On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Referral patterns to a specialist eating disorder service: the impact of the referrer's gender

There is some evidence that the characteristics of general practitioners (GPs) and of the services that they operate influence the likelihood of referring patients to specialist eating disorder services. The aim of this study was to determine whether the gender of the GP is associated with referral rates for different eating disorders. The sample was a retrospective case series of 93 patients, referred to a specialist eating disorder service by local GPs. Associations between GP gender and clinical characteristics of the patients were determined using chi‐squared tests and t‐tests. Patients with binge eating disorder were substantially more likely to be referred by female GPs, while other atypical cases were more likely to be referred by male GPs. There was no evidence that the patients referred by male GPs differed in clinical presentation from those referred by female GPs. Clinical hypotheses are advanced to explain these biases in the referral practices of male and female clinicians. There is a need for greater education of GPs about the importance of identifying atypical eating disorders and treating them appropriately. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.     

Cardiovascular risk profile and risk stratification of the hypertensive population attended by general practitioners and specialists in Spain. The CONTROLRISK study

The CONTROLRISK study was designed to determine the cardiovascular risk profile of the hypertensive population attended at primary care and specialist setting in Spain and to investigate whether physicians stratify the risk correctly, according to the 2003 European guidelines. A total of 8920 patients were recruited from primary care (n=4485) and specialist outpatient clinic (n=4435). The age criteria was 62.6+/-11.1 years; 51.6% were women. No differences were observed in the severity of hypertension. More than 85% presented other cardiovascular risk factors, similarly in both groups. Target organ damage (TOD) and associated clinical conditions (ACC) were more frequent in specialist setting (57.6 vs 34.3% and 39 vs 28.7%, both P<0.0001). The most common risk factor was age. The most frequently reported TOD was left ventricular hypertrophy (42.3 and 22.1%; P<0.0001). Ischemic heart disease was the most common ACC (21.5 vs 13.1%; P<0.0001). The risk profile was significantly higher in specialist population (75.1 vs 60.3% of patients belonged to high- or very high-risk groups). Specialists and primary care physicians stratified only 54.6 and 48% of their patients correctly, respectively (P<0.05). Both, specialists and general practitioners (GPs) strongly underestimated the risk. Very high-risk patients were adequately assessed only in 44.9% of cases by specialists and in 25.3% by GPs (P<0.001). More than half of the hypertensive patients attended by GPs in Spain belong to the high- or very high-risk groups. GPs and specialists tend to underestimate the cardiovascular risk in daily clinical practice, mainly in very high-risk patients.     

Management of asthma in patients supervised by primary care physicians or by specialists.

French asthma patients may be supervised by general practitioners (GPs) and/or specialists. Therefore, this study examined asthma management in patients exclusively supervised by specialists (SPE), GPs, (GP) and both (GP+SPE group), and compared the findings. Asthma patients were consecutively recruited in 348 pharmacies. Each patient completed a questionnaire providing data on personal characteristics, asthma management, perception of disease and asthma supervision. Asthma control was measured using the Asthma Control Test. Questionnaires were linked to computerised records of medications which had been dispensed before inclusion in the study. From the 1,256 patients (mean age = 36.1 yrs, 54.3% females), 11.4, 36.6, and 52.0% were placed in the SPE, GP, and GP+SPE groups, respectively. During the previous 4 weeks, most patients in the SPE group were properly controlled (52.2 versus 26.4 and 21.5% in GP and GP+SPE groups, respectively). The SPE group made more use of fixed combinations of long-acting beta agonist and inhaled corticosteroid, while receiving less short-acting beta agonists, antitussives and antibiotics. Striking differences in symptoms and asthma management were observed according to the type of asthma supervision. The current results strongly support the need to improve the management of asthma in primary care, and the coordination of care between general practitioners and specialists.     

Part II. General practitioner-specialist referral process

This is the second of two articles that explore the general practitioner (GP)-specialist relationship. In this article, we explore the nature of the referral process, beginning with referrals frequently made by GPs in Australia and reasons for referral to specialists. In Australia, GPs commonly refer patients to specialists, particularly orthopaedic surgeons, ophthalmologists, surgeons and gynaecologists for a variety of reasons, including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient). GPs will choose a specialist after considering a variety of factors, such as the specialist's medical skill, their previous experience with the specialist, the quality of communication between them, office location and patient preferences. The referral is generally made by telephone or by letter, the latter of which is known to vary significantly in content and quality. The specialist, GP and patient expectations of the referral and the consultation process are also described. Specialists expect the GP to provide information about the problem to be addressed and adequate patient history, GPs expect a clear response regarding diagnosis and management as well as justification for the course of action, and patients expect clear communication and explanation of the diagnosis, treatment and follow-up requirements. When these expectations remain unmet, GPs, specialists and patients end up dissatisfied with the referral process.     

Present status of insulin therapy for type 2 diabetes treated by general practitioners and diabetes specialists in Japan: Third report of a cross‐sectional survey of 15,652 patients

Aims/Introduction: Insulin therapy is often required to achieve good glycemic control in patients with type 2 diabetes mellitus. However, some providers, particularly general practitioners (GPs), are reluctant to prescribe insulin to their patients. The aim of the present study was to clarify any differences in, as well as any problems associated with, insulin therapy in patients with type 2 diabetes being treated by either a GP or a diabetes specialist in Japan. Materials and Methods: Of 15,652 patients across 721 clinics and hospitals, 15,350 were diagnosed with type 2 diabetes (14,312 by GPs and 1038 by specialists). Data regarding glycated hemoglobin (HbA_1c) levels, age, height, bodyweight and treatment modality were collected for each patient. Results:  Of the patients with type 2 diabetes, 9.1 and 22.9% had been prescribed insulin monotherapy, and 38.8 and 37.0% were also receiving insulin with an oral antidiabetic (OAD) by GPs or specialists, respectively. Diabetes specialists prescribed analog insulin more frequently than did GPs. GPs chose premixed insulin more frequently than did specialists, and this factor correlated with higher HbA_1c levels. A younger age and daily insulin dose in groups being treated by both providers were correlated with high HbA_1c levels on insulin monotherapy. Neither type of insulin nor OAD was correlated with HbA_1c on insulin plus OAD therapy. Conclusions:  To achieve better glycemic control with insulin therapy, sufficient insulin dose and intensive treatment regimen, in addition to lifestyle interventions, might be necessary. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2012.00198.x, 2012)     

General practitioners' knowledge of and attitudes to inflammatory bowel disease

Background: Inflammatory bowel disease (IBD) is a chronic disease requiring long‐term management. General practitioners (GPs) are often the first point of contact for initial symptoms and flares. Thus we assessed GPs' attitudes to and knowledge of IBD. Methods: A state‐wide postal survey of GPs was performed collecting demographic details, practice and attitudes in IBD‐specific management and knowledge. Results: Of 1800 GPs surveyed in South Australia, 409 responded; 58% were male, 80% Australian trained and 73% practised in metropolitan areas. Most GPs (92%) reported seeing zero to five IBD patients per month. Overall, 37% of the GPs reported being generally ‘uncomfortable’ with IBD management. Specifically, they were only somewhat comfortable in providing/using maintenance therapy, steroid therapy or unspecified therapy for an acute flare. They were uncomfortable with the use of immunomodulators and biologicals (71 and 91% respectively). No GP reported never referring, referring sometimes (12%), often (34%) or always (55%). Most (87%) GPs rated their communication with private specialists positively; while only 32% were satisfied with support from public hospitals. Of concern, most (70%) monitored patients on immunosuppression on a case‐by‐case basis rather than by protocol. In multivariable analyses, GPs' IBD‐specific knowledge did not influence comfort with overall management, nor did knowledge influence GP comfort with any particular therapy. Conclusion: Individual GPs care for few IBD patients and have variable attitudes in their practice. Whether improvement can realistically be achieved given individual GP's paucity of patients is questionable. These data support the provision of better support and specific action plans for IBD patients.     

A randomized controlled trial on office spirometry in asthma and COPD in standard general practice: data from spirometry in Asthma and COPD: a comparative evaluation Italian study

STUDY OBJECTIVES: To evaluate whether office spirometry by general practitioners (GPs) is feasible and may improve the diagnosis of asthma and COPD. METHODS: A prospective, randomized, comparative trial was planned involving 57 Italian pulmonology centers and 570 GPs who had to enroll consecutive subjects aged 18 to 65 years with symptoms of asthma or COPD without a previous diagnosis. Patients were randomized 1:1 into two groups with an interactive voice responding system: conventional evaluation alone vs conventional evaluation and spirometry. Office spirometry was performed by GPs who were trained by reference specialists using a portable electronic spirometer (Spirobank Office; MIR; Rome, Italy). Diagnosis was confirmed by the reference specialist center in blind fashion. RESULTS: Seventy-four GPs complied to the trial. Of 333 patients enrolled, 136 nonrandom violators completed the protocol. Per-protocol analysis showed a concordant diagnosis between GPs and specialists in 78.6% of cases in the conventional evaluation-plus-spirometry group vs 69.2% in the conventional evaluation group (p = 0.35). In the intention-to-treat analysis, the respective percentages of concordant diagnosis were 57.9 and 56.7 (p = 0.87). CONCLUSIONS: Office spirometry by GPs is feasible, but frequent protocol violation and inadequate sample size did not allow us to prove a significant advantage of office spirometry in improving the diagnosis of asthma and COPD in standard general practice as organized at present in Italy, thus reinforcing the need for close cooperation between GPs and specialists in respiratory medicine.     

Underdiagnosis of Nocturnal Symptoms in Asthma in General Practice

Objective. To evaluate the prevalence of nocturnal symptoms in a large sample of asthmatic patients, and to assess the agreement between patients' complaints and general practitioners' (GPs') reports in primary care. Design. Cross-sectional survey involved 3,526 GPs and 751 specialists (pulmonologists and allergists) and included 13,493 patients with persistent asthma. Symptoms, treatment, and social and medical data were collected in real time by the patients and their GPs. Setting. France. Results. Prevalence of nocturnal symptoms was 60%. A total of 7,989 patients with nocturnal symptoms had complete data for both patients and GPs; 3,849 (48.1%) had perfect agreement between GP and their complaints for nocturnal symptoms (agreement group; [kappa = 1]); 3,376(42.2%) declared having no symptoms during the night, but these were detected by the GP during the visit (underestimated by patients and detected by GPs); 773(9.6%) declared having nocturnal symptoms, but these were not detected by GPs. Patients with a good agreement with their GP's opinion were significantly more frequently followed-up by a specialist than other patients (p = 0.002). Conclusions. Nocturnal symptoms appear to be underdeclared by patients. GPs should therefore systematically ask their patients about nocturnal symptoms to increase control of asthma and to adequately manage its treatment.     

The use of a telematic connection for the follow-up of hypertensive patients improves the cardiovascular prognosis

BACKGROUND: Inadequate blood pressure (BP) control could be due to incorrect management of hypertensives caused by the lack of interaction between general practitioners (GP) and hypertension specialists. OBJECTIVES: To test the effectiveness on BP and total cardiovascular risk (TCVR) control of an internet-based digital network connecting specialists and GPs. METHODS: We created a network among the Hypertension Clinic, Federico II University (Naples, Italy), 23 hospital-based hypertension clinics and 60 GPs from the area (CampaniaSalute Network, CS). Randomized GPs enrolled in CS could update online records of patients (n = 1979). As a control, we included 2045 patients referred to the specialist clinics by GPs from outside the network. All patients completed a 2-year follow-up. RESULTS: CS provided a larger reduction in BP [systolic/diastolic BP (SBP/DBP): 7.3 +/- 0.4/5.4 +/- 0.3 versus 4.1 +/- 0.4/3.1 +/- 0.26 mmHg, CS versus control; P < 0.001 for both] and percentage of patients with BP < 140/90 mmHg (CS versus control: baseline, 33 versus 34%, NS; end of follow-up, 51 versus 47%, chi = 13.371; P < 0.001). A European Society of Hypertension-European Society of Cardiology (ESH/ESC) TCVR score was calculated [from 1 (average) to 5 (very high TCVR)]. The CS group showed a reduction in the mean TCVR score (CS: from 3.5 +/- 0.02 to 3.2 +/- 0, P < 0.01, ANOVA; control group: 3.5 +/- 0.03 to 3.4 +/- 0.03, NS) and, accordingly, fatal and non-fatal major cardiovascular events (MACE) were less frequent (2.9 versus 4.3%; chi = 5.047, P < 0.02). CS predicts fewer MACE in multiple binary regression analysis (beta:-7.27, P < 0.008) reducing the risk for MACE compared to control [odds ratio (OR): 0.838; 95% confidence interval (CI): 0.73-0.96]. CONCLUSION: Our results support the idea that telemedicine can achieve better control of BP and TCVR.     

Management of reflux disease in clinical praxis in hungary

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is a chronic condition that affects a large proportion of the population. The majority of patients are treated in the primary care but effective management of the disease still remains a challenge for specialists as well. A recent survey - based on the case of a typical GERD patient - conducted in Germany indicated that mainly specialists adhered to the guidelines. AIM: The purpose of this study was to conduct a survey among specialists and primary care physician members of the Hungarian Society of Gastroenterology about the practical management of GERD using the same questionnaire as in the German study. METHODS: A questionnaire based on the case of a typical patient with GERD was sent out to a total of 1090 members of the society. The questions concerned general measures for avoiding reflux symptoms (dietary and life-style modifications), diagnosis of GERD and the type of treatment. Answers were compared with those in the German study. RESULTS: A total of 421 questionnaires were evaluated (38 %), which had been returned by 174 general practitioners (GP), 173 gastroenterologists (GE), 41 paediatricians, and 33 surgeons. Only 9 % (38/421) of the responders think that there is no necessity to carry out specific diagnostic approaches before starting any treatment. In 91 % of the cases (25 % always and 66 % only if symptoms persist) doctors carry out specific diagnostic tests (75 % endoscopy, 13 % 24 hours pH-metry, and 12 % X-ray). 47 % of responders start drug treatment at once while 35 % start medications only after getting the results of the requested examinations. 18 % of Hungarian doctors do start with a non-medical therapy. Almost all responders feel that it is important to advise a reduction of weight and a cessation of smoking for GERD patients. Altering specific dietary and life-style habits was considered useful by more than 85 % of our responders. Hungarian physicians were more concerned about different alcoholic drinks and spicy, fatty or bloating meals and less about sweets than their German counterparts. More than 85 % of GPs administer some kind of drug therapy as first choice. Over 65 % of GPs are using the step-down approach with proton pump inhibitors as the initial strategy and 78 %, 76 %, and 81 % of GEs, paediatricians, and surgeons, respectively, do the same. Almost one-third of GPs and paediatricians are willing to continue therapy and almost two-thirds of GPs will reduce the dose of current medical therapy if the GERD patient is responding well to the initial therapy. CONCLUSIONS: Irrespective of the country, specialists are adhering more strictly to the guidelines on the diagnosis and treatment of GERD than general practitioners. The majority of responders, however, ask for endoscopy prior to initiation of any medication and use the step-down approach. Despite the lack of scientific evidence, reduction of weight, cessation of smoking, dietary and life-style modifications are still part of the treatment of GERD in both Germany and Hungary.     

How do clinical nurse specialists influence primary care management of asthma? A qualitative study.

METHODS: We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma. RESULTS: Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative. CONCLUSIONS: Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.     

Part I. General practitioner-specialist relationship

This article is the first of a two-part series that seeks to explore the relationship and interaction between general practitioners (GPs) and medical specialists. A historical account of the medical profession is given, beginning from the tripartite division (i.e. the physicians, surgeons or barbers and the apothecaries), the Apothecaries Act of 1815, and the Medical Act of 1858. An account is also given of factors that exacerbated the division and friction between GPs and specialists, and how general practice developed in Australia. The role of the GP is stated as the provision of primary care, preventive care, patient-centred care, continuing care, comprehensive care, and community-based care to individuals and their families. The role of the specialists on the other hand is that of a consultant to advise GPs who carry on the management after the patient leaves the specialist. The dynamics of the GP-specialist relationship are discussed in relation to power, interdependence, morale, public image, education and training, and support from the Colleges, and we conclude by discussing the importance of collaboration between professions.     

Irritable bowel syndrome in general practice: prevalence, characteristics, and referral

BACKGROUND AND AIMS: Little is known about the prevalence, symptoms, diagnosis, attitude, and referral to specialists of patients with irritable bowel syndrome (IBS) in general practice. This study aimed to determine these characteristics. METHODS: 3111 patients attending 36 general practitioners (GPs) at six varied locations in and near Bristol, UK, were screened to identify those with a gastrointestinal problem. These patients (n=255) and their doctors were given questionnaires. Six months later the case notes were examined to reach criteria based diagnoses of functional bowel disorders. RESULTS: Of 255 patients with a gastrointestinal complaint, 30% were judged to have IBS and 14% other functional disorders. Compared with 100 patients with an "organic" diagnoses, those with IBS were more often women and more often judged by their GP to be polysymptomatic and to have unexplained symptoms. The majority of patients with IBS (58%) were diagnosed as such by the GP; 22% had other functional diagnoses. Conversely, among 54 patients diagnosed as having IBS by the GPs, the criteria based diagnosis was indeed functional in 91%; only one patient had organic disease (proctitis). More patients with IBS than those with organic disease feared cancer. In most some fear remained after the visit to the doctor. On logistic regression analysis, predictors of referral to a specialist (29% referred) were denial of a role for stress, multiple tests, and frequent bowel movements. CONCLUSIONS: Half the patients with gut complaints seen by GPs have functional disorders. These are usually recognised, and few patients are referred. In IBS, cancer fears often remain, suggesting unconfident diagnosis or inadequate explanation.     

The management of knee pain in primary care: factors associated with consulting the GP and referrals to secondary care

OBJECTIVES: To investigate the treatment of knee pain in primary care and the factors associated with consulting general practitioners (GPs) and referrals to specialist services. METHODS: Individuals with knee pain were identified through postal questionnaires sent to patients aged 50 and over from two GP practices in southeast London. Patients with knee pain were then invited to the department, where demographic, clinical and service use data were collected. Participants also completed measures of pain, function, handicap and illness beliefs. RESULTS: From the 2940 questionnaires that were sent out, the response rate was 34%. Of these, 49% reported experiencing knee pain in the previous 12 months. Two hundred and thirty-one patients with knee pain attended the department. One hundred and thirty-four (58%) had seen their GP about their knee pain, with 50 (37%) referred on to specialist services. Compared with non-consulters, consulters had more severe disease and higher levels of disability and handicap, and believed the condition was more severe and had major consequences on their lives. Those referred to specialist care had higher levels of handicap and also believed the condition was more severe, with major consequences on their lives, than those not referred. CONCLUSION: In this sample nearly half of those who reported knee pain had not seen their GP and were self-managing their condition. A mixture of physical, social and psychological factors predicted visits to GPs and rates of referral to secondary care. Patient perceptions about knee pain were important predictors of both consultations and referrals, highlighting the need to address both physical and psychosocial factors in relation to help-seeking.     

Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation.

AIMS: The aim of this study was to evaluate an innovative approach to the provision of primary care-based diabetes services in Bradford, UK. The service model differs from others in comprising 19 clinics which offer a specialist service, intermediate between primary and secondary care, to all patients within the Bradford area. METHODS: The study included: analysis of referral, attendance and register data; questionnaires to general practitioners (GPs) and specialist clinic providers; qualitative interviews with clinic and other professional staff and patients; and an economic analysis. RESULTS: The 19 clinics adopt a range of organizational models. In the first 3 1/2 years, 2415 patients were referred. There was a significant reduction in out-patient attendances at hospital, but also a significant increase in overall patient attendances. Specialist clinic patients differed from hospital patients in being older and having had diabetes for longer since diagnosis. Ten of the 14 clinics run by practising GPs attracted more referrals from within their practices than from outside. GPs and patients across the city believed the clinics were valuable, the main benefits being geographical accessibility, availability of specialists in a community setting, short waiting times for first appointments at most clinics, and continuity of staff. Their reservations included a lack of strategic planning in the location of clinics, long waiting times at some clinics, and poor communication at some clinics with referring GPs. The cost of the primary care clinics is similar to hospital clinics. CONCLUSIONS: This model of specialist primary care services offers an opportunity to develop diabetes services that are convenient to patients, popular with practitioners, and increase capacity. However, the shortcomings as well as the advantages of the model need to be addressed if it is to be implemented elsewhere or for other patient groups.     

Underdiagnosis of Nocturnal Symptoms in Asthma in General Practice

Objective. To evaluate the prevalence of nocturnal symptoms in a large sample of asthmatic patients, and to assess the agreement between patients' complaints and general practitioners' (GPs') reports in primary care. Design. Cross-sectional survey involved 3,526 GPs and 751 specialists (pulmonologists and allergists) and included 13,493 patients with persistent asthma. Symptoms, treatment, and social and medical data were collected in real time by the patients and their GPs. Setting. France. Results. Prevalence of nocturnal symptoms was 60%. A total of 7,989 patients with nocturnal symptoms had complete data for both patients and GPs; 3,849 (48.1%) had perfect agreement between GP and their complaints for nocturnal symptoms (agreement group; [kappa = 1]); 3,376(42.2%) declared having no symptoms during the night, but these were detected by the GP during the visit (underestimated by patients and detected by GPs); 773(9.6%) declared having nocturnal symptoms, but these were not detected by GPs. Patients with a good agreement with their GP's opinion were significantly more frequently followed-up by a specialist than other patients (p = 0.002). Conclusions. Nocturnal symptoms appear to be underdeclared by patients. GPs should therefore systematically ask their patients about nocturnal symptoms to increase control of asthma and to adequately manage its treatment.     

Treatment preferences,return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (The General Practitioner Hypertension Practice Study)

Abstract. Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. Design. Mailed case report questionnaires. Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.     

Joint consultation of general practitioner and rheumatologist: does it matter?

OBJECTIVE: To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. METHODS: All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. RESULTS: During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001). CONCLUSIONS: Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.