Factors that influence general practitioners' choice of hospital when referring patients for elective surgery.

To describe the factors that influence general practitioners' choice of hospital when referring patients for elective surgery in three specialties, a postal questionnaire was distributed in January 1991 to 449 doctors who had referred patients to one of six hospitals in the North Western Regional Health Authority. Responses were received from 260 general practitioners (58%). Of the respondents 95% selected 'local and convenient' as a factor that commonly influenced their choice of hospital for at least one specialty and 65% mentioned this across all three specialties. Seventy four per cent mentioned patient preference as influencing choice for at least one specialty and 57% across all three specialties. Only 32% of doctors mentioned waiting times for appointment across the three specialties and 26% waiting times for surgery across the three specialties. When asked to select the single most important factor 'local and convenient' was selected by 33% of general practitioners for a least one specialty, the general standard of clinical care by 28% and waiting time for appointment by 23%. Patient preference was only selected by 6% of doctors as the most important factor. It is of note that 33% of general practitioners perceived there to be no choice of hospital for at least one specialty and 14% thought this to be the single most important influence on choice for at least one specialty. Approximately half the general practitioners (49%) considered it always or often appropriate to give their patients a choice. Most general practitioners received waiting time information from hospitals in their own health district but fewer received such information from hospitals outside their district.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice.

The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity.     

Factors influencing waiting times and consultation times in general practice.

Using data collected from 85 general practitioners in Lothian, large variations were found in the time patients wait for and spend with their doctor. This study, which sets consultations into their administrative framework, examines factors which cause this variation. Consultation time was found to be affected by the total number of patients attending a particular surgery, while waiting time was found to be affected by an individual patient's place within that surgery queue. Taking these two results together suggests that patients seen at the end of large surgeries are likely to get a different service from their doctor than they would have done earlier in the session, or when attending a less busy surgery. Possible strategies are discussed for reducing average waiting times, thereby decreasing the relative cost of consultation to patients.     

Routine treatment of cutaneous warts: a questionnaire survey of general practitioners.

A postal questionnaire was sent to 185 general practitioners to assess their approach to cutaneous warts and their views on the future development of the routine wart treatment service; 159 (85.9%) replied. A wide range of treatments were offered and most patients were given some treatment. The main reasons respondents gave for referring patients to hospital were failure of wart paints (73.6%) and lack of availability of liquid nitrogen (70.4%). Most general practitioners (74.2%) believed that dermatologists should spend less than 5% of their time treating warts. Many general practitioners (61.6%) wanted a practice-based wart clinic offering cryotherapy and 30.8% would like to refer directly to a hospital clinic run by a nurse. A practice clinic was more popular with general practitioners who have a treatment room nurse (P less than 0.01). Most seemed to appreciate the need for training to use liquid nitrogen. We conclude that general practitioners are keen to use cryotherapy and we argue that hospital management should provide the necessary resources for running a community-based service.     

Changes in patient satisfaction and experience in primary and secondary care: the effect of general practice fundholding.

BACKGROUND: The contributions of patients' opinions to the evaluation of health care is widely acknowledged. This study investigates whether the patients of a fundholding practice perceived any changes in the services offered. AIM: To examine the effect of general practice fundholding on patient satisfaction with both primary and secondary care services. METHOD: In April 1992, questionnaires were sent to 180 patients in each of four second-wave fundholding practices and four non-fundholding practices in the former South East Thames region. This took place before any changes were made in the practices as a result of fundholding. Repeat questionnaires were sent 30 months later. RESULTS: The overall response rate was 70% in 1992 and 66% in 1994/1995. Satisfaction levels were generally high for primary care services and changed little over time. There was no evidence to suggest that fundholding GPs were less inclined to prescribe or refer to secondary care services. Waiting times for the first appointment with a consultant in secondary care had reduced between 1992 and 1994 for patients referred from the fundholding practices. However, there were no differences in the time patients had to wait for subsequent treatments or further investigations. One-fifth of the fundholding patients referred to secondary care were seen by the specialist in their doctor's surgery, and those seen in this setting preferred it. CONCLUSION: Patients perceived no major differences in primary care services over the period between the two surveys. There was some evidence of preferential treatment for patients of fundholding practices, but only in waiting times for the first appointment with the secondary care specialist.     

Information about patients'' deaths: general practitioners'' current practice and views on receiving a death register.

BACKGROUND. Although general practitioners are involved in the care of most dying patients, they do not routinely receive information about their deceased patients for whom they did not complete the death certificate, and often they rely upon informal communication channels. AIM. This study set out to assess how general practitioners obtained, recorded and used information about deceased patients and to determine their views on receiving a death register. METHOD. A questionnaire was sent to all 305 general practitioners in the Newcastle upon Tyne and Sunderland Family Health Services Authority areas. RESULTS. A total of 225 questionnaires were returned (response rate 74%). General practitioners usually first learnt about their patients' deaths from hospital discharge summaries (54%) and patients' relatives (46%) and less commonly from newspaper obituary columns (20%) and hospital telephone calls (9%). Two thirds of respondents recorded information about decreased patients, mainly listing personal details and the immediate cause of death. One third or fewer of those recording information listed contributory causes. The information was used mainly for following up bereaved relatives and notifying hospitals and other agencies. CONCLUSION. Current informal systems for handling information about patients' deaths are inadequate. General practitioners need and would welcome prompt, accurate and comprehensive information about all their deceased patients.     

Integrated care for patients with asthma: views of general practitioners.

BACKGROUND. In 1989, a shared or integrated care scheme was developed for hospital outpatients with asthma, using the computerized patient record system of Grampian Health Board, Scotland. Patients with asthma attending hospital clinics were entered into this scheme and were invited to attend their general practitioner instead of an outpatient clinic for review of their asthma. Three-monthly questionnaires covering clinical aspects of asthma were sent to these patients and their general practitioners; the latter then returned them to the specialist. Patients could be recalled to the hospital clinic if either the general practitioner or consultant felt this was necessary and all patients were reviewed after one year by the specialist. The success of integrated care for patients with asthma relies on the cooperation of general practitioners. AIM. The aim of this study was to investigate how this scheme worked in general practice, and general practitioners' perceptions of it, in order to identify factors that enhance or inhibit integrated care for patients with asthma in general practice. METHOD. A qualitative survey was carried out with a random, stratified sample of 38 of the 317 general practitioners in the region. Semi-structured interviews were designed to elicit general practitioners' accounts of their operation of integrated care and their attitudes towards the scheme. RESULTS. General practitioners perceived the scheme to have several advantages: the continuity and quality of care provided was improved; and the transmission of information between general practitioner and specialist was enhanced. Regular general practitioner reviews, instigated by standard letters generated by computer, were favoured as being clearly structured. Concerns were raised about the processing of paperwork, and the possibility that unnecessary reviews might be generated. CONCLUSION. Integrated care for asthma patients is an acceptable management option among general practitioners.     

Time between presentation and treatment of six common cancers: a study in Devon.

The time between a person presenting to a general practitioner with a symptom of cancer and that person starting treatment has been studied in Devon. Retrospective analysis was undertaken of the general practitioner records of 1465 patients proven to have cancer who were registered with 245 general practitioners. During inspection of these records dates of first presentation, of referral, of first hospital consultation and of the start of treatment were noted for people with six common types of cancer (cancer of the breast, large bowel, lung, oesophagus, prostate and stomach). The general practitioner stage time and hospital stage time (pre-appointment and post-appointment) were calculated for each patient. Large differences were found in median times for the general practitioner stage according to the type of cancer, ranging from a median value of 0 days for people with breast cancer to 84 days for people with cancer of the oesophagus. For patients with cancer of the breast, large bowel, lung or prostate, median general practitioner times were shorter than median hospital stage times, while for patients with cancer of the oesophagus and stomach cancer, median general practitioner stage times were longer than median hospital stage times. Comparison of the hospital stage times for people with breast cancer and cancer of the large bowel showed notable differences between the four health districts in Devon, pre- and post-appointment times being twice as long in one district as in another. This retrospective record analysis was acceptable to participating practitioners. The results provide a basis for general practitioners and hospital staff to review their own work.     

Knowledge of HIV infection and AIDS, and attitudes to testing and counselling among general practitioners in Northern Ireland.

All 922 general practitioners in Northern Ireland were sent a questionnaire on human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome (AIDS). Five hundred and ninety four general practitioners (64.4%) returned the questionnaire. Thirty eight respondents (6.4%) knew of an HIV positive patient in their practice and 93.3% felt they should be informed if one of their patients was found to be HIV positive at a genitourinary medicine clinic, even without the patient's consent. Of the respondents, 76.8% were willing to be involved in the management of AIDS patients in their practice in cooperation with hospital colleagues but only 37.5% felt confident to provide AIDS counselling and advice. Of the 368 general practitioners who did not feel confident to provide AIDS counselling and advice, 41.3% felt that they had insufficient knowledge and 79.6% felt uncertain of their counselling skills. The information gathered on the administration of injections, taking blood samples and disposal of needles indicated that further education for general practitioners is required to ensure safety at work.     

Monitoring anticoagulant control in general practice: comparison of management in areas with and without access to hospital anticoagulant.

BACKGROUND. Hospital anticoagulant clinics are available only in some areas. There is little information on the contribution of general practitioners to oral anticoagulant monitoring, and whether their management varies with access to hospital clinics. AIM. A study was undertaken to compare general practice management of anticoagulant therapy in two health boards with contrasting access to hospital clinics. METHOD. A postal questionnaire was sent to the senior partners in all 198 practices in Lothian and Fife, Scotland. RESULTS. Lack of access to hospital clinics in Lothian health board resulted in more practices reporting taking sole responsibility for anticoagulant control than in Fife where there was access (P < 0.001). However, there was no significant difference in management policies. Overall, 93% of practices used a protocol for thrombotest target ranges, but 75% had no policy on review frequency and only 2% assessed complication or failure rates. Reduced access to hospital clinics was associated with a decreased likelihood of favouring hospital involvement. Sole responsibility for anticoagulant management was undertaken by 56% of general practices, although only 21% of doctors viewed this as ideal. Most general practitioners felt that they should monitor patients on anticoagulant therapy but should refer to hospital those with problematic control. CONCLUSION. Access to hospital clinics affected the degree of involvement of general practitioners in oral anticoagulant monitoring, but did not considerably alter their management practice.     

Fundholders'' referral patterns and perceptions of service quality in hospital provision of elective general surgery.

BACKGROUND. The introduction of fundholding established an internal market in public sector health care, involving purchasers and providers contracting for the supply of health care. AIM. This study set out to examine fundholders' hospital referral patterns, and to evaluate the quality of the service provided to patients undergoing elective general surgery, as perceived by fundholding general practitioners. METHOD. A questionnaire was posted to the senior partners of all fundholding practices in the Trent Regional Health Authority area. This questionnaire requested assessments of the importance of 13 specified aspects of service quality and the quality of provision by general practitioners' most frequently-used hospitals. Five-point scales were employed in each case. Respondents were asked to provide additional details about their practice. RESULTS. A 67% response rate was achieved. Confidence in the consultant's ability, short waiting times and informative feedback from the providers emerged as the most important elements in referral decisions, while the cost of treatment and patient convenience received lower importance ratings. In terms of how well their providers were seen to perform, fundholders ranked confidence in the consultant and patient convenience highest, and style of hospital management lowest. The majority of referrals seemed to be local. CONCLUSION. Judged in terms of fundholders' perceptions, sizeable variations in service quality between hospital providers of general surgery are evident.     

Written information to patients in clinical genetics: what's the impact?

In all countries of the European Union, oral information must be given to the patient. Written information is generally optional, but physicians are tending more and more to send a copy of the clinical report to the patient. In this study, we aimed to evaluate the impact on patients of sending them written information after a clinical consultation in a French genetics department. During a period of three months, two geneticists and one genetic counselor offered to send each patient a copy of the letter sent to their general practitioners. A questionnaire was sent with this copy. Three hundred and seventy-five patients were seen and 64% of the questionnaires were sent back. Of these, 99% showed that this practice was considered a good idea, and 80% reported that the letter reflected the clinical aspects well. Seventy-two percent thought that receiving this letter improved their understanding of the clinical situation. In general, patients found the words understandable (83%), too medical (20%) or even shocking (3%). Sixty-three percent said that they would have asked their general practitioner to give them the letter. Their main motivation for wanting a copy of this letter was to remember the information in the future, to have the information to pass on to other physicians involved in their health in the future, or to have information concerning the family. Finally, 58% would have preferred a letter sent specifically to them rather than a copy, and suggestions for the contents of such a letter should be further studied.     

Do patients read health promotion posters in the waiting room? A study in one general practice.

BACKGROUND. General practitioners are aware of the need to provide easily accessible health promotion information for their patients. Although many practices use health promotion posters in their surgeries, there appears to have been no formal evaluation of their effectiveness. AIM. A study was undertaken to investigate whether patients read and remembered waiting room posters, and if so, what factors influenced this. METHOD. A short questionnaire was distributed to patients in one practice following their consultation. It asked what they remembered of the poster display in the waiting room. RESULTS. Of 319 patients attending a doctor during the study period 82% said they had noticed the posters, 95% of whom reported they had also read them. Patients over 50 years of age were significantly more likely to say they had read the posters than younger patients, but significantly fewer showed interest in further information. The sex of patients did not influence their reading of posters or their interest in further health promotion literature. The longer patients had to wait for the doctor, the more likely they were to remember the subject of the posters correctly. Some subjects appeared to attract more patients' attention than others, in particular the displays about smoking cessation and about the human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS). Overall 53% said they would be interested in more information. CONCLUSION. Patients say they read and remember the subject of waiting room posters. Posters in the waiting room can increase awareness of health promotion issues.     

Travelling for earlier surgical treatment: the patient''s view.

As part of the northern region's programme within the national waiting list initiative, schemes have been funded to test the feasibility and acceptability of offering patients the opportunity to travel further afield in order to receive earlier treatment. A total of 484 patients experiencing a long wait for routine surgical operations in the northern region were offered the opportunity to receive earlier treatment outside their local health district; 74% of the patients accepted the offer. The initiative was well received by the participating patients and the majority stated that if the need arose on a future occasion they would prefer to travel for treatment rather than have to wait for lengthy periods for treatment at their local hospital. These findings, interpreted in the light of the National Health Service reforms introduced in April 1991, suggest that for some types of care, patients would welcome greater flexibility in the placing of contracts, not merely reinforcement of historical patterns of referral.     

A national evaluation of specialists' clinics in primary care settings.

BACKGROUND: Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend. AIM: To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics. DESIGN OF STUDY: A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics. SETTING: Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England. METHOD: Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses. RESULTS: In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients clinics, NHS costs were more expensive per patient in outreach. The benefits of outreach clinics on patients' health status at six months' follow-up were relatively small. CONCLUSIONS: Outreach clinics are a means of improving access to specialist services for patients, in addition to improving the efficiency and quality of health care. Most results were similar across specialties and areas. The benefits of the outreach service need to be weighed against their substantially higher NHS costs, in comparison with outpatients clinics. Outreach clinics are unlikely to be financially justifiable for NHS funding given that the impact on patients' health status was small.     

General practitioners' use of community psychiatric nursing services: a preliminary survey.

A questionnaire on general practitioners' use of community psychiatric nursing services was sent to a random sample of 100 general practitioners in two contrasting areas, Croydon and Cambridgeshire. General adult services were widely available though used less often by Cambridgeshire general practitioners than Croyden doctors. Apart from services for the elderly, specialist services were uncommon. Over a third of doctors reported that their adult services were based in a psychiatric hospital. Less than a quarter of general practitioners had access to primary care based nurses. The pattern of responses demonstrates the wide variety of ways in which general practitioners relate to community psychiatric nurses, even where the psychiatric nursing services are long-established. There remains a need for more consistent and coherent policies about the ways in which community psychiatric nurses are employed in primary care.     

One-year prospective study of cases of suspected acute myocardial infarction managed by urban and rural general practitioners.

BACKGROUND: The role of the general practitioner in the management of patients with suspected acute myocardial infarction is important and specific. It has been recommended that eligible patients should receive thrombolysis within 90 minutes of alerting medical or ambulance services. The administration of prehospital thrombolysis by general practitioners is controversial. Most research into the management of acute myocardial infarction has been hospital based and has not explored differences between urban and rural general practice. AIM: In 1993-94 a one-year prospective survey was undertaken of samples of urban and rural general practitioners to examine their management of cases of suspected acute myocardial infarction and to determine whether differences in management existed between the two settings. METHOD: General practitioners were recruited through the continuing medical education faculty network of the Irish College of General Practitioners. Participating general practitioners completed a report form for cases of suspected acute myocardial infarction. Six-week follow-up forms were also completed. RESULTS: A total of 113 general practitioners (54 urban and 59 rural) participated in the study. A total of 57 general practitioners contributed 195 cases, 49 from urban and 146 from rural areas. The mean number of cases of suspected acute myocardial infarction per participant for urban and rural doctors was 0.9 and 2.5, respectively. Median delay time from onset of symptoms to contacting the general practitioner was 90 minutes for both urban and rural patients. Median general practitioner response times for urban and rural doctors were 10 and 15 minutes, respectively. Median estimated journey times from location of the patient to hospital for urban and rural patients were 10 and 40 minutes, respectively (P<0.001). Rural doctors were more likely, in comparison with their urban counterparts, to administer aspirin (given to 40% of patients versus 16%, P<0.01) but less likely to administer intravenous morphine (26% versus 41%, P<0.05). Twenty one patients (11%) died at the scene; follow-up forms were received for 94% of the remaining patients. Of these 163 patients, 99% were admitted to hospital; 49% were discharged with a diagnosis of acute myocardial infarction and a further 25% had final diagnoses consistent with acute coronary heart disease. CONCLUSION: This study suggests that the management of patients with suspected acute myocardial infarction differs in urban and rural settings. Delay times suggest that in order to meet current guidelines, prehospital thrombolysis must become a reality in rural areas.     

Appropriate place of death for cancer patients: views of general practitioners and hospital doctors.

BACKGROUND. The majority of cancer patients in the United Kingdom die in a National Health Service hospital, a setting that is contrary to the wishes of those patients expressing a preference to die elsewhere, for example at home or in a hospice. AIM. A study was undertaken to determine clinicians' views of the appropriate place of death for cancer patients and to examine factors leading to patients being admitted to a hospital specialist services unit where they died. METHOD. A questionnaire was sent to all general practitioners and hospital doctors who had cared for cancer patients who had died between May 1991 and April 1992 in a single health district. The appropriateness of the place of death, whether the patient was terminally ill, reasons for hospital admission and effect on management had different resources been available were determined. RESULTS. A total of 1022 deaths attributable to cancer were recorded for patients registered with general practitioners in the study area. Questionnaires were returned by general practitioners for 951 of the deaths (93%); hospital doctors returned questionnaires for 216 out of 268 patients (81%) who had been admitted to hospital under the care of a consultant. For deaths which had occurred at home, in a community hospital, residential/nursing home or Marie Curie hospice, the place of death was considered appropriate by general practitioners in over 92% of cases. For deaths in the hospital specialist services unit the place of death was considered probably or definitely appropriate by general practitioners in 83% of the 212 cases, but not appropriate in 17% of cases (P < 0.001 compared with all other settings). Hospital doctors considered 27% of deaths in the unit inappropriate. Significantly fewer cases fulfilled the criteria for terminal illness (death expected and palliative treatment commenced) according to general practitioners among those dying in the specialist services unit compared with deaths elsewhere (P < 0.001). The most common main reasons for admission to the specialist services unit were for investigation, because of difficult symptom control (apart from pain) and for curative/active treatment. General practitioners reported that management of between a sixth and a quarter of patients admitted to the specialist services unit would have been affected by the availability of 24-hour home cover, community hospital beds and a city-based hospice. Among the group of patients fulfilling the study criteria for terminal illness, the effect of other services on patient management would have been considerably higher. CONCLUSION. A greater proportion of cases where patients died from cancer in settings other than a specialist services unit were considered appropriate by general practitioners compared with deaths in a specialist services unit. For a considerable minority of patients, death in a specialist services unit was not considered appropriate by the general practitioners or by the hospital doctors. Improvements in local hospice facilities, community hospitals and community support would mean that a substantial proportion of hospital admissions could be avoided and thus cancer patients could die in more appropriate settings.     

Management of angina pectoris in general practice: a questionnaire survey of general practitioners.

BACKGROUND. Little is known about the current management of angina pectoris in general practice. AIM. This survey set out to assess general practitioners' perceptions of current investigation and treatment for angina pectoris. METHOD. A postal questionnaire was sent to all 217 general practitioners listed with the Hampshire Family Health Services Authority who have access to a regional cardiac centre in Southampton. RESULTS. The response rate was 79% (171 of 217). The majority (80%) of general practitioners reported referring 10% or fewer of their patients with angina to a cardiologist at the regional centre, and 72% reported referring a quarter or fewer of their patients to a hospital physician. Most (77%) considered an exercise test useful for diagnosis of angina, but almost half (47%) were uncertain about its prognostic value. Most respondents (79%) were not confident of interpreting the results of an exercise test. The majority (79%) believed that there was scientific evidence to show that coronary angioplasty relieves symptoms and 21% were of the opinion that it prolongs survival. Ninety six per cent believed coronary artery bypass grafting relieves symptoms and 62% that it prolongs survival. CONCLUSION. General practitioners do not appear to refer the majority of patients with angina pectoris for hospital investigation, and express divergent and contradictory opinions about exercise testing and the scientific evidence for the benefits of coronary angioplasty and coronary artery bypass surgery. Easier access to cardiological investigation and population based data about the value of exercise testing and survival benefits from coronary intervention are required to optimize selection of patients in the community who are most likely to benefit from coronary revascularization.