A survey of access to medical services in nursing and residential homes in England.

BACKGROUND: Residential and nursing homes make major demands on NHS services. AIM: To investigate patterns of access to medical services for residents in homes for older people. DESIGN OF STUDY: Telephone survey. SETTING: All nursing and dual registered homes and one in four residential homes located in a stratified random sample of 72 English primary care group/trust (PCG/T) areas. METHOD: A structured questionnaire investigating home characteristics, numbers of general practitioners (GPs) or practices per home, homes' policies for registering new residents with GPs, existence of payments to GPs, GP services provided to homes, and access to specialist medical care. RESULTS: There were wide variations in the numbers of GPs providing services to individual homes; this was not entirely dependent on home size. Eight percent of homes paid local GPs for their services to residents; these were more likely to be nursing homes (33%) than residential homes (odds ratio [OR] = 10.82, [95% CI = 4.48 to 26.13], P<0.001) and larger homes (OR for a ten-bed increase = 1.51 [95% CI = 1.28 to 1.79], P<0.001). Larger homes were more likely to encourage residents to register with a 'home' GP (OR for a ten-bed increase = 1.16 [95% CI = 1.04 to 1.31], P = 0.009). Homes paying local GPs were more likely to receive one or more additional services, over and above GPs' core contractual obligations. Few homes had direct access to specialist clinicians. CONCLUSION: Extensive variations in homes' policies and local GP services raise serious questions about patient choice, levels of GP services and, above all, about equity between residents within homes, between homes and between those in homes and in the community.     

Influence of magnetic resonance of the knee on GPs' decisions: a randomised trial.

BACKGROUND: Magnetic resonance imaging (MRI) of the knee for meniscus and ligament injuries is an accurate diagnostic test. Early and accurate diagnosis of patients with knee problems may prevent the onset of chronic problems such as osteoarthritis, a common cause of disability in older people consulting their GP. AIM: To assess the effect of early access to MRI, compared with referral to an orthopaedic specialist, on GPs' diagnoses and treatment plans for patients with knee problems. DESIGN OF STUDY: A multi-centre, pragmatic, randomised controlled trial. SETTING: Five hundred and fifty-three patients with knee problems were recruited from 163 general practices across the UK from November 2002 to October 2004. METHOD: Eligible patients were randomised to MRI or consultation with an orthopaedic specialist. GPs made a concomitant provisional referral to orthopaedics for patients who were allocated to imaging. GPs recorded patients' diagnoses, treatment plans, and their confidence in these decisions at trial entry and follow-up. Data were analysed as intention to treat. RESULTS: There was no significant difference between MRI and orthopaedic groups for changes in diagnosis (P = 0.79) or treatment plans (P = 0.059). Significant changes in diagnostic and therapeutic confidence were observed for both groups with a greater increase in diagnostic confidence (P<0.001) and therapeutic confidence (P = 0.002) in the MRI group. There was a significant increase in within-group changes in diagnostic and therapeutic confidence. CONCLUSION: Access to MRI did not significantly alter GPs' diagnoses or treatment plans compared with direct referral to an orthopaedic specialist, but access to MRI significantly increased their confidence in these decisions.     

Barriers to early diagnosis of cancer in primary care: a needs assessment of GPs

This is the first needs assessment of general practitioners (GPs) in relation to early detection of cancer in the Republic of Ireland. Data was collected using focus groups with 47 GPs and a national survey of 929 GPs. Overall,74.6% of survey respondents had >10 years experience in general practice and 22.7% were single handed. Distance from the practice to the nearest hospital to which they could refer patients for assessment of suspected cancer was <5 miles for 53.3% of GPs. The principle barriers identified were not confined to early diagnosis but apply to the diagnosis of cancer at any stage. These included delayed patient presentation, lack of direct GP access to investigations, difficulty with hospital referral, lack of clear recommendations for screening, poor communication with hospital services, inequitable access to hospital services and a need for further education and clinical practice guidelines. The barriers identified have serious implications for early detection of cancer in primary care and are remedial.     

Management of epilepsy in the community

We posted a questionnaire on epilepsy to all 375 GPs in Cork and Kerry (population 500,000) The questionnaire consisted of 10 sections, covering areas like GP demographics, initial referral practice following a first seizure, advice given to patients and GP's attitudes towards patients with epilepsy. The main focus of the study was GP awareness of 7 of the newer anti-epileptics and their side effects. There was a response rate of 46.7% (175) and revealed that the majority (87%) initially refer patients to a neurologist for further assessment. The majority of GPs gave patients advice about driving, AED side effects, interaction with the OCP and pregnancy counselling. GP awareness of the newer anti-epileptics is very variable with Gabapentin and Lamotrigine having the highest GP awareness rates. Almost 25% of GPs would initiate treatment following a first time seizure although only 30% would change therapy initiated by a consultant neurologist. Finally the majority of GPs were unhappy with the level of access to neurologists and 95% of GPs felt that the provision of an Epilepsy Clinical Nurse Specialist would help alleviate the problem.     

Sex and attitude: a randomized vignette study of the management of depression by general practitioners.

BACKGROUND: The management and detection of depression varies widely, and the causes of variation are incompletely understood. AIMS: To describe and explain general practitioners' (GPs') current practice in the recognition and management of depression in young adults, their attitudes towards depression, and to investigate associations of GP characteristics and patient sex with management. METHOD: All GP principals in the Greater Glasgow Health Board were randomized to receive questionnaires with vignettes describing increasingly severe symptoms of depression in either male or female patients, and asked to indicate which clinical options they would be likely to take. The Depression Attitude Questionnaire was used to elicit GP attitudes. RESULTS: As the severity of vignette symptoms increased, GPs responded by changing their prescribing and referral patterns. For the most severe vignette, the majority of GPs would prescribe drugs (76.4%) and refer the patient for further help (73.7%). Male and female patients were treated differently: GPs were less likely to ask female patients than male patients to attend a follow-up consultation (odds ratio [OR] = 0.55), and female GPs were less likely to refer female patients (OR = 0.33). GPs with a pessimistic view of depression, measured using the 'inevitable course of depression' attitude scale, were less willing to be actively involved in its treatment, being less likely to discuss a non-physical cause of symptoms (OR = 0.77) or to explore social factors in moderately severe cases (OR = 0.68). CONCLUSIONS: Accepting the limitations of the method, GPs appear to respond appropriately to increasingly severe symptoms of depression, although variation in management exists. Educational programmes should be developed with the aim of enhancing GP attitudes towards depression, and the effects on detection and management of depression should be rigorously evaluated.     

Open Access Tubal aSsessment for the initial management of infertility in general practice (the OATS trial): a pragmatic cluster randomised controlled trial

Background

GPs investigate approximately half of all infertile couples with semen analysis and endocrine blood tests. For assessment of tubal status, hysterosalpingography (HSG) is recommended as a first-line investigation for women not known to have comorbidities.

Aim

To test whether providing GPs with open access to HSG results in infertile couples progressing to a diagnosis and management plan sooner than with usual management.

Design of study

A pragmatic cluster randomised controlled trial.

Setting

Seventy-one of 173 general practices in north-east England agreed to participate.

Method

A total of 670 infertile couples presented to 33 intervention practices and 25 control practices over a 2-year period. Practices allocated to the intervention group had access to HSG for those infertile women who fulfilled predefined eligibility criteria. The primary outcome measure was the interval between presentation to the GP and the couple receiving a diagnosis and management plan.

Results

An annual incidence of 0.8 couples per 1000 total population equated to each GP seeing an average of one or two infertile couples each year. Open access HSG was used for 9% of all infertile women who presented to the intervention practices during the study period. The time to reach a diagnosis and management plan for all infertile couples presenting was not affected by the availability of open access HSG (Cox regression hazard ratio = 0.9, 95% confidence interval [CI] = 0.7 to 1.1). For couples who reached a diagnosis and management plan, there was a non-significant difference in time to primary outcome for intervention versus control practices (32.5 weeks versus 30.5 weeks, mean difference 2.2 weeks, 95% CI = 1.6 to 6.1 weeks, P = 0.1). The intracluster correlation coefficient was 0.03 across all practices.

Conclusion

Providing GPs with open access to HSG had no effect on the time taken to reach a diagnosis and management plan for couples with infertility.     

Qualitative study of depression management in primary care: GP and patient goals, and the value of listening.

BACKGROUND: Guidelines for depression management have been developed but little is known about GP and patient goals, which are likely to influence treatment offers, uptake, and adherence. AIM: To identify issues of importance to GPs, patients, and patients' supporters regarding depression management. GP and patient goals for depression management became a focus of the study. DESIGN OF STUDY: Grounded theory-based qualitative study. SETTING: GPs were drawn from 28 practices. The majority of patients and supporters were recruited from 10 of these practices. METHOD: Sixty-one patients (28 depressed, 18 previously depressed, 15 never depressed), 18 supporters, and 32 GPs were interviewed. RESULTS: GPs described encouraging patients to view depression as separate from the self and 'normal' sadness. Patients and supporters often questioned such boundaries, rejecting the notion of a medical cure and emphasising self-management. The majority of participants who were considering depression-management strategies wanted to 'get out' of their depression. However, a quarter did not see this as immediately relevant or achievable. They focused on getting by from day to day, which had the potential to clash with GP priorities. GP frustration and uncertainty could occur when depression was resistant to cure. Participants identified the importance of GPs listening to patients, but often felt that this did not happen. CONCLUSION: Physicians need greater awareness of the extent to which their goals for the management of depression are perceived as relevant or achievable by patients. Future research should explore methods of negotiating agreed strategies for management.     

Do people attending a same day testing clinic discuss their need for a HIV test with their GP?

In the United Kingdom, people with HIV infection present with advanced disease and general practitioners (GPs) are currently an underused resource for HIV testing. We describe the reasons for using an open-access clinic rather than primary care for testing for HIV. People attending the clinic were asked to complete a questionnaire asking about GP registration, access, and whether HIV testing was discussed in primary care. Despite access to GPs, HIV testing in primary care was rarely discussed. If HIV testing is to move to a general practice setting, GPs could address the issues, such as the recording of sensitive information in notes, future life insurance, and confidentiality, which this report identifies as the main barriers for using primary care.     

Effectiveness of GP access to magnetic resonance imaging of the knee: a randomised trial

Background

GPs commonly see patients with knee problems. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test for meniscus and ligament injuries of the knee, but there is uncertainty about the appropriate use of MRI and when it should enter the diagnostic pathway for patients with these problems.

Aim

To assess the effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems.

Design of study

Pragmatic multicentre randomised trial with two parallel groups.

Setting

A total of 553 patients consulting their GP about a continuing knee problem were recruited from 163 general practices at 11 sites across the UK.

Method

Patients were randomised to MRI within 12 weeks of GP referral including a provisional orthopaedic appointment, or orthopaedic appointment without prior MRI within a maximum of 9 months from GP referral. The primary outcome measures were the Short Form 36-item (SF-36) physical functioning scale and the Knee Quality of Life 26-item Questionnaire (KQoL-26) at 6, 12, and 24 months.

Results

Patients randomised to MRI improved mean SF-36 physical functioning scores by 2.81 (95% confidence interval [CI] = −0.26 to 5.89) more than those referred to orthopaedics (P = 0.072). Patients randomised to MRI improved mean KQoL-26 physical functioning scores by 3.65 (95% CI = 1.03 to 6.28) more than controls (P = 0.007). There were no other significant differences.

Conclusion

GP access to MRI yielded small, but statistically significant, benefits in patients'' knee-related quality of life but non-significant improvements in physical functioning.     

The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care.

BACKGROUND: The vast majority of mental health problems present to primary care teams. However, rates of under-diagnosis remain worryingly high. This study explores a GP-centred approach to these issues. AIM: To examine the impact of training in problem-based interviewing (BPI) on the detection and management of psychological problems in primary care. METHOD: The detection and management of psychological problems by 10 general practitioners (GPs) who had received PBI training 12 months earlier was compared with that of 10 control GPs matched for age, sex, clinical experience, and practice setting; and had originally applied for, but had not been able to attend, BPI training. Consecutive attendees at one randomly selected surgery undertaken by each GP were invited to participate in the study. Two hundred and eighty patients living in Newcastle upon Tyne met inclusion criteria and gave informed consent. The presence or absence of psychological problems was assessed using patient self-ratings on the 28-item version of the General Health Questionnaire (GHQ) and blind independent observer ratings of the brief Present State Examination (PSE). Patient satisfaction with interviews was rated using the Medical Interview Satisfaction Scale (MISS). After each consultation, the GPs (blind to subjective and observer ratings) recorded their assessment and management of the patients' problems on a Practice Activity Card (PAC). RESULTS: In comparison with control GPs, index GPs demonstrated significantly greater sensitivity in the detection of psychological problems in the GHQ-PAC ratings. The absolute decrease in misdiagnosis of GHQ cases was 9% and of PSE cases was 15%. Patients meeting GHQ criteria for caseness were more likely to be prescribed psychotropic medication by an index GP than compared with a control GP. Length of interview did not differ between the groups and mean scores on the MISS suggested that patients attending PBI-trained GPs, compared with control GPs, were as satisfied or slightly more satisfied with their consultation. CONCLUSION: In comparison with control GPs, PBI-trained GPs were better at recognizing and managing psychological disorders. The potential benefits of BPI training are discussed in light of other attempts to improve mental health skills in primary care.     

To test or not: A registry-based observational study of an online decision support for prostate-specific antigen tests

BackgroundWatchful waiting is an essential part in the handling of patients with prostate cancer (PC). More effective disease management may be achieved by this strategy. Correct use of prostate-specific antigen (PSA) test is crucial and the general practitioner (GP) may therefore benefit from access to a clinical decision support system (CDSS) that focuses on this challenge. There are many barriers to the use of CDSSs. The aim of the present paper is to study if such barriers may be overcome by granting GPs easier access to a web-based CDSS via a hyperlink in the GPs’ electronic medical record system (EMR).MethodsIn the present population-based observational registry study with an intervention and control group, we created a web-based CDSS that was made accessible to GPs via hyperlink inserted into the EMR medical chart contents. The intervention was introduced 1 January 2011. Our outcome measure was the number of age-standardised PSA test rates per 1000 men per practice during three equally sized periods of 6 months within the study period from 1 January 2010 to 30 June 2011.ResultsWe found that none of the differences between intervention and control groups were statistically significant.ConclusionsProviding GPs with access to a CDSS to aid their decision to use the PSA, had no measurable effect on the GPs’ PSA testing behaviour.     

General practitioner psychological management of common emotional problems (I): Definitions and literature review.

General practitioners' (GPs') treatment of patients with common emotional problems often includes some form of psychological management within the consultation. Such psychological management may be limited to listening and discussion or may also include more specific psychological approaches, such as use of counselling, problem-solving, or cognitive-behavioural techniques. This paper defines GP psychological management and reviews what is known about its frequency and effectiveness. MEDLINE and PsychLIT searches were undertaken of empirical studies of the psychological management of emotional problems by GPs in routine consultations published up to 1998. Thirty-six studies were identified. Most lacked details of the nature of the psychological management reported, making it difficult to compare studies. The frequency of use of psychological management by GPs was found to be generally less when rated by external observers than when assessed by GP self-report. There is preliminary evidence from a few studies of the clinical effectiveness of GP psychological management in routine consultations.     

Monitoring recovery from traumatic brain injury using automated neuropsychological assessment metrics (ANAM V1.0).

Twenty-two students in the Coastline Community College Traumatic Head Injury Program completed two sessions of neuropsychological testing spaced 2-3 months apart, using ANAM V1.0. Eight (GP1) were marginally injured, seven (GP2) mildly, and seven (GP3) moderately. Comparisons of first-session accuracy scores with normative data revealed that GP1 was impaired on one test, while GPs 2 and 3 were impaired on 3 and 4 tests, respectively. Second-session accuracy scores were normal for GPs 1 and 2 on all tests, and impaired on one for GP3. Comparisons of first-session efficiency scores with normative data indicated that GP1 was significantly impaired on 2 tests, while GPs 2 and 3 were impaired on all 6. Second-session efficiency scores were normal for GP1 on 5 tests; GPs 2 and 3 also improved but remained impaired on all 6 tests. Based on efficiency, 91 % of the individuals were correctly classified.     

Cost-effectiveness of magnetic resonance imaging of the knee for patients presenting in primary care

Background

Musculoskeletal problems generate high costs. Of these disorders, patients with knee problems are commonly seen by GPs. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test, but there is uncertainty as to whether GP access to MRI for these patients is a cost-effective policy.

Aim

To investigate the cost-effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems.

Design of study

Cost-effectiveness analysis alongside a pragmatic randomised trial.

Setting

Five-hundred and thirty-three patients consulting their GP about a knee problem were recruited from 163 general practices at 11 sites across the UK.

Method

Two-year costs were estimated from the NHS perspective. Health outcomes were expressed in terms of quality-adjusted life years (QALYs), based on patient responses to the EQ–5D questionnaire administered at baseline, and at 6, 12, and 24 months’ follow-up.

Results

Early MRI is associated with a higher NHS cost, by £294 ($581; €435) per patient (95% confidence interval [CI] = £31 to £573), and a larger number of QALYs, by 0.050 (95% CI = −0.025 to 0.118). Mean differences in cost and QALYs generated an incremental cost per QALY gained of £5840 ($11 538; €8642). At a cost per QALY threshold of £20 000, there is a 0.81 probability that early MRI is a cost-effective use of NHS resources.

Conclusion

GP access to MRI for patients presenting in primary care with a continuing knee problem represents a cost-effective use of health service resources.     

Detection of child mental health disorders by general practitioners

BACKGROUND: Few children with mental disorders access specialist services. Although previous studies suggest that general practitioner (GP) recognition is limited, parents may not be presenting these problems. AIM: To compare GP recognition of disorders with child mental health data and to examine factors affecting recognition, in particular whether recognition is enhanced if the parent expresses concern during the consultation. DESIGN OF STUDY: A two-phase design involving an initial community survey of children between the ages of 5 and 11 years. In the second phase, primary care attenders who were regarded by their GP as having a mental health disorder were compared with those who were not. SETTING: Five general practices in Croydon, outer London. METHOD: For 186 children attending primary care, GP recognition of disorders was compared with the results of a child mental health questionnaire completed by parents. Accuracy and predictors of GP recognition were examined. RESULTS: Seventy-four per cent of children meeting criteria for caseness were not recognised by GPs as having a mental health disorder. The expression of parental concern in the consultation about a mental health problem increased the sensitivity of recognition from 26% to 88%. Expression of concern also increased GP recognition of non-cases; this reflected GP identification of other mental health and learning problems. Only a third of parents who had concerns expressed these during the consultation. CONCLUSIONS: GPs are responsive to concern and take parental views into account. As well as detecting disorders, GPs are also sensitive to other psychosocial and educational problems that may present in primary care. There is a need for parental education about child mental health disorders.     

Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms.

BACKGROUND: Although the vast majority of respiratory tract symptoms are self-limiting, many patients visit their GP for these symptoms and antibiotics are over-prescribed. AIM: To explore determinants of patients visiting GPs for recent cough, sore throat, or earache; for being prescribed antibiotics; and for patients' satisfaction with visiting the GP. Design of the study: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: A total of 7057 adult patients of 163 GPs in the Netherlands. METHOD: Characteristics of patients and GPs as well as morbidity data were derived from the DNSGP-2 and a health interview. Characteristics of the symptoms, GPs' management and patients' satisfaction were measured by an additional written questionnaire. Data were analysed by means of multivariate logistic regression. RESULTS: About 40% of the responders (n = 1083) reported cough, sore throat, or earache in the 2 weeks preceding the interview and, of them, 250 visited their GP. Of this latter group, 97 patients were prescribed antibiotics. Apart from non-medical reasons, relevant medical factors played an important role in deciding to visit the GP. Smokers and patients with cardiac disease or diabetes mellitus were not especially inclined to see their GP. Smoking behaviour, fever, and views on respiratory tract symptoms and antibiotics of patients and GPs were associated with being prescribed antibiotics. Patients' perception of having been carefully examined was associated with their satisfaction, while receiving antibiotics was not. CONCLUSION: GPs should inform patients with clear elevated risk when to visit their GP in cases of cough, sore throat, or earache. There is still a need for GPs and patients to be better informed about the limited significance of single inflammation signs (for example, fever and green phlegm) as an indication for antibiotics. Careful examination of the patient contributes to patient satisfaction.     

Evaluation of Advanced Access in the National Primary Care Collaborative

BACKGROUND: An aim of the National Primary Care Collaborative is to improve quality and access for patients in primary care using principles of Advanced Access. AIMS: To determine whether Advanced Access led to improved availability of appointments with general practitioners (GPs) and to examine GPs' views of the process. DESIGN: Observational study. SETTING: Four hundred and sixty-two general practices in England participating in four waves of the collaborative during 2000 and 2001. METHOD: Regression analysis of the collaborative's monthly data on the availability of GP appointments for the 352 practices in waves 1-3, and a postal survey of lead GPs in all four waves. The main outcome measures were the change in mean time to the third available appointment with GPs, and the proportion of GPs thinking it worthwhile participating in the collaborative. RESULTS: The time to the third available appointment improved from a mean of 3.6 to 1.9 days, difference = 1.7 days, 95% confidence interval (CI)= 1.4 to 2.0 days. It improved in two-thirds of practices (66% [219/331]), remained the same in 16% (53/331), and worsened in 18% (59/331). The majority of GPs in all four waves, 83% (308/371, 95% CI = 79 to 87), felt that it was worthwhile participating in the collaborative, although one in 12 practices would not recommend it. One-fifth of GPs cited a lack of resources as a constraint, and some expressed concerns about the trade-off between immediate access and continuity of care. CONCLUSION: Advanced Access helped practices to improve availability of GP appointments, and was well received by the majority of practices.