, were offered a home visit. Datafrom this prospective cohort were linked with data from a communitysurvey two years previously, which had achieved a 95% responserate. The main outcome measures were perceived health status,perceived loneliness, morale score, physical and mental disability,use of primary care and social services. RESULTS: Thirty-six percent of all elderly people registered with thepractice declined to take up the offer of a home visit. Thoserefusing a visit had not recently joined the practice and hadvery similar distributions of all demographic and most healthand wellbeing characteristics to those who took up the offer.However, those declining appeared to have higher levels of morale(P = 0.010) and less contact with the general practitioner (P= 0.021) including an average of three weeks longer since lastconsultation with their general practitioner than those acceptingthe visit. CONCLUSIONS: There appears little evidence in this population that elderlypeople who decline a home visit are necessarily part of an ‘iceberg’of unmet need. Keywords. Elderly, GP contract, home visits, patient take-up.     

Effect of Helicobactor pylori eradication therapy on dyspeptic symptoms in primary care

OBJECTIVE: The aim was to explore the effect of eradication therapy ondyspeptic symptoms in patients with known peptic ulcer disease(PUD). METHOD: A total of 164 known dyspeptics and 147 non-dyspeptic attendersat six UK general practices were recruited. The Helisal RapidBlood test was performed in the practices and eradication therapyleft to the preference of the general practitioner. Patientswere followed prospectively by a Likert scaled symptom questionnaireand record review. The symptom questionnaire distinguished betweenpatients known to have dyspepsia and those not. RESULTS: There was a statistically significant decrease in dyspepticsymptoms in patients with known PUD who received eradicationtherapy (n = 43, Z = –2.63, P = 0.009). CONCLUSIONS: Eradication of Helicobacter pylori in primary care can leadto a reduction in consumption of H2 receptor antagonists andhence cost savings. This study demonstrates that dyspeptic symptomsalso decrease. The questionnaire could be used in further studiesto evaluate the effect of management on dyspeptic symptoms inthe primary care setting. Keywords. Dyspepsia, Helicobactor pylori, primary care, therapy, outcome measures.     

Acute cooling of the feet and the onset of common cold symptoms

Background. There is a common folklore that chilling of thebody surface causes the development of common cold symptoms,but previous clinical research has failed to demonstrate anyeffect of cold exposure on susceptibility to infection withcommon cold viruses. Objective. This study will test the hypothesis that acute coolingof the feet causes the onset of common cold symptoms. Methods. 180 healthy subjects were randomized to receive eithera foot chill or control procedure. All subjects were asked toscore common cold symptoms, before and immediately after theprocedures, and twice a day for 4/5 days. Results. 13/90 subjects who were chilled reported they weresuffering from a cold in the 4/5 days after the procedure comparedto 5/90 control subjects (P = 0.047). There was no evidencethat chilling caused any acute change in symptom scores (P =0.62). Mean total symptom score for days 1–4 followingchilling was 5.16 (±5.63 s.d. n = 87) compared to a scoreof 2.89 (±3.39 s.d. n = 88) in the control group (P =0.013). The subjects who reported that they developed a cold(n = 18) reported that they suffered from significantly morecolds each year (P = 0.007) compared to those subjects who didnot develop a cold (n = 162). Conclusion. Acute chilling of the feet causes the onset of commoncold symptoms in around 10% of subjects who are chilled. Furtherstudies are needed to determine the relationship of symptomgeneration to any respiratory infection. Keywords. Cold exposure, common cold, infection, nose.     

Colorectal cancer and polyps in patients aged 40 years and over who consult a GP with rectal bleeding

BACKGROUND: Rectal bleeding is common in the community and in general practice,but few studies have examined the causes of rectal bleedingin patients presenting to general practitioners. OBJECTIVE: To determine the frequency of neoplastic conditions in patientswith rectal bleeding presenting in general practice and to explainthe associations between presenting symptoms and final diagnoses. METHODS: We conducted two studies, the first in 1989, the second in 1991,in which we invited Danish general practitioners to register3–4 patients aged 40 and over presenting with rectal bleeding. RESULTS: In Study 1 among 208 patients aged 40 and over and presentingwith a first episode of rectal bleeding, colorectal cancer andpolyps were present in 15.4 and 7.7%, respectively. In Study2 among 209 patients aged 40 and over and presenting with overtrectal bleeding, 156 reported a first bleeding episode or achange in their usual bleeding pattern, and in this group colorectalcancer and polyps were diagnosed in 14.1 and 11.5%, respectively.In the group with unchanged bleeding the cancer polyp prevalencewas 6.7% (P < 0.05). The patients in both studies were followedthrough a yearly letter to the GP for at least 32 and 22 months,respectively. CONCLUSIONS: A joint analysis of the two study populations showed that onlyage and change in bowel habit contributed to differentiatingthe cancer from the non-cancer patients. Keywords. Colorectal cancer, polyps, rectal bleeding.     

Antibiotics for upper respiratory tract infections. Follow-up utilization and antibiotic use.

OBJECTIVES: To examine the effects of antibiotic prescribing during an initial visit for viral respiratory tract infections on future care seeking and the cost of care. MATERIALS AND METHODS: Retrospective analysis of recorded visits for viral respiratory tract infections (N = 49,862) between January 1, 1995, and December 31, 1997, to practices in a large network of affiliated practices that use the same electronic medical record. RESULTS: Patients receiving antibiotics at the initial visit were less likely to return for a second visit, but this difference was small (15.4% vs 17.4%, P < .001). When returning for the second visit, those who received an antibiotic on the initial visit were prescribed more expensive antibiotics than those who had not received an antibiotic on the initial consultation. Overall, cost from initial antibiotic use outweighed any benefit from reduced utilization in adults and children. CONCLUSIONS: Antibiotic prescribing at an initial contact for a viral respiratory tract illness may reduce the likelihood that an individual will return for a subsequent visit, but adds substantial costs to care for the initial antibiotic and for more expensive antibiotics used on subsequent visits.     

Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice

BACKGROUND.: The effectiveness of health promotion activity in general practiceon risk factor reduction for coronary heart disease remainsthe subject of active debate. OBJECTIVE.: The study aimed to assess the impact of practice-based healthcheck-ups on health behaviours over a 2-year period. METHOD.: A general practice cohort of 7123 patients from 18 practiceswas surveyed. Eight hundred and forty (12%) patients had beenoffered a heafth check within a 12-month period from September1992 and 621 (9%) received one. Two hundred and fifty patients(40%) were asked back for follow-up after their health check. RESULTS.: Over a 2-year period there was no difference in smoking cessation,alcohol consumption, weight loss nor the amount of exercisetaken between those who attended for a health check and thosewho did not. The food score chosen to assess dietary change(Oxcheck) showed a statistically significant 1.16-point risefor the whole sample over the survey period. There was a significantdifference in mean food score change between heafth check attendersand non-attenders (Mann-Whitney U test: P << 0.002). Maintenanceof dietary improvement over a 2-year period was not affectedby health check attendance. CONCLUSIONS.: This study confirms the low impact of health checks on the selfreported modification of cardiovascular risk factors and showsthat maintenance of appropriate health behaviour change is nomore likely in those who have received a health check. Keywords. Health promotion, general practice.     

Teaching to inhale: better utilization of powder inhalators after counseling and instruction

OBJECTIVE: To study the effect of instruction of patients who used an dry powder device on the correct performance of the inhalation technique and whether the effect lasts. DESIGN: Prospective. METHOD: A number of patients who used at least one drug by the dry powder devices Diskhaler or Diskus/Accuhaler were asked to demonstrate their inhalation technique in the outpatient clinic, Department of Pulmonary Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. On a score list the receptionist recorded the correctness of every step of use of the device. Then information and instruction on the correct performance of the inhalation technique were supplied by the same receptionist until the patient mastered the inhalation technique. A simple instruction card was handed to the patient. At the next outpatient visit the effect of the instruction was measured by means of the same score list registered by the same or another receptionist. RESULTS: Data from 97 patients could be evaluated; 42 men and 55 women, with a mean age of 58 years (range: 16-84). The percentage of patients who performed all essential actions correctly increased from 12 to 62. Almost all actions were performed better at the second than at the first visit. Better inhaling technique was observed in the 53 patients who paid their second visit within 30 days as well as in the 44 who came later (mean: 96 days; range: 34-352). CONCLUSION: The performance of the inhalation technique with the Diskhaler and the Diskus/Accuhaler was poor. By means of instruction the inhalation technique improved. This improvement was also seen in the group checked after an average of 3 months.     

Secondary depression in weaned alcoholics: implications of Lesch's typology of chronic alcoholism

Schuckit (1983) described two types of alcohol-related depression:(1) the common type, in which secondary depression disappearswithout treatment within the first few weeks of abstinence;(2) a less frequent type, primary depression, requiring specifictreatment. It is difficult to anticipate whether an alcoholicpatient needs antidepressive treatment or whether depressionwill remit spontaneously. A potential guide to differentiatedepressed alcoholic patients who might need specific treatmentfor depression could be the typology of Lesch et al. (1990).Based on . . . [Full Text of this Article]ConclusionFOOTNOTESREFERENCES     

Beyond administrative data: characterizing cardiorespiratory disease episodes among patients visiting the emergency department

We attempted to address deficiencies in administrative health service data during a study of cardiorespiratory emergency department visits. From 1994-1996, we obtained data on 9,264 visits and conducted 1,772 follow-up interviews. The median interval between symptoms and visit ranged from 0.8 days (95% CI 0-1.7) for cardiac conditions to 4.0 days for chronic obstructive pulmonary disease (COPD) (95% CI 2.7-5.3) and respiratory infections (95% CI 3.5-4.5). Infection was the most common trigger of respiratory visits. Although most had improved at follow-up, symptoms persisted following the visit for a mean of 4.5 days (95% CI 3.8-5.4) for cardiac conditions to 8.4 days (95% CI 7.2-9.5) for COPD. Among adults aged < 70, the mean number of reduced activity days per episode ranged from 4.7 (95% CI 3.9-5.4) for asthma to 6.6 (95% CI 5.9-7.4) for respiratory infections. Our data assist in interpreting epidemiological studies based on administrative data, and illustrate the broad impacts of cardiorespiratory disease episodes.     

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

OBJECTIVE: The aim was to establish the potential efficacy, tolerabilityand side-effect profile of electromagnetic therapy as an adjunctto conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinicaltrial was carried out in a dedicated leg ulcer clinic basedin one urban general practice. Nineteen patients with leg ulcersof confirmed venous aetiology were assessed. The main outcomemeasures were rate and scale of venous leg ulcer healing, changesin patient-reported pain levels, quality of life, degree ofmobility, side effect profile and acceptability to patientsand staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinicachieved improvements in the size of their ulcer (4, 21%, healedfully) and in reduced pain levels (P < 0.05) during the trial,despite the chronicity of ulcer histories. Patients treatedwith electromagnetic therapy at 800 Hz were found at day 50to have significantly greater healing (P < 0.05) and paincontrol (P < 0.05) than placebo therapy or treatment with600 Hz. All patients reported improved mobility at the end ofthe study. The electromagnetic therapy was well tolerated bypatients, with no differences between groups in reporting adverseevents, and proved acceptable to staff. CONCLUSION: Despite the small numbers in this pilot study, electromagnetictherapy provided significant gains in the healing of venousleg ulcers and reduction in pain. Keywords. Electromagnetic therapy, RCT, leg ulcers, primary care.     

Self-reported prevalence of warts in children and GP consultation

Objective: Respiratory infections are a frequent causes of medical attendance. Influenza viruses increases this phenomena. The aim of this study was to prospectively identify GPs’ increased work in terms of visits and time. Methods: Over a period of five months 5 GPs recorded sex, age, number and place of visits, telephone consultations of the patients visited for acute respiratory disease (ARD)which included acute respiratory infections (ARI), influenza (FLU) and Influenza-like illness (ILI). Upper respiratory tract infections (URTI) were classified as sinusitis, rhinitis, otitis, tonsillitis, pharyngitis, laryngitis, Lower respiratory tract infections (LRTI) were classified as tracheitis, bronchitis, pneumonia, bronchopneumonia, acute episodes of chronic obstructive pulmonary disease (COPD) and asthma. FLU and ILI were considered two different entities on the basis of symptoms. Results: Acute respiratory disease increase of 22 patients attending every GP's office monthly (from 176 to 198 total visits). 6542 patients were observed. The incidence of ARD was 33.5% (2191: 1091 female and 1100 males). URTI affected 944 patients, LRTI 739, FLU 328 and ILI 180. The increase in home visits grew from 10 to 36. Each home visit took from 15 to 45 minutes. In a high number of cases (236), home visits were necessary for sick-leave certificates. FLU (54%) and LRTI (37.5%) required more attention, and they were the primary causes for visits. Telephone consultations took place for all ILI or FLU of minor severity and in young people.

Conclusion: During the winter there is an increased work-load for GPs due to the diffusion of influenza virus and respiratory tract diseases. “Burn out syndrome” is increasing among the GPs. Territorial GPs’ action is highly efficacious. Patients self-certification should be evaluated. Vaccine therapy could be more effective if done on a larger population. More research is needed.     

Performance failure of an evidence-based upper respiratory infection clinical guideline.

BACKGROUND: We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization. METHODS: Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation. RESULTS: A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05). CONCLUSIONS: Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.     

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.     

Parents' health and demographic characteristics predict noncompliance with well-child visits

BACKGROUND: The purpose of this study was to investigate factors related to well-child visit noncompliance in an ethnically diverse family practice clinic population. METHODS: Participants included 146 parents (131 mothers and 15 fathers) of children aged 0 to 24 months who received care at a St. Paul residency clinic. Participants completed telephone surveys that asked about their demographic characteristics, attitudes toward well-child visits, whether the most recent planned well-child visit had been kept, and their own and their child's health characteristics. RESULTS: All participants thought that well-child visits were important, with immunizations being the highest rated reason for importance. Fourteen percent of parents said they had missed a recent well-child visit, mostly because they forgot. More than three fourths of parents believed visit reminders were helpful, and the preferred type of reminder was a telephone call. Noncompliance with well-child visits was associated with the parent's depressive symptoms, transportation difficulties, working at a job, having private (vs public) health insurance, and being older (vs younger). CONCLUSIONS: These results suggest that well-child visit compliance might be enhanced by visit reminders and improved access to transportation. The relationship of well-child visit noncompliance to parental depressive symptoms, if verified in other populations, points to a need for greater surveillance of children/families who do not schedule or keep well-child visits.     

Childhood vulvovaginitis and vaginal discharge in general practice

OBJECTIVE.: This study aims to examine the aetiology, clinical featuresand response to treatment of childhood vulvovaginitis in generalpractice. METHOD.: A longitudinal survey of consecutive premenarchal patients presentingwith vulvovaginitis and/or vaginal discharge in the course ofnormal consultations with a general practitioner was conductedin a a semi-rural, group general practice with 11 000 patientsin Plymouth, UK. Forty-two premenarchal girls with vaginal inflammationor discharge were surveyed, with main outcome measures beingclinical evaluation, microbiological assessment of urine andvaginal swabs, and patients' and parents' assessments of resolutionand relapse of symptoms. RESULTS.: Non-specific vulvovaginitis with mixed bacterial flora, associatedwith poor hygiene and atrophic vaginal mucosa, was the commonestcause; specific bacteria were found in 10 out of 42 cases, includingsix of Streptococcus pyogenes. No candida was isolated. Treatmentwith topical oestrogen cream was effective only with mixed infection,oral antibiotics were effective in both mixed and single organisms.No evidence of sexual abuse nor foreign body was found. CONCLUSIONS.: Childhood vulvovaginitis is not uncommon in general practice,is usually associated with mixed growth of faecal organisms,and is seldom due to serious causes such as sexual abuse orforeign body. Keywords. Vulvovaginitis, vaginal discharge, children, general practice.     

Is daily single dosage of diazepam as effective as chlordiazepoxide in divided doses in alcohol withdrawal--a pilot study

We report on a pilot double-blind study on the effectivenessof divided doses of chlordiazepoxide and a single daily doseof diazepam in the treatment of the alcohol-withdrawal syndrome.While a variety of drugs (chlormethiazole, propranolol and clonidine)have been used for treatment of alcohol-withdrawal symptoms,benzodiazepines remain the drugs of choice for alcohol detoxification(Mayo-Smith, 1997). Diazepam and chlordiazepoxide are both . . . [Full Text of this Article]APPENDIXFOOTNOTESREFERENCES