A community study of diabetes in Oxfordshire

A mailed questionnaire was used to identify people with diagnosed diabetes in a population of approximately 14,000. A response rate of 90 per cent was obtained and the prevalence of diabetes was found to be 0.8 per cent. The questionnaire method compared favourably with other methods of identifying diabetics in the area.

Eighty-two diabetics were interviewed and examined for diabetic complications and 55 of these completed a questionnaire on their attitudes to diabetes and its care.

The medical records of all 108 diabetics identified were examined. A greater proportion of patients who attended either a general practice mini-clinic or a hospital diabetic clinic had examination for complications recorded than patients attending their general practitioner in ordinary surgery time. Patients attending on demand were seen less often and had fewer observations recorded when they came.

Comparison of measures of control between hospital and general practice patients showed that hospital patients tended to be more tightly controlled even though most were on insulin and likely to have more severe diabetes.

Half of non-insulin diabetics and a quarter of those on insulin considered that their diabetes should be managed solely by their general practitioner.

This was a pilot study and caution should be exercised in interpreting results from comparatively small numbers. The study has since been extended to a larger population. f10sl60

     

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

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

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

     

The diabetic, the hospital and primary care

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

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

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

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

     

Acute low back pain: patients' perceptions of pain four weeks after initial diagnosis and treatment in general practice

In a nationwide study of the treatment of acute low back pain with and without radiation in general practice in the Netherlands the subjective well-being of patients was evaluated by means of a short questionnaire sent to patients four weeks after the initial contact with their general practitioner.

After this period pain had disappeared in 28% of the patients, was diminished in 47%, was unchanged in 2% and was aggravated in 4%. There was no difference in the pain score of patients with and without follow-up encounters with their general practitioner. In all instances patients with low back pain without radiation fared significantly better than those with radiation. Radiation of pain was not constant — during the four-week follow-up period it developed in 19% of the patients originally without radiation and it disappeared in 44% of the patients originally suffering radiation.

     

First encounters

Some conclusions are reported from a series of seminars involving several experienced general practitioners over a period of three years. The aim was to examine first consultations in general practice.

We found that these were often handled superficially and that both doctors and patients seemed hesitant in their new relationship. We believe that the loss of a trusted family doctor can create a bereavement reaction in patients, especially where the relationship has been long and when the doctor leaves or dies suddenly.

We are investigating the possibility that the death rate is increased among patients who have recently lost their general practitioner suddenly.

     

The findings reported in patients undergoing excretory urography for recurrent urinary tract infection

There was little difference between the proportion of lesions found by excretion urography in patients with recurrent urinary tract infections referred by general practitioners or hospital staff, or between Horton General Hospital which is a district general hospital, and the United Oxford Hospitals, which is a teaching group. Many patients with urinary tract infections may be saved an unnecessary visit to the hospital consultant if this is first investigated by the general practitioner.

About one fifth of all patients had significant lesions shown by excretory urography which suggests that the investigation is worthwhile in patients with recurrent urinary tract infections.

     

Comparison of the work of a nurse practitioner with that of a general practitioner

The work of a nurse practitioner was compared with that of a general practitioner. Both were equally available to the same patient population over the same period. The nurse practitioner saw a similar age and sex distribution of patients to the doctor but saw different types of problems. More of the patients she saw were for followup of chronic diseases, health advice and screening measures while fewer were acutely ill. The doctor dealt with four times as many patients. The nurse practitioner managed 78% of her consultations without referral to a doctor, and 89% without resorting to prescribed drugs. There was a high level of patient satisfaction with her work and 97% of the patients who saw the nurse would choose to consult her again. The role of the nurse practitioner in our practice has developed differently from a similar post in another setting, thus emphasizing the need for flexibility when defining the role.

Nurse practitioners are a valuable extra resource for the development of new areas of care, rather than a cheaper substitute for a general practitioner.

     

Comparison of outcome of low-risk labour in an isolated general practice maternity unit and specialist maternity hospital

The outcome of labour of 185 low-risk pregnancies at an isolated general practitioner maternity unit was compared with that for 185 comparable low-risk pregnancies at a specialist maternity hospital. No difference was found in mode of delivery or in the proportion of women requiring no analgesia, although significantly more women in the general practice group received analgesia beyond nitrous oxide. There was a significantly higher level of intervention in labour in the maternity hospital group in the form of fetal monitoring and augmentation of labour. The duration of first stage of labour was longer and meconium staining less frequent in the general practice group. Fourteen (7.6%) of the general practice group were transferred in labour to the specialist unit.

The results suggest that where considerations for selection of low-risk pregnancy permit, the general practice maternity unit can provide a distinctive style of intrapartum care with minimum intervention.

     

Specialization in general practice

Ideas about general practitioner specialism may have been hampered in the past because of the three models of general practitioner specialism — in the hospital service, the fee-earning specialoid or the general practitioner obstetrician — none of which is satisfactory.

However, general practitioner specialism can be justified in guaranteeing standards by concentrating groups of patients, accepting responsibility, and planning care. Medico-political changes may be needed to achieve improvement in clinical standards.

     

Total care usage of a defined population

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

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

     

Acute myocardial infarction: an easy diagnosis in general practice?

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

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

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

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

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

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

     

The doctor's deputizing service in a single-handed practice

The out-of-hours calls received by a doctor's deputizing service on behalf of a single-handed general practitioner were studied over the course of one year.

It was found that the overall rate of call (66.3 per 1,000 patients per year) and the rate of night call (10 per 1,000 patients per year) differed little from the rates found by general practitioners who did their own out-of-hours calls. The main users of the service were children under five and women. The time when the service was used least was between 23.00 and 07.00.

It is concluded that employing a deputizing service did not necessarily increase the rate of out-of-hours calls, but that the rate was influenced by the age/sex structure of the practice list. The most economical time to employ the service was found to be from 23.00 to 07.00.

     

Deliberate self-poisoning: implications for pyschotropic drug prescribing in general practice

Several surveys have confirmed that the majority of patients who take an overdose of drugs have seen their general practitioner within the preceding few weeks; as many as a third attend within the previous week.

We studied 130 patients who had taken an overdose and interviewed 122 of the general practitioners. We found that they had identified many interpersonal problems and had usually prescribed psychotropic drugs.

We question the wisdom of this response and suggest other ways of handling such problems in general practice.

     

Terminal care: the role of the general practitioner hospital

A survey of all deaths occurring over a two-year period in a group practice population was carried out to assess the contribution of the local general practitioner hospital to terminal care overall. With the availability of the hospital, the general practitioners were able to provide a higher proportion of terminal care for their patients than in areas where general practitioners did not have access to hospital beds. This was particularly so in terminal care for patients dying of cancer.     

General practitioner prescribing of total parenteral nutrition at home

An increasing number of patients, returning to the community after major surgical procedures, receive short- or long-term total parenteral nutrition at home. As total parenteral nutrition is initiated by specialist hospital centres patients may find themselves a considerable distance from that centre when they return home. The hospital may therefore relinquish responsibility for funding the supply of parenteral fluid to a more local source.

This report describes how total parenteral nutrition can be managed by a general practitioner.

     

Paediatric developmental screening: a survey of general practitioners

A questionnaire survey of 293 general practitioner trainers in England to investigate paediatric screening yielded a response rate of 86%. Paediatric screening sessions were being held by a practice member in the practices of 54% of respondents. In one-third of these practices the practice member was acting in the capacity of clinical medical officer. Of responding trainers 28% held sessions personally and these doctors did not differ significantly from the remainder in terms of sex, seniority, hospital paediatric experience or membership of the Royal College of General Practitioners. About one-third of the doctors holding sessions had spent six months or more working in hospital paediatric departments. First-hand experience of paediatric screening was gained by 60% of the current trainees.

Sixty-one per cent of trainers agreed with the view that developmental screening is an appropriate task for all general practitioners, while 71% saw it as an appropriate task for themselves. Eight-six per cent of trainers agreed that doctors should be paid for this service if trained for it, and 56% that they should be paid regardless of training.

Comparative figures were determined from a parallel survey of 333 non-training general practitioners of whom 225 (68%) replied. Paediatric screening sessions were held in the practices of 34% of respondents and personally by 21%.

It is concluded that there is a high level of interest in paediatric screening among general practitioners, but that there is a need for further expansion in postgraduate paediatric training.

     

Disinfection methods in general practice and health authority clinics: a telephone survey

Concern about the epidemic of the acquired immune deficiency syndrome led to discussions in one health district about the dangers of cross-infection from instruments in general practice and health authority clinics. In order to establish what current disinfection practices were in use a telephone survey was adopted as a quick and easy method of data collection. Information was collected on who was responsible for disinfection as well as details of how each instrument was disinfected. Results from 69 general practices and 21 health authority clinice in one health district are reported.

Some form of sterilizer was used in 63 general practices. These included water boilers (49%), dry heat sterilizers (41%), autoclaves (5%) and pressure cookers (5%). Sixty one practices were using metal vaginal specula and of these 29 were disinfecting by boiling, three were using pressure cookers, 18 dry heat, seven chemical methods, three autoclaves and one the central sterile department of the local hospital. Of those who were boiling after simple washing, three practices boiled for five to 10 minutes and reused instruments during the same clinic. Of the 29 using simple boiling 20 (69%) were boiling for less than 20 minutes.

The study highlights the fact that no formal advice has been given on disinfection practice by the DHSS, the health authorities or the family practitioner committees. The need to set up local guidelines and develop practical steps for their introduction are discussed.

     

The organization of cervical screening in general practice

Well organized cervical screening in general practice can have considerable clinical and financial rewards. Yet in a randomized survey of general practitioners in the United Kingdom only 43% operated a system for cervical screening which allows previously untested women to be identified and invited for testing.

A younger age of general practitioner, a more rural practice, a larger practice size, employment of a practice nurse, a belief in the effectiveness of cervical screening and a positive view of the time spent on screening were all strong predictors of an organized approach to cervical screening within a practice. Being female or having a female partner was not statistically associated with systematic screening. The results demonstrate a need for education within general practice which emphasizes the relevance and significance of cervical screening and the essential contribution that can be made by each individual general practitioner to the success of the whole cervical screening programme.

     

Written advice: compliance and recall

Sixty-two women consulting their general practitioner with symptoms of urinary tract infection were assigned at random to either an experimental group, who were given a set of pre-standardized instructions both verbally and in written form, or a control group, who received the same advice in verbal form only.

On follow-up, the written advice was found to increase the amount of information remembered by the patients both about the medication and other behavioural advice, but to have no obvious effect on compliance with the course of antibiotics prescribed.

Further research is needed, investigating different diseases, to substantiate these findings and help to decide whether patients in general practice should be given written advice.

     

The monitoring of prothrombin time ratios in general practice--a model for chronic disease care?

A small group of ten patients on long-term treatment with anticoagulant drugs were offered the opportunity to attend an anticoagulation clinic run by their general practitioner over a one year period. All had previously been travelling long distances to attend over-crowded hospital clinics. Attendance at general practice clinic was excellent, control of anticoagulation was good and there were no problems advising on dose alterations. The implications of this study for the management of this and other chronic conditions in General Practice are discussed.