Organising unrestricted open access gastroscopy in South Tees.

Increasing demand for upper gastrointestinal endoscopy has forced many clinicians to reconsider the policy of seeing all patients in a specialist clinic before gastroscopy. The following are considered essential in setting up an open access gastroscopy service. (1) Assessment of the need by examination of waiting times for the outpatient clinic and the proportion of patients requiring upper gastrointestinal endoscopy, and consultation with colleagues in general practice. During the first 2 years of the service the average waiting time for a medical gastrointestinal outpatient appointment has fallen from over 120 days to 37 days in this area. (2) An adequately staffed and equipped gastrointestinal unit with well motivated nurses (the workload will increase) and sufficient clinical support to allocate patients to the next available gastroscopy list is vital. A safe mechanism for relaying information back to the GP (including histology reports) is essential otherwise medicolegal problems could arise. Open access gastroscopy now accounts for 29% of the total endoscopy workload in South Tees. (3) Close cooperation between medical and surgical gastroenterologists must be achieved to ensure a uniform approach to the provision of this service and equal distribution of the endoscopy workload. This will require close examination of the potential numbers and may necessitate appointment of a clinical assistant or additional consultant. Clinical assistants perform just over 50% of the open access gastroscopies in South Tees and the waiting time has been kept short (average 17 days). (4) A comprehensive request form with guidelines for GPs and a specific box identifying whether the GP requires a report and brief advice only or follow up at the discretion of the endoscopist (often a clinical assistant) is required. (5) Management must be involved in identifying adequate resources. (6) Methods of monitoring requests and outcome measures to ensure effective audit must be established.     

The incidences of and consultation rate for lower extremity complaints in general practice

OBJECTIVE: To estimate the incidence and consultation rate of lower extremity complaints in general practice. METHODS: Data were obtained from the Second Dutch National Survey of General Practice, in which 195 general practitioners (GPs) in 104 practices recorded all contacts with patients during 12 consecutive months in computerised patient records. GPs classified the symptoms and diagnosis for each patient at each consultation according to the International Classification of Primary Care (ICPC). Incidence densities and consultation rates for different complaints were calculated. RESULTS: During the registration period 63.2 GP consultations per 1000 person-years were attributable to a new complaint of the lower extremities. Highest incidence densities were seen for knee complaints: 21.4 per 1000 person-years for women and 22.8 per 1000 person-years for men. The incidence of most lower extremity complaints was higher for women than for men and higher in older age. CONCLUSIONS: Both incidences of and consultation rates for lower extremity complaints are substantial in general practice. This implies a considerable impact on the workload of the GP.     

Open access echocardiography has diagnostic yield similar to outpatient echocardiography and is highly rated by general practitioners and patients

BACKGROUND: Open access echocardiography is widely available to General Practitioners (GP). There is little data comparing the proportion of echocardiographic studies which are abnormal in open access series with that in hospital outpatient practice. This study compares the diagnostic yield from echocardiograms performed for similar indications by open access and hospital out patient requested groups and assesses the attitudes of GPs and patients to open access echocardiography. METHODS: The reports of 151 consecutive patients who had open access echocardiograms were analysed using predefined criteria for an abnormal study. The reports of 100 consecutive patients who had a new outpatient requested echocardiograms for similar indications were used as the control group. The attitudes of GPs and patients to the open access service were also assessed. RESULTS: Fifty seven percent of patients in the open access group and 51% in the hospital requested group had abnormal studies (p>0.05). 92% of GPs who responded to the questionnaire thought the report was easy to understand while 69% thought it led to a change in patient management. 74% said a clinic referral would have been made without this service and 79% preferred a management strategy to be included in the report. 90% of patients had been informed of the result by their GP. CONCLUSIONS: Open access echocardiography has a diagnostic yield similar to echocardiograms requested on new hospital outpatients in a district general hospital setting. GPs and patients report high levels of satisfaction with this service.     

The proportion of general practitioner referrals to a hospital Respiratory Medicine clinic suitable to be seen in a GPwSI Respiratory Clinic.

AIMS: The purpose of this study was to examine the proportion of general practitioner (GP) referrals to a hospital Respiratory Medicine clinic which might be suitable for a General Practitioner with a Special Interest (GPwSI) Respiratory Clinic. METHOD: All GP referral letters to the Respiratory Medicine Department of a teaching hospital, apart from urgent cancer referrals, were identified from two two-week periods. All patient and practice identifications were removed. Two GPs and one Consultant Respiratory Physician assessed each of the anonymised referral letters to determine the patient's suitability to be seen in a GPwSI Respiratory Clinic, assuming such a clinic had a predetermined range of investigative facilities. RESULTS: Out of 96 referrals covering a wide range of respiratory conditions apart from lung cancer, 22 (23%) were considered by all assessors to be suitable for a GPwSI clinic, and there was full agreement that 40 referrals (42%) were unsuitable. The other 34 referrals (35%) had varying degrees of agreement on suitability. The largest groups of patient referrals considered suitable for a GPwSI clinic were those with chronic obstructive pulmonary disease (COPD) or cough as the main presenting clinical problem. The commonest groups considered unsuitable were referrals of patients with an abnormal chest radiograph, haemoptysis, or possible interstitial lung disease. CONCLUSION: This small study has shown that at least a fifth of GP referrals to a hospital Respiratory Medicine clinic could be seen in a suitably resourced GPwSI clinic, with consequent reductions in hospital outpatient waiting lists and improved accessibility for patients. This finding will be of interest to potential commissioners of GPwSI services especially with the advent of Practice-based Commissioning.     

The management of common gastrointestinal disorders in general practice: A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

BACKGROUND: Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS: We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS: We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION: The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.     

Incidence and prevalence of complaints of the neck and upper extremity in general practice

OBJECTIVE: To study the incidence and prevalence of neck and upper extremity musculoskeletal complaints in Dutch general practice. METHODS: Data were obtained from the second Dutch national survey of general practice. In all, 195 general practitioners (GPs) from 104 practices across the Netherlands recorded all contacts with patients during 12 consecutive months. Incidence densities and consultation rates were calculated. RESULTS: The total number of contacts during the registration period of one year was 1 524 470. The most commonly reported complaint was neck symptoms (incidence 23.1 per 1000 person-years), followed by shoulder symptoms (incidence 19.0 per 1000 person-years). Sixty six GP consultations per 1000 person-years were attributable to a new complaint or new episode of complaint of the neck or upper extremity (incidence density). In all, the GPs were consulted 147 times per 1000 registered persons for complaints of the neck or upper extremity. For most complaints the incidence densities and consultation rates were higher for women than for men. CONCLUSIONS: Neck and upper extremity symptoms are common in Dutch general practice. The GP is consulted approximately seven times each week for a complaint relating to the neck or upper extremity; of these, three are new complaints or new episodes. Attention should be paid to training GPs to deal with neck and upper limb complaints, and to research on the prognosis and treatment of these common complaints in primary care.     

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.     

A rheumatology consultancy program with general practitioners in Catalonia, Spain

OBJECTIVE: To analyze the influence of a primary care rheumatology consultancy program on the number of referrals to the rheumatology unit (RU), the waiting times for new visits at the RU, and the satisfaction of the general practitioners (GPs) with respect to the RU. METHODS: From September 2003 to August 2004 a consultancy program was carried out by 4 consultant rheumatologists of the RU and 117 GPs, consisting of biweekly clinical sessions in which cases were commented upon prior to referral and local clinical guidelines on 10 musculoskeletal disorders were discussed. Referral rates to the RU, 5-item GP satisfaction questionnaires (patient accessibility to the RU, information obtained after the visit, GP accessibility to the RU, communication between levels, and resolution capacity of the RU), waiting times, and number of patients waiting for a visit were analyzed. These variables were compared before and after the intervention. RESULTS: New referrals to the RU significantly diminished during the intervention year (1141 vs 1652 in the previous year, 5.5% patients referred vs 8.1% previous year; p < 0.0001). GP satisfaction improved significantly for all items (p < 0.0001). The waiting time for first non-urgent visit diminished from 7 months to 1 month (p < 0.01) during the intervention year, and the number of patients on the waiting list was reduced from 790 to 51 (p < 0.05). CONCLUSION: A consultancy program between rheumatologists of a RU and GPs of the same area showed improvement in GP satisfaction and reduced the number of referrals to the RU and the waiting times for new non-urgent visits.     

Trends in HIV-related consultation in Dutch general practice.

New medicine against AIDS and a possible changing attitude towards AIDS will affect the role of the general practitioner (GP). We aim to explore and assess the changing role of the GP in preventing and detecting AIDS, which will be done by providing insight into the changing numbers and content of HIV-related consultations in the general practice. Since 1988 a representative sample of 63 Dutch GPs have participated in a network. They recorded all face-to-face consultations with non HIV-infected patients in which the subject of AIDS was brought up. Timetrend analysis is used to investigate variations over time in the number and content of the consultations, GPs' actions and patients' characteristics. The influence of a rural or urban setting and the characteristics of the patients who are involved are also taken into account. Until 1994 a significant increase was found in the number of consultations. In highly urban areas the number of consultations is higher and still growing, whereas physicians in rural areas see fewer patients every year. The most important topic of conversation was the request for an HIV test (74%). This figure grew over the years, as did the number of tests performed. GPs became less passive and restrictive in advising tests. The group of patients has also changed, e.g. patients do not mostly belong to traditional risk groups anymore, and are significantly younger. AIDS seems to have become more familiar to patients and doctors. A lot of general information is available from different sources. Because of this change in attitude and knowledge of patients, the GPs' role as it relates to AIDS is becoming more specific in tracing infected patients and giving customized information to individuals. Patients visit their physicians less often because of concerns about AIDS, but the GP continues to fulfil a very important role in the prevention and detection of AIDS.     

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.     

A randomised study of two training programmes for general practitioners in the techniques of shoulder injection

OBJECTIVES: To evaluate the impact of two different modes of shoulder injection training on the level of confidence and number of injections performed by general practitioners (GPs) METHODS: Demographic details, and information on referrals for shoulder problems, shoulder joint injection activity, and confidence in the six months before training were obtained for 40 GP principals at baseline. Standardised training in the techniques of shoulder joint injection using rubber mannequins was given to all GPs. Twenty of these GPs were randomly allocated to receive additional training on patients in hospital joint injection clinics. Six months after both forms of training the shoulder injection and referral activities of all GPs were reassessed. RESULTS: Both training groups had comparable demographic characteristics and baseline clinical activity. GPs who had additional training with patients reported a marked increase in their level of confidence in performing shoulder injections and the number performed. The number of shoulder referrals did not differ between the groups CONCLUSION: Training on patients in addition to conventional training on mannequins increased GPs' shoulder injection activity and their level of confidence. Hospital injection clinics may provide a suitable setting in which to train GPs interested in developing their shoulder joint injection skills.     

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.     

Co-ordination of Diabetes Care in the Primary and the Secondary Health Care System in Denmark

In Denmark the co-operation between the primary and secondary health care system is organized through referrals. Recommendations for improving interaction between the diabetes team (diabetologists, diabetes nurses, dietitians, chiropodists etc.) at the diabetes clinic, and general practice have been prepared by a working party for the Danish National Board of Health. General recommendations: (a) Appointment of a liaison committee in each county consisting of general practitioners (GPs), diabetologists, administrators, etc. (b) Employment of a GP at the diabetes clinic to take care of improving communication, teaching, research, quality assessment, etc. (c) Referral of all newly diagnosed patients with Type 1 diabetes and younger or complicated patients with Type 2 diabetes to the diabetes clinic. More far-reaching forms of co-operation to be discussed in the liaison committees include: (a) Based upon his own knowledge of where to look for help to solve a specific health problem, the diabetic patient may on his own initiative consult either the diabetes clinic or general practice. (b) Provision of access to consult the diabetes nurse/dietitian at the diabetes clinic for instruction without a formal referral. (c) Patients treated solely in general practice and thus unknown to the diabetes clinic may be referred or reported systematically to the diabetes clinic.     

AN EVALUATED PROGRAMME OF RHEUMATOLOGY TRAINING FOR GENERAL PRACTITIONERS

The management of painful, upper-limb disorders by 34 generalpractitioners (GPs) was examined 3 months before and 3 monthsafter personal instruction of GPs by a consultant rheumatologist.Tuition was conducted either in GP surgeries or a hospital out-patientdepartment. Following instruction there were significant increases in theapplication of appropriate treatments (p<0.0005) and of localcorticosteroid injections by GPs (p<0.005), fewer requestsfor investigations and less-frequent hospital referrals forconsultant rheumatology opinions. Hospital out-patient instructionwas associated with a significant reduction of patients' timeoff work (p<0.005) and, in general, differences of managementappeared to be more pronounced amongst those GPs instructedin the hospital than in GP surgeries. The study showed that personal instruction of GPs by a consultantrheumatologist may result in modifications of practice, at leastin the short term. The evidence indicates that such alterationsof GP management may significantly reduce patient morbidity. KEY WORDS: Rheumatology training, Primary care, General practice     

Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

OBJECTIVES: To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs). METHODS: Four GPs and two RNs were trained in the assessment of early inflammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical findings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA. RESULTS: Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was 0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Significant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions. CONCLUSION: Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.     

Referral patterns between primary care and genitourinary medicine

Many patients attending genitourinary medicine (GUM) clinics are self referred, but some patients initially present to their general practitioner (GP). The aim of this study was to describe the referral pattern of GPs in the Lothian region of Scotland to the local GUM clinic. A questionnaire was completed by all patients referred by their GP and a case note review supplied further diagnostic and demographic information. Of 1140 (23%) patients, 965 were available for study and were referred by their GP. There was a wide variability in referral rates from different practices and from different partners within a practice. The median referral rate per 100,000 practice population was 22.4/year (range 0-586). A referral letter accompanied the patient in 797/965 (83%) cases. The detection of cases of chlamydia and gonorrhoea in patients in primary care subsequently referred to the GUM clinic was low and poor diagnostic acumen for herpes simplex virus (HSV) was notable. No consistent practice for investigation or treatment prior to referral was found and there was marked failure of the investigations initiated in primary care to achieve diagnosis. Despite this, 24% of patients were already on treatment at the time of their GUM consultation. Few STDs were diagnosed in primary care and subsequently referred to the GUM clinic suggesting either failure to diagnose infections or reluctance to refer on for confirmation, treatment, test of cure and health education.     

Strategies to address increased demand for colonoscopy: Guidelines in an open endoscopy practice.

BACKGROUND AND AIMS: Since Medicare approval for reimbursement of screening colonoscopies, the number of colonoscopy requests has increased. Physician resources have often been inadequate to meet the demand. We sought to reduce the demand for colonoscopy in an open endoscopy system by using a guideline-based triage system to eliminate inappropriate procedures and to align the timing of surveillance colonoscopies with recommendations made by national organizations. METHODS: This was a cohort study with primary care outpatients. From October 2002 to February 2003, 498 consecutive patients on a waiting list of 2400 awaiting colonoscopy for all indications were triaged and are the focus of the study. Selection of patients for appropriate colonoscopy was based on consensus guidelines developed for institutional use by using established published guidelines for appropriate colonoscopy indications. RESULTS: Of the 498 consecutive patients triaged, 139 (28%) were deemed inappropriate. The most common reason was inappropriate referral for surveillance of colorectal polyps. The percentage of inappropriate referrals by the 3 largest referring specialties (internal medicine, family medicine, and gastroenterology) combined was also 28% with no statistically significant differences between specialties. CONCLUSIONS: Most referrals for colonoscopy in an open-access endoscopy system were appropriate, although about 1 in 4 were not. Use of triage and further education of physicians regarding colonoscopy may optimize colonoscopy utilization.     

Patients at the outpatient rheumatology clinic: do they really need to be there?

BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.