The diabetic, the hospital and primary care

In a survey of mainly elderly patients discharged from a hospital diabetic clinic, it was found that 41 per cent were being seen by the general practitioner only when required or not at all, 36 per cent were being seen fairly regularly, and 23 per cent at routine appointments.

The transfer from hospital to primary care was popular with two thirds of these patients, mainly because of the time, trouble, and money they saved in no longer travelling to hospital.

Over 20 per cent of patients thought they had been discharged from the diabetic clinic because they were cured, a further 37 per cent thought they could be cured, about a third did not test their urine, and a similar proportion admitted that they did not keep to their diet.

Of 204 known diabetics examined in general practice, about half had high blood sugars, a third of lower limbs had undoubted signs of peripheral vascular disease, and one fifth of the sample had both.

     

Asian diabetics attending a British hospital clinic: a pilot study to evaluate their care.

A questionnaire survey of 40 Asian and 31 British non-insulin dependent diabetics attending a hospital clinic showed that both groups remembered receiving education about diabetes (90%) but Asian diabetics knew less about glucose monitoring and diabetic complications. Asians also had a more negative attitude towards the clinic, feeling they were made to wait longer than the British. They were frustrated by a lack of communication with the staff. Forty per cent of both Asian and British diabetics felt that diabetes prevented them from leading a normal lifestyle. Twenty seven per cent of both Asian and British diabetics used herbal or alternative medicines, but Asians differed in that they used these medicines specifically for diabetes. A further sample of 50 Asians had poorer glycaemic control than a sample of British diabetics matched for age, sex and type of diabetes. It is concluded that despite receiving the same education as British diabetics, Asians did not understand it as well. The education was often not relevant to their diets or customs. This may contribute to their poorer glycaemic control. Diabetic clinic facilities need to be improved for Asian diabetics, to improve their understanding of diabetes.     

Diabetes and its care--what do patients expect?

A sample of 77% of the non-insulin dependent diabetics aged 30-70 years from two urban practices offering no structured diabetic care were interviewed. The 55 patients (mean age 60 years) were asked about their experiences and expectations of diabetes and the health professionals involved in their care. Twenty-six patients attended the hospital diabetic clinic regularly but 13 patients received no review at all; 46 patients wanted their general practitioner to be involved in future care and only six wanted to continue with hospital review alone. Patients gave hospital doctors and general practitioners similar high ratings for knowledge of diabetes and its management but general practitioners and practice nurses were rated more highly for communication and accessibility. The aspect of care valued most was being given clear information about diabetic management. Twenty two patients thought that diabetes would have a significant impact on their future health and 35 rated regular diabetic review as extremely important in keeping themselves healthy. Most patients felt it likely that they would have a high blood glucose level most of the time and develop diabetic complications. Little difference was found between the views of clinic attenders and non-attenders, and there was no evidence that non-attenders had actively rejected review. These non-insulin dependent diabetics considered diabetes to be a serious disorder warranting regular care and expressed confidence in the primary care team's ability to provide such care.     

Comparison of patients attending general practitioner and consultant day hospitals for the elderly

A comparative study of patients attending general practitioner and consultant day hospitals for the elderly in Clwyd is described. The general characteristics of both patient groups were similar. There were, however, differences in the types of illness represented: disorders of the nervous system, mainly strokes, comprised over one third (37 per cent) of the consultant day hospital cases; disorders of the musculoskeletal system, mainly osteoarthrosis, comprised nearly one third (29 per cent) of the general practitioner group. Over 70 per cent of patients attending both types of day hospital had been discharged within six months and most attended once or twice each week. Clinical evaluation on discharge showed that over 80 per cent of the patients in both types of hospital had shown improvement or had not further deteriorated during their period of attendance.

It is concluded that day hospital care in community hospitals, supervised by general practitioners, can make an effective contribution to total health care provision for the elderly.

     

Survey and audit of diabetes care in general practice in south London.

A survey was made of the diabetic care given by general practitioners in six family practitioner committee areas. Replies were received from 388 practices, representing 1034 principals (effective response rate 69%), serving over two million patients. Fourteen per cent of practices offered mini-clinic facilities for their diabetic patients, although a much greater proportion professed to give either full or shared care to patients in ordinary surgery time. One quarter of practices kept a diabetes register, but fewer had a system of recall for patients to ensure anticipatory care. The barriers which general practitioners most often perceived in the provision of adequate care for diabetics were: lack of time, absence of a recall system and deficiency in their own clinical skills. Seventy seven of the doctors responding to the initial questionnaire participated in an audit of the level of supervision provided for 378 of their diabetic patients. Better levels of supervision of non-insulin dependent diabetics were shown in those practices where diabetes registers were kept, and where special arrangements were made for caring for diabetes. The levels of care provided by those doctors setting aside specific clinic times were not demonstrably superior to those who did not. The findings suggest that provision of support services, particularly expertise in dietetics, would help to increase general practitioners' confidence and enable more of them to improve their care of diabetic patients.     

Total care usage of a defined population

The North Staffordshire (Stoke) Morbidity Survey was set up to bring together data about the total use of general practice, hospital and local authority services by each individual patient in a representative sample of the population of Stoke, and to examine the associated problems of data linkage and confidentiality. Approximately 47·8 per cent (32·1 per cent if allowance is made for all measurable possible errors) of the patients attending hospital and 43·8 per cent of patients attending local authority services during the year, did not attend their general practitioner.

Primary automation of the registered list of patients at risk is essential to the success of any automated linkage study. Where the list consists of Hogben numbers to identify individuals, this also ensures the necessary confidentiality of sensitive data.

     

Care of diabetic patients in hospital clinics and general practice clinics: a study in Dudley.

A five year retrospective casenote review was undertaken of 452 patients attending 11 different general practice diabetic clinics, and 506 patients attending a diabetic clinic at hospital A and 210 patients attending a diabetic clinic at hospital B. The populations attending the clinics, the degree of glycaemic control achieved and the monitoring for the development of diabetic complications were investigated. Insulin dependent patients comprised 57.9% of patients attending the diabetic clinic at hospital A, 35.7% at hospital B and 25.0% of patients attending the diabetic clinics at general practices. Of these 55.6%, 37.3% and 30.1% respectively received multiple daily insulin injections. Hospital A had a higher proportion of patients under 40 years old than hospital B or the general practice clinics. The ages of diabetic patients attending the general practice diabetic clinics were broadly similar to those attending hospital B. Significantly more general practice patients, both insulin and non-insulin dependent, had a mean blood glucose level of less than 11 mmol l-1 compared with patients attending clinics at hospitals A and B (P < 0.001). Glycosylated haemoglobin levels did not differ between patients attending hospital A and the general practice clinics. More non-insulin dependent and insulin dependent diabetic patients attending the general practice clinics and hospital A had been monitored satisfactorily for diabetic retinopathy (general practice clinic 68.8% and 39.7% respectively, hospital A 61.7% and 43.5%) than at hospital B (43.0% and 19.4%). Referral rates among all groups for ophthalmological assessment were similar.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute myocardial infarction: an easy diagnosis in general practice?

In the imminent myocardial infarction Rotterdam (IMIR) study, contacts by patients with their general practitioners for symptoms of potential coronary artery disease were registered. Those who had acute myocardial infarction were diagnosed on the basis of the modified World Health Organization criteria, and those with this definite diagnosis were then compared with the initial diagnosis made by the general practitioner at the moment of contact without laboratory assistance.

Of the 1,343 patients included in the study, 93 (seven per cent) had `definite' acute myocardial infarction and another 37 (three per cent) had `possible' acute myocardial infarction according to the diagnostic criteria used.

At the time of contact with the general practitioner 41 (44 per cent) of the 93 patients with definite myocardial infarction were recognized as such by the general practitioner, while in another 31 (33 per cent) the general practitioner diagnosed `imminent' myocardial infarction.

Of the 1,213 patients free of acute myocardial infarction at the time, 40 (three per cent) were incorrectly diagnosed by the general practitioner as having `acute' myocardial infarction.

In the 22 patients who in fact had acute myocardial infarction but in whom the general practitioner did not make this diagnosis at the time, it was found that there was an absence of physical signs and, similarly, in patients who subsequently did not have infarction the presence of physical signs was related to a falsepositive general practitioner diagnosis of myocardial infarction.

In view of the inaccuracy of the general practitioner's provisional diagnosis of acute myocardial infarction, we believe that electrocardiogram and enzyme tests should be carried out systematically in all patients who present to general practitioners with symptoms of potential coronary artery disease. Laboratory support should be readily available and we support the idea of having a special diagnostic service.

     

Characteristics and pattern of care of a diabetic population in mid-Wales.

The pattern of care and demographic features of diabetes in a largely rural Welsh population were investigated before the introduction of measures to improve diabetic care. All data were obtained from general practice notes. Of the population studied 1.01% were identified as diabetic. There were no demographic differences from recently published English studies. Seventy per cent of the diabetic patients had not seen a consultant within the preceding year. The level of surveillance for biochemical control and complications of diabetes was better in those who had had recent consultant care. However, basic surveillance data was missing in many consultant letters to general practitioners. The prevalence of known serious diabetic eye disease (9%) in the study population was similar to that found in a recent study of a structured care system. Proposed improvements in diabetic care must take into account the large number of patients not attending hospital clinics. Communication between consultant clinics and general practitioners must be improved.     

Soluble immune complexes in the sera of newly diagnosed insulin-dependent diabetics and in treated diabetics

Soluble immune complexes were detected by the Raji cell assay in seven out of thirteen newly diagnosed insulin-dependent diabetics, six of whom had islet cell antibodies (ICAb) in the serum. None of the others had ICAb. The titres for a wide range of viral antibodies were similar in these thirteen diabetics as in age- and sex-matched controls, except for antibodies to Coxsackie B4. Six had titres of Coxsackie B4 antibodies greater than or equal to 1:32, but only three of these had evidence of immune complexes in the serum, and these were not correlated with the titres of Coxsackie B4 antibodies. None of these diabetics had antibodies to insulin and none of their age- and sex-matched controls had evidence of immune complexes in the serum.

53% of thirty-two diabetics treated with insulin and 10% of fifty-two diabetics requiring oral hypoglycaemic agents (OHA) or diet had evidence of immune complexes in the serum, compared to 6% of control subjects. High titres of insulin antibodies correlated with evidence for immune complexes. There was a stronger tendency for immune complexes to occur in the presence of moderate titres of insulin antibodies when the age at onset of insulin-dependent diabetes was less than 30 years. Out of sixteen patients treated with heterologous insulin for 13 years or more, and who also had late diabetic complications, twelve had immune complexes in the serum.

     

Organized personal care--an effective choice for managing diabetes in general practice.

A system of diabetic review was introduced in two Southampton training practices in March 1985. Each partner, with the help of the practice nurse, retained responsibility for review of their own diabetic patients. During the study period (1984-86) 213 diabetics remained with the practices. In 1984 there were 94 non-insulin dependent patients who were not receiving hospital outpatient care. Over the study period there was an increase in the surveillance of blood glucose, blood pressure, weight, urine (for protein), fundi, visual acuity and feet for this group so that in 1986 between 79% and 89% of patients were having these parameters checked at least annually. More complications were found and more referrals for specialist evaluation were made. There was a trend towards transfer of care from the hospital to the general practitioner, and the proportion of non-insulin dependent diabetic patients receiving their care entirely from general practice increased from 22% to 60% over the period. There was a small increase in the workload of the general practitioners and a considerable contribution to care was made by the practice nurses. It is concluded that structured personal diabetic care based on a nurse coordinated service is a satisfactory alternative to the 'specialist' general practitioner mini-clinic model.     

Development and use of a short self-rating instrument to screen for psychosocial disorder

This paper describes the preliminary testing and use of a short self-report instrument designed to identify psychosocial disorder. It combines a shortened version of the social problem questionnaire with the 12 item general health questionnaire. In a survey of 100 patients attending a health centre in inner London 46% recorded a psychiatric problem on the general health questionnaire compared with 35% identified by the general practitioner. For social problems 54% of patients assessed themselves as having one or more social problem compared with 23% detected by the general practitioner. The instrument normally takes five to 10 minutes for the patient to complete and thus can be filled out in busy situations such as a general practice surgery or a hospital outpatient department.     

A comparison of hospital and general practice blood pressure readings using a shared-care record card

Shared-care blood pressure record cards were issued to 149 consecutive hypertensive patients attending our hospital clinic. In 108 (72.5 per cent), general practitioners entered readings they had obtained onto the cards. The use of the record card has proved helpful in the management of patients, and we are encouraged by the co-operation of the family doctors.

A comparison of blood pressures measured in hospital and in general practice showed that general practitioners found systolic pressures to be an average of 5.5 mm Hg lower than hospital doctors, but there were no differences in diastolic pressure. In many cases, wide discrepancies were found both in hospital and general practice. We conclude that it is a myth that patients' blood pressures are lower when they consult their family doctor, or that outpatient blood pressure readings are falsely elevated by the stress of hospital attendance.

     

One-to-one teaching with pictures--flashcard health education for British Asians with diabetes.

BACKGROUND: Type 2 diabetes is up to four times more common in British Asians, but they know little about its management and complications. AIM: To design and evaluate a structured pictorial teaching programme for Pakistani Moslem patients in Manchester with type 2 diabetes. METHOD: A randomized controlled trial of pictorial flashcard one-to-one education in 201 patients attending a hospital outpatient clinic or diabetic clinics in ten general practices in Manchester. Patients' knowledge, self-caring skills and attitudes to diabetes were measured on four topics before the structured teaching, and compared with results six months later. RESULTS: All parameters of knowledge were increased in the study group; for example, percentage scores for correctly identifying different food values increased from 57% to 71% (Analysis of Variance (ANOVA) adjusted difference +11.8%) and knowledge of one diabetic complication from 18% to 78%. Self-caring behaviour improved, with 92% of patients doing regular glucose tests at six months compared with 63% at the start. Attitudinal views were more resistant to change, with patients still finding it hard to choose suitable foods at social occasions. Haemoglobin A1c control improved by 0.34% over six months (ANOVA adjusted difference, 95% CI -0.8% to +0.1%). CONCLUSION: It is concluded that this health education programme can empower Asian diabetics to take control of their diets, learn to monitor and interpret glucose results, and understand the implications of poor glycaemic control for diabetic complications.     

Telephone messages received by seven general practices

Telephone calls were recorded in seven general practices in Aylesbury in a study of communications received from the hospitals, local health authority (L.H.A.), social services department, and other sources, but excluding calls from patients.

Analysis of 855 telephone calls revealed patterns of communication with the staff of the practices which have not previously been recorded. The general practitioners were central in communications from all sources except the local health authority, while calls to health visitors came overwhelmingly from the local health authority. Community nurses received only 36 (four per cent) of all the calls despite the interests expressed by hospital nursing staff in their responses to a postal questionnaire. A hypothesis is advanced to explain this discrepancy between interest and action.

     

Adolescent patients in an Inner London general practice: their attitudes to illness and health care

A postal questionnaire was sent to 121 patients aged 16-20 years identified from the age-sex register of an Inner London practice; 87 replied. Information was sought about adolescents' perceptions and experience of illness and health care, and their attitudes to preventive medicine. Few of the girls reported that they were in good health; 59 per cent of girls and 23 per cent of boys had visited their general practitioner in the previous three months. Thirty per cent of girls and 15 per cent of boys felt that there was something wrong with their health and in particular that they were overweight. Smoking and drinking were common. Adequate contraception was being practised by most girls.

Detailed interviews with 18 of the respondents identified a number of family problems and difficult relations with staff in hospitals. Most of them considered that good health was not merely a matter of luck.

Adolescents are usually described as being a most healthy group, but this study of an inner city practice suggests that adolescents themselves do not share this view.

     

Death in practice

For a nationwide study of terminal care, Gallup Polls took a sample of 950 general practitioners. Fourteen questionnaires could not be delivered; 376 doctors (40 per cent of the register) returned forms; 313 doctors (33.4 per cent) provided information on 301 home deaths and 292 hospital deaths and responded also to statements about care of the dying.

The patients who died at home were well supported by the general practitioner and the family and neighbourhood network. Control of pain was perceived to be better at home. Patients dying at home were more likely to be aware of their impending death. General practitioners usually discussed the imminence of death with relatives, but few relatives and patients raised the question of terminating life. All the available major services were under-used. There was support for more hospices and for more spending on social services. Postgraduate medical education on care of the dying was considered to be inadequate.

     

An audit of the care of diabetics in a group practice

The diabetics in a general practice of 20,175 patients were identified during one year and 119 were found—a prevalence of 5·9 per thousand.

The age and sex distribution, method of treatment, criteria of diabetic control, complications, and present method of care were analysed from the medical records to examine the process of medical care of a chronic disease in general practice.

     

Epilepsy monitoring and advice recorded: general practitioners'' views, current practice and patients'' preferences.

BACKGROUND: Epilepsy is a common condition that is managed at the interface between primary and secondary care. AIM: A study aimed to describe general practitioners' criteria for aspects of optimal epilepsy care and their estimates of current levels of care achieved; to compare these estimates with clinical data extracted from their patients' medical records; and to compare general practitioners' estimates and recorded data with information provided by the patients themselves. METHOD: Thirty seven general practitioners from six practices in the south Thames region were sent a questionnaire enquiring about current practice with regard to general practitioner and specialist monitoring of patients with epilepsy and provision of advice, and about their criteria for the optimum levels of aspects of epilepsy care. Of patients aged over 15 years in the study practices, 0.6% were found to have active epilepsy; 283 of these 326 patients were sent a questionnaire enquiring about their epilepsy, the service and advice provided, and whether they required more information. Responses to the general practitioners' questionnaire and to the patients' questionnaire were compared and also compared with information extracted from the patients' medical records. RESULTS: Ninety five per cent of the general practitioners responded. Of 255 patient questionnaires (90%) returned, 251 could be analysed. Of 247 patients, 168 (68%) reported having had no seizure in the previous six months. Forty of 241 patients (17%) had a regular arrangement to see their general practitioner regarding their epilepsy. Of 191 patients who expressed a preference, 116 (61%) reported preferring to receive their epilepsy care mainly from their general practitioner. General practitioners reported that ideally patients should be monitored in primary care every six months (the median recorded frequency was 14 months) and that there should be a record of advice given to all patients on driving, adverse effects of antiepileptic drugs, and self-help groups. Advice was recorded in patients' records as having been given on driving (46% of records), adverse effects of antiepileptic drugs (9%), and self-help groups (3%); 82 of 237 patients (35%) reported not receiving enough advice. CONCLUSION: Patients generally preferred to receive their epilepsy care in general practice. Monitoring and provision of advice were less than optimal from both the general practitioners' and the patients' point of view. New resources and skills will be necessary to bridge this perceived gap. Specially trained nurses may have a role in this monitoring and advice provision.     

Computers in general practice: the patient's voice

Analysis of answers to a questionnaire on the use of computers in general practice showed that 19 per cent of patients in two practices in Staffordshire would be worried if their general practitioner used a computer to store medical records. Twenty-seven per cent of patients would be unwilling to speak frankly about personal matters to their general practitioner if he or she used a computer and 7 per cent said that they would change to another doctor. Fifteen per cent stated that their general practitioner already had information about them that they would not want to be included in a computerized record of their medical history.