Predictive value of signs and symptoms for colorectal cancer in patients with rectal bleeding in general practice

The aim of the study is to determine the diagnostic value of(combinations of) signs, symptoms and simple laboratory testresults for colorectal cancer in patients with rectal bleedingpresenting in general practice. Initial complaints and findingswere compared with the final diagnoses based on clinical follow-upafter at least 1 year. Patients studied were those presentingovert rectal bleeding to the general practitioner (83 GPs inthe South of the Netherlands). Outcome measures are sensitivity,specificity, predictive values, odds ratios and a predicitionmodel derived from multiple logistic regression analysis. Age,change in bowel habit and blood mixed with or on stool showa statistically significant independent value in the discriminationbetween patients with a low and those with a high probabilityof colorectal cancer. Many other variables did not show predictivevalue. The prediction model has a sensitivity of 100% and aspecificity of 90%. Although the number of patients with colorectalcancer is small (n=9) it was possible to identify three characteristicswhich can be helpful in the prediction of presence or absenceof colorectal cancer in general practice. Application of themodel presented might prevent 90% of ‘unnecessary’invasive diagnostic procedures for patients with rectal bleedingwho do not have colorectal cancer (true negative). Testing theperformance of the model in other general practice populationsis recommended.     

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

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

WestREN: a description of an Irish academic general practice research network

Background

The intuitive early diagnostic guess could play an important role in reaching a final diagnosis. However, no study to date has attempted to quantify the importance of general practitioners' (GPs) ability to correctly appraise the origin of chest pain within the first minutes of an encounter.

Methods

The validation study was nested in a multicentre cohort study with a one year follow-up and included 626 successive patients who presented with chest pain and were attended by 58 GPs in Western Switzerland. The early diagnostic guess was assessed prior to a patient's history being taken by a GP and was then compared to a diagnosis of chest pain observed over the next year.

Results

Using summary measures clustered at the GP's level, the early diagnostic guess was confirmed by further investigation in 51.0% (CI 95%; 49.4% to 52.5%) of patients presenting with chest pain. The early diagnostic guess was more accurate in patients with a life threatening illness (65.4%; CI 95% 64.5% to 66.3%) and in patients who did not feel anxious (62.9%; CI 95% 62.5% to 63.3%). The predictive abilities of an early diagnostic guess were consistent among GPs.

Conclusions

The GPs early diagnostic guess was correct in one out of two patients presenting with chest pain. The probability of a correct guess was higher in patients with a life-threatening illness and in patients not feeling anxious about their pain.     

Western European best practice in primary healthcare

Objective: To establish how general practitioners (GPs) in the Netherlands diagnose and treat vaginal candidiasis. Methods: Questionnaires were sent to 1160 Dutch GPs. The GPs were asked to make an inventory of the annual number of consultations for vulvovaginal candidiasis. Furthermore, information was requested with regard to diagnostic examinations performed and preferred treatment when dealing with vulvovaginal candidiasis. Results: 380 (32.87%) GPs returned the questionnaire, of which 189 GPs worked in single-person practices (n=189). The group of 380 GPs consisted of 269 (70.8%) males and 111 (29.2%) females. On average, GPs reported 105.6 consultations concerning vaginal candidiasis per practice per year. Only 61 (16.1%) Dutch GPs always or often performed microscopy when diagnosing candidiasis, while 143 (37.6%) GPs never used a microscope to confirm their diagnosis. Furthermore, only 30 (7.9%) GPs regularly took Candida cultures, whereas 154 GPs (40.5%) never took a vaginal swab to diagnose acute candidiasis. Treatment of choice was mostly miconazole (50%) or clotrimazole (24%).

Conclusion: GPs often diagnose “vulvovaginal candidiasis” in their practices, but often do not perform the laboratory examinations required to confirm their putative diagnosis. This may lead to wrong diagnoses and maltreatment with antimycotics, without cure of the patients’ vaginal complaints.     

Self-reported information on the diagnosis of colorectal cancer was reliable but not necessarily valid

OBJECTIVE: Self-report is commonly used in epidemiologic studies; however, few data exist on the reliability and validity of this method for eliciting information related to the diagnosis of colorectal cancer. We examined the test-retest reliability and validity of colorectal cancer patients reporting on the process of their diagnosis. STUDY DESIGN AND SETTING: One hundred and sixteen participants completed two telephone interviews, 1 month apart, and 95 general practitioners (GPs) completed a written questionnaire, to elicit information relating to key elements of the process of diagnosis of colorectal cancer. RESULTS: Acute symptoms such as rectal bleeding had higher reliability and validity than more general symptoms. Colonoscopy was the most accurately recalled diagnostic test. Recall of diagnosis date, and date of colonoscopy, had high test-retest reliability. There were considerable differences between dates of diagnostic tests given by participants and GPs, but there was no evidence of a bias in a particular direction. Accuracy of recall did not diminish as time from diagnosis increased. CONCLUSION: This study confirms that self-reported symptoms, tests, and dates in the colorectal cancer diagnostic pathway are generally reliable; however, the validity of reported symptoms and tests can be moderate to poor.     

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners

Background: Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations.

Objectives: This postal survey asked German GPs about their counselling for end-of-life decisions.

Methods: In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD.

Results: The participation rate was 50.3% (n?=?482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21?min for LWs and 16?min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document.

Conclusion: The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.     

Diabetes and its Long-term Complications in General Practice: a Survey in a Well-defined Population

The aim of this study was to assess the prevalence of long-termcomplications in all patients with non-insulin-dependent diabetesmellitus, who were known to their general practitioners (GPs).During one year 19 GPs in the area of Hoogeveen in the Netherlandsexamined their non-insulin-dependent (NIDDM) patients, includingthose under specialist's care. A detailed protocol was used;the GPs were trained in the diagnostic procedures. Complicationswere either already known from the records or newly discoveredduring screening. In a population of 41940 14.5/1000 patientswith diabetes were identified: 12/1000 NIDDM and 2.5/1000 insulin-dependent-diabetesmellitus (IDDM). Of the 509 NIDDM patients, 387 (76%) couldbe screened for late complications. Signs and symptoms of latecomplications were found in many patients: retinopathy (14%),nephropathy (57%), neuropathy (68%) and macroangiopathy (53%).The prevalence of serious complications was: proliferative retino-and maculopathy (3.3%); diabetic foot (2.6%); renal failure(2.5%). The systemic screening revealed a high number of previouslyunknown cases. It is concluded that many patients with NIDDMdevelop signs and symptoms of late complications. Most casesare identified by systemic screening only. More long-term studiesof the prognosis of late com plications in NIDDM are needed.     

Statistical analysis of referrals by general practitioner at Health Insurance Organization clinics in Alexandria

Referral of patients generates significant economic costs for both physician fees and diagnostic tests. Variation in referral rates between general practices and between individual GPs has long been the focus of attention for policy makers. The present study aimed to analyze the referrals by General Practitioners (GP) at Health Insurance Organization (HIO) clinics in Alexandria. The study was conducted at 18 Health Insurance Organization (HIO) comprehensive clinics in Alexandria, distributed in the 6 districts of Alexandria HIO. Retrospective analysis of records and cross sectional interview to 180 GPs were carried out. Male GPs comprised 82.2% of the sample. On the average, GPs received 6.6 +/- 4.5 patients per working hour. Over the year 2002, 8.4% of consultations were referred to specialists, 5.4% referred to laboratory and only 0.09% were referred to hospital. The highest percent of referrals from GP to specialist were directed to internal medicine followed by orthopedics, general surgery, E.N.T, dermatology, neuropsychiatry, chest then urology clinics. Referral rate from GPs to specialists was found to have a 6.6-fold variation among clinics, and a 54.8-fold variation among individual GPs. Moreover, there was no homogeneity in variations in referral rates of clinics within 3 of the 6 districts. Using multiple regression analysis, the only significant factor was the indirect relation with workload. Comparison of referral rates of GPs with the limits set by HIO (8-17%) revealed that, 48.9% of GPs were within limits, 37.2% were lower and 13.9% were higher than limits. GPs who had diploma or master were average referrers in 51.5%, low referrers in 30.3% and high referrers in 18.2%, compared to 45.6%, 50.6% and only 3.8%, respectively for those with bachelor degree; the difference was statistically significant.     

The clinical assessment of patients with large bowel symptoms by general practitioners

Objective: To describe the nature and extent of the clinical assessment of patients prior to referral for barium enema examinations within a health district in the UK.

Method: By means of a modified barium enema request form, general practitioners' clinical practices prior to making requests for a barium enema examination were examined over the course of one year. Using a request form with a ‘tear-off’ slip, GPs in Hudders-field, UK, were asked to indicate up to two primary reasons for referral, provide some simple demographic details on patients and to indicate what specific clinical activities had been undertaken prior to ordering a barium enema.

Results: Over the course of the one-year study period, 275 modified x-ray request forms were returned. In relation to the 326 primary reasons given for referral these were subdivided into change in bowel habit (101 [42%]), abdominal pain (55 [23%]), frank or occult rectal bleeding (26 [11%]), weight loss (21 [9%]), iron-deficiency anaemia (6 [3%]), and other (117 [49%]). Patients presenting for barium enema examinations were only likely to have had a rectal examination in 72% of situations, an abdominal examination in 89% and a full blood count in 38%. Proctoscopy was very infrequently performed. In relation to the primary reason for referral, 72% had undergone a rectal examination if they had had a change in bowel habit (90% an abdominal examination). If the patients being referred had experienced abdominal pain, 60% of these would have had a rectal examination and 91% an abdominal examination. No significant effect of age on the tendency to perform rectal or abdominal examinations was noted. Any patient presenting for a barium enema was significantly more likely to have had an abdominal than a rectal examination (odds ratio=3.23 [1.99-5.27]).

Conclusions: This study, taken in context, highlights a need to encourage the adoption of a more rational approach to the assessment of patients within primary care settings. Unfortunately the available evidence to assist general practitioners in the diagnosis of colorectal cancer amongst the types of patients they encounter and in the settings where they work remains unsatisfactory.     

Preference for practice: a Danish study on young doctors’ choice of general practice using a discrete choice experiment

Objective

This study examines the preferences of general practitioners (GPs) in training for organizational characteristics in general practice with focus on aspects that can mitigate problems with GP shortages.

Study design

A discrete choice experiment was used to investigate preferences for the attributes practice type, number of GPs in general practice, collaboration with other practices, change in weekly working hours (administrative versus patient related), and change in yearly surplus.

Data collection

In May 2011, all doctors actively engaged in the family medicine program in Denmark were invited to participate in a web-based survey. A total of 485 GPs in training responded to the questionnaire, resulting in a response rate of 56 %.

Principal findings

A mixed logit model showed that GPs in training prefer to work in smaller shared practices (2 GPs). This stands in contrast to the preferences of current GPs. Hence, a generational change in the GP population is likely to introduce more productive practice forms, and problems with GP shortages are likely to be mitigated over the coming years. Results further showed that a majority of the respondents are willing to work in larger shared practices (with 3–4 GPs) if they receive an increase in surplus (approximately 50,000 DKK/6,719 EUR per year) and that they may be willing to take in more patient-related work if the increase in surplus is sufficient (approximately 200,000 DKK/26,875 EUR per year for 5 extra hours per week). Monetary incentives may therefore be an effective tool for further improving productivity.     

Patellar chondropathy in family practice

Aim of the investigation was to study the frequency and prognosis of patellar chondropathy in general practice. As far as the frequency was concerned a secondary analysis was done of data from the Nijmegen Continuous Morbidity Registration (4 general practices, 12,000 patients). The prognosis was studied in patients in these practices with at least one episode of patellar chondropathy in the years 1985-1988. The GPs were asked about the diagnostic criteria they used. The registration showed an average of 6 new cases of patellar chondropathy per 1000 patient-years; in 7% of the cases the GPs referred a patient for specialist care. To study the prognosis patients were asked to fill in a questionnaire. Response was 84%, 178 questionnaires were analysed. The female-male ratio of the respondents was 2, 60% were younger than 60 years. In 44% of the cases the complaints subsided within 6 months. Interventions such as X-ray and physiotherapy depended on severity, duration and frequency of the knee complaints.     

Delay in consulting a medical practitioner about rectal bleeding.

STUDY OBJECTIVE--The aims were to estimate the incidence of rectal bleeding in the community, and to determine the proportion of individuals who delay or fail to seek medical advice after a first episode of rectal bleeding. DESIGN--The data were collected as part of a large scale general population survey of the health practices and attitudes of individuals in a randomly selected sample of 2121 households. SETTING--The survey was conducted in the Newcastle and Lake Macquarie areas of New South Wales, Australia, during 1987-88. PARTICIPANTS--Information about rectal bleeding was collected from 1213 individuals aged 40 years and over. MEASUREMENTS AND MAIN RESULTS--Of the 1213 people aged 40 years and over, 239 (20%) reported noticing rectal bleeding at some time in their life. However, since an estimated 4.5% had noticed rectal bleeding for the first time in the past year the true lifetime incidence of rectal bleeding is likely to be much higher. Of the 77 individuals who had noticed a first occurrence of rectal bleeding more than three months but less than five years prior to the interview, 23 (30%) had either not sought medical advice or had only done so after a period of delay. The most commonly reported reason for delay or failure to consult was thinking that the bleeding was not serious and would clear up by itself. CONCLUSIONS--The data suggest that prompt investigation of rectal bleeding is not occurring in a relatively large proportion of cases. However, in the absence of firm evidence that early detection improves prognosis, and considering the costs of screening, it would be premature to initiate programmes which encourage people to seek care promptly for this symptom.     

Implementation of neuroreflexotherapy for subacute and chronic neck and back pain within the Spanish public health system: Audit results after one year

Controlled randomized trials have demonstrated the efficacy, safety, effectiveness, and cost-effectiveness of neuroreflexotherapy (NRT) for the management of non-specific back pain. In this audit study, we describe the implementation of NRT into the routine practice of primary care within the Spanish public health service of the Balearic Islands and the results obtained after one year (2004). A referral protocol was made available to all general practitioners (GPs) who could refer eligible patients to specialized units in performing NRT interventions. A total of 1209 patients (median age 52 years, 68% women) were referred to NRT by 412 GPs (80% of all GPs), with a mean (standard deviation (S.D.)) referral rate of 1.57 (0.84) patients per month/10,000 persons affiliated to each practice, and an appropriate referral rate of 95.5%. Pain decreased from a median score (visual analog scale) of 8 at baseline to 1 at discharge, referred pain from 7 to 1, and disability (Roland–Morris Questionnaire) from 12 to 1. NRT was refused by 2.7% of patients. Adverse effects related to the procedure were only a skin reaction in 3.3% of patients. We conclude that it is feasible to implement NRT in the public health service complying with methods and application conditions used in previous randomized controlled trials (RCTs). In such conditions, implementation of this technology obtained positive audit results at one year.     

Implementation of neuroreflexotherapy for subacute and chronic neck and back pain within the Spanish public health system: audit results after one year

Controlled randomized trials have demonstrated the efficacy, safety, effectiveness, and cost-effectiveness of neuroreflexotherapy (NRT) for the management of non-specific back pain. In this audit study, we describe the implementation of NRT into the routine practice of primary care within the Spanish public health service of the Balearic Islands and the results obtained after one year (2004). A referral protocol was made available to all general practitioners (GPs) who could refer eligible patients to specialized units in performing NRT interventions. A total of 1209 patients (median age 52 years, 68% women) were referred to NRT by 412 GPs (80% of all GPs), with a mean (standard deviation (S.D.)) referral rate of 1.57 (0.84) patients per month/10,000 persons affiliated to each practice, and an appropriate referral rate of 95.5%. Pain decreased from a median score (visual analog scale) of 8 at baseline to 1 at discharge, referred pain from 7 to 1, and disability (Roland-Morris Questionnaire) from 12 to 1. NRT was refused by 2.7% of patients. Adverse effects related to the procedure were only a skin reaction in 3.3% of patients. We conclude that it is feasible to implement NRT in the public health service complying with methods and application conditions used in previous randomized controlled trials (RCTs). In such conditions, implementation of this technology obtained positive audit results at one year.     

Changes in drug therapy following hospital discharge for patients in a general practice: a German incident study

Objective  In primary care, clinically recommended drug medication is often modified after hospitalization. The aim of the study was to examine the frequency and factors associated with GPs changing the hospital drug treatment in a sample of patients discharged from the hospital. Methods  In a prospective study, the prehospital, hospital and posthospital diagnoses and drug treatment of 130 patients consecutively recruited from 15 general practices were recorded over a period of 12 months. The ICD-10 classification was used to compare the data from hospitals and general practices. GPs who changed the hospital drug treatment were interviewed in a semistructured way concerning their reasons for changing. Results  The most frequent diagnoses during and after hospitalization were listed in the ICD-10 chapters ‘Diseases of the cardiovascular system’ (34.3%) and ‘Endocrine, nutritional and metabolic diseases’ (18%). Accordingly, the most frequently prescribed drug medication was related to these chapters (47.5% and 15.9%, respectively). Hospitalization led to a significant increase in the number of drugs per patient [prehospital 5.4; hospital 6.6; posthospital 6.7; (p < 0.001)]. GPs changed the hospital drug recommendations of the discharge letters in 60.7% of the cases. They omitted drugs in 27.6%, replaced prehospital drug medication in 26.3%, changed to other manufacturers in 9.3%, added new drugs in 13.1% and changed the dosage in 4.2% of the cases. Changes in drug medication correlated significantly with the number of drugs and number of diagnoses (p < 0.001). The most frequently mentioned reason for drug changing by GPs was cost savings (30.3%). But more often they changed drug medication for patient-related reasons (42.4%): ‘better individual drug effect’ in 18.5%, ‘no reasonable indication’ in 17.1% and ‘not related to adequate diagnosis’ in 6.8% of the cases. Conclusion  After hospital discharge, GPs changed more than half of posthospital drug recommendations. Although they believed that economical aspects were the most important reason for their behavior, most drug changes were done for patient-related reasons.     

Quality of care in stroke prevention: results of an audit study among general practitioners

BACKGROUND: In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke. METHODS: Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel. RESULTS: A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) (n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment. CONCLUSIONS: A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.     

Quality of oral anticoagulation in patients with atrial fibrillation: A cross-sectional study in general practice

Objective: To evaluate the quality of management of oral anticoagulation among patients on oral anticoagulation for atrial fibrillation, and to verify the relation between patient performance and the risk of an event due to therapy. Methods: In a retrospective cross-sectional study involving 66 general practices, international normalized ratio (INR) values obtained over a 6-mo period were analysed. All INR values were determined by a single clinical laboratory, and additional medical information was provided by GPs. Results: 395 patients were included in the study, with a mean age of 74±9.6 y. In total, 3111 INR values were obtained. The mean number of tests/month per patient was 2.7±4.3. A total of 49?728 d of therapy was evaluated. Fifty-three per cent of the day values were within 0.5 INR units of the target (and 69% within 0.75 INR units of the target). The incidence rate for major bleeding was 4.4/100 patient years (and 2.9/100 patient years for thromboembolic events). There was a significant relation between patient performance and the presence of an event (p=0.017), with an odds ratio of 2.8 (95% CI 1.3–6.3). Conclusion: The quality of oral anticoagulation in patients with atrial fibrillation is suboptimal. This is significantly related to an increased risk of haemorrhagic events.     

Sexual contact between general practitioner and patient in the Netherlands: prevalence and risk factors

OBJECTIVE: To obtain data on sexual contact between general practitioners (GPs) and their patients and to determine the relationship between sexual abuse and GP characteristics. DESIGN: Cross-sectional. METHOD: In February-May 2002, anonymous questionnaires were mailed to a randomized sample of 1250 general practitioners in the Netherlands. RESULTS: A total of 977 general practitioners responded (response: 80%). This number included relatively large numbers of women and GPs aged > or = 50. Out of the 977 GPs, 32 had had sexual contact with a patient at some time: 30/695 (4.3%) of the male GPs and 2/247 (0.8%) of the female GPs Coitus was reported by 24 (75%) of them. Of the 32 perpetrators 11 (34%) had had sexual contact with 2 or more patients. Of the 30 male GPs who engaged in sexual contact with patients, 20 (67%) afterwards felt positive about the sexual encounter for himself and 22 (73%) for the patient. Sexual contact with a patient occurred more often among men who at the time of the survey were aged < or = 50 [corrected]. The incidence was not related to the degree of urbanisation of the practice area or to the size of the practice partnership. CONCLUSION: Sexual contacts between general practitioners and their patients are not just incidents. It is not enough to be conscious of one's own sexual feelings towards patients. Implementation of a clear policy is needed.     

Frequent attenders in general practice: an attempt to reduce attendance

BACKGROUND: 'Frequent attenders' in general practice are known to include patients with a variety of problems. Most studies of frequent attenders have not assessed the impact of providing GPs with detailed summaries of the clinical records of these patients on consultation rates. Good medical records are associated with good care. If it is not relatively easy or quick for GPs to ascertain which chronic illness or psychosocial problems the patient has from the records, it will be difficult to manage the patient proactively. OBJECTIVE: The aim of this study was to investigate the impact on the consultation rate of providing a detailed and accessible summary of patients' problems including physical, social and psychological data based on information already recorded in the patients' records. METHOD: A prospective controlled study was made of frequent attenders at one UK general practice comprising four full-time GPs. A total of 104 frequent attenders were identified by examining the lists of patients attending the surgery and by including the names of patients identified by GPs from memory. The final study groups were patients who consulted a GP 11 times or more in a year. The sample was divided into two groups. In both groups, the clinical notes were summarized for data relating to physical, social and psychological problems. In the intervention group, summaries were displayed prominently in the notes which were marked with a distinctive label. GPs were asked to read and initial the available summaries in these notes. In the control group, summaries were not included in the notes and the notes were not highlighted in any way. The consultation rate of these 104 patients was recorded for 5 months after the availability of the summaries in the notes. RESULTS: Summarizing the notes in the style described in this study failed to reduce the consultation rate of the identified frequent attenders (Kruskal-Wallis H = 2.75, P = 0.1) Furthermore, in the intervention group, patients for whom there was evidence that the summaries had been consulted by their GP (24; 46%) continued to attend as frequently as those whose summaries were not endorsed as consulted (mean attendance 4.8 consultations compared with 4.2 in 5 months). CONCLUSION: Frequent attenders often have multiple problems, but prominently displayed summaries of their history for use by GPs during consultations do not reduce the frequency of consultations.