Diagnosis of lung cancer in primary care: a structured review

BACKGROUND: Lung cancer has the highest cancer incidence and mortality in the UK. Despite this, an individual GP encounters only one new presentation approximately every 8 months, so gains relatively little experience of its diagnosis. This is partly addressed by referral guidelines which aim to help GPs in selection of patients for chest X-ray or referral for specialist investigation. OBJECTIVE: The purpose of this study was to review the primary care presenting features of lung cancer, in the light of the UK Referral Guidelines for Suspected Cancer. METHODS: A structured literature review was carried out. RESULTS: Little research has been undertaken in primary care, and the predictive values for most symptoms are unknown. Approximate likelihood ratios could be calculated for six symptoms or signs: haemoptysis 13; fatigue 5.7; cough 5.3; finger clubbing 3.9; weight loss 2.9; and dyspnoea 1.5-5.7, but none of these figures derived from single primary care studies. Three recommendations for urgent investigation of possible lung cancer in the UK Referral Guidelines are questioned: for unexplained dyspnoea, hoarseness or cervical lymphadenopathy. For all these presentations, other serious diagnoses are more likely. CONCLUSION: The UK Guidelines for referral of suspected lung cancer have a weak evidence base.     

Less haste more speed: factors that prolong the interval from presentation to diagnosis in some cancers

BACKGROUND: In the UK, the GP is the gatekeeper to specialist services in addition to many other roles. Recently, the GP is also expected to select cases that warrant 'urgent' as opposed to 'routine' specialist investigation. Failure to refer on the appropriate timetable may have implications for timely diagnosis. OBJECTIVE: Our aim was to explore the circumstances in which the diagnosis of cancer is delayed with reference to the primary care records and by a structured investigation of clinical records in one practice. METHODS: The study was set in an urban group practice serving a mixed population of deprived and affluent communities. List size was 10 440 patients, with five whole time equivalent partners and three practice nurses. The appointment system was fully computerized and there were no personal lists. Records for all cases with specified common cancers diagnosed since 1990 and still registered in the practice were reviewed. The interval from presentation to referral, referral to diagnosis and presentation to diagnosis was compared for a series of factors including 'urgent' referral. The clinical team currently working in the practice conducted a structured review of the case records for the most delayed cases. RESULTS: Fifty-four cases were listed in the practice. A series of factors were identified as having a bearing on delayed diagnosis, including a reticence on the part of patients to seek to expedite specialist appointments, failures of communication, and patients presenting multiple problems in short general practice consultations. The action plan agreed by the clinical team includes improving the quality of communication with secondary care, follow-up of patients who have been referred for radiological or ultrasound investigation and reviewing patients who fail to attend specialist clinics. CONCLUSIONS: The data imply that delays sometimes result from avoidable errors before and after referral and especially by the patient entering secondary care on the wrong pathway. Improving the patients' experience in health care requires the provider to take a global view of the service. Primary care is not merely a filter but influences and is influenced by policies in other parts of the health care system.     

Minimizing delays in ovarian cancer diagnosis: an expansion of Andersen's model of 'total patient delay'

BACKGROUND: Ovarian cancer symptoms are vague and commonly occur in benign conditions; it often presents late and is diagnosed at an advanced stage when survival rates are poor. Studies of diagnostic delay in conditions with non-specific symptoms are rare. OBJECTIVES: To study accounts of diagnostic delays in a sample of British women with ovarian cancer using Andersen's five-stage model of 'total patient delay' as an analytic framework. METHODS: Semi-structured interviews were conducted with 43 women. Maximum variation sample was recruited via GPs, clinicians, support organizations and personal contacts. RESULTS: Most women reported pre-diagnostic symptoms and diagnostic delays. Patient delays conformed to Andersen's first four types: 'appraisal, illness, behavioural and scheduling' delays. 'Treatment delays', attributable at least in part to a doctor or the health care system, were common and we have broken them down into five categories: non-investigation of symptoms, treatment for non-cancer causes, lack of follow-up, referral delays and system delays. CONCLUSIONS: Our data illuminate the reasons why some British women experience delays in obtaining an ovarian cancer diagnosis. Delays attributable to the women were often compounded by doctor or health service delays, enabling us to expand the fifth stage of Andersen's model. Diagnostic delays in general practice could be minimized by better history taking, explaining the rationale for ruling out non-cancer causes, adopting an 'open-door' policy for patients whose symptoms persist, considering abdominal ultrasound scans and introducing educational sessions for GPs about ovarian cancer symptomatology.     

The assessment of genetic risk of breast cancer: a set of GP guidelines.

BACKGROUND: Assessing a genetic risk for developing breast cancer is not an easy task for a GP. Current expert guidelines for referring and counselling women with a family history positive for breast cancer are complex and difficult to apply in general practice, and have only two strategies (to refer or not to refer for genetic counselling), giving no guidance for the GP on the management of women with a moderately increased risk of familial breast cancer. OBJECTIVES: We aimed to develop a set of simple practical guidelines for use in primary care for assessing risk and advising women with a positive family history in general practice and aimed to explore its performance. METHODS: Based on a consensus meeting of the Leiden working party of hereditary tumours, the GPs of a university-related health care centre developed a set of GP guidelines to assess risk and advise women with a family history positive for breast cancer in general practice. The GP guidelines include four therapeutic strategies (reassuring, starting surveillance, starting surveillance and contacting a family cancer clinic, referring to a family cancer clinic). Its performance was tested in 67 patients whose pedigrees were available together with the risk assessment of a clinical geneticist using Claus' tables as a gold standard. The gold standard was dichotomized regarding (i) referral to a family cancer clinic and (ii) surveillance. Two existing expert guidelines were similarly compared. RESULTS: Regarding referral to a family cancer clinic, the GP guidelines were very specific, whereas the expert guidelines were more sensitive. Regarding surveillance, the GP guidelines were very sensitive, whereas the expert guidelines were very specific. The total number of misclassified patients was lowest when using the GP guidelines, and higher when using the expert guidelines. CONCLUSIONS: The GP guidelines provide a simplification of current guidelines. Before using them on a larger scale, more testing and refining are needed to increase their sensitivity regarding a referral to a family cancer clinic and their specificity regarding surveillance. They incorporate a role for the GP in the care for women with a family history positive for breast cancer with a moderately increased risk.     

Comparison of symptoms in Japanese and American depressed primary care patients.

BACKGROUND: Depression is a highly prevalent, worldwide problem with multiple social and health consequences. It often presents in primary care with physical symptoms. Little research has been done on cross-cultural expression of depression in primary care. This paper examines the hypothesis that depressed Japanese patients present with more and with more distinct somatic complaints than depressed American patients. METHODS: Data were collected by chart audit for patients with a diagnosis of depression at two sites: Minamikawachi Tochigi, Japan and Cleveland, Ohio, USA. Patient demographics and type and number of presenting symptoms in the two populations were compared. Logistic regression was used to determine whether there were differences between countries in physical symptoms and to adjust for relevant demographic characteristics. RESULTS: Japanese family physicians charted more somatic complaints from patients diagnosed as depressed than did American family physicians. Specific physical symptoms differed by country: Japanese patients had more abdominal distress, headaches, and neck pain. These symptoms have strong cultural significance for Japanese patients. CONCLUSIONS: This study clearly indicates the prominence and importance of physical symptoms in the presentation of depression in Japanese primary care patients. Their physicians must be alerted to the possibility of depression, especially when patient complaints include abdominal, neck or head pain.     

Patient factors related to the presentation of fatigue complaints: results from a women's general health care practice

The aim of this study was to examine which patient-related factors predicted: (1) fatigue, (2) the intention to discuss fatigue and (3) the actual discussion of fatigue during consultation with a GP in a women's general health care practice. Patients were asked to complete two questionnaires: one before and one after consultation. The patient-related factors included: social-demographic characteristics; fatigue characteristics; absence of cognitive representations of fatigue; nature of the requests for consultation; and other complaints. Some 74% of the 155 respondents reported fatigue. Compared to the patients that were not fatigued, the fatigued patients were more frequently employed outside the home, had higher levels of general fatigue, and a higher need for emotional support from their doctor. A minority (12%) intended to discuss fatigue during consultation. Of the respondents returning the second questionnaire (n = 107), 22% reported actually discussing their fatigue with the GP while only 11% had intended to do so. In addition to the intention to discuss fatigue during consultation, the following variables related to actually discussing fatigue: living alone, caring for young children, higher levels of general fatigue, absence of cognitions with regard to the duration of the fatigue, and greater psychological, neurological, digestive, and/or musculoskeletal problems as the reason for consultation. Fatigue was found to be the single reason for consultation in only one case. It is concluded that fatigue does not constitute a serious problem for most patients and that discussion of fatigue with the GP tends to depend on the occurrence of other psychological or physical problems and the patient's social context.     

Factors associated with speed of diagnosis, referral, and treatment in colorectal cancer.

Delay in the presentation of symptoms and in referral of patients for surgical opinion remains an important problem in colorectal cancer. Factors influencing patients to consult early include advice from close family or other associates and abdominal pain or vomiting, or both, as one of the early symptoms. More localised rectal symptoms and loss of weight are often associated with long delay. The "classic" symptom pictures are not often seen in the early stages of the disease. Few identifiable factors were associated with delay in referral for surgical opinion. Doctors who examine their patients (rectally or otherwise) refer them sooner. In the districts studied delay in instituting definitive treatment after consultant referral does not seem to be a major problem. There is some evidence that delay is associated with stage of the disease at presentation.     

Diagnostic and therapeutic management of patients with chronic inflammatory bowel disease

BACKGROUND: The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD). METHODS: Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D > 9 and D < or = 9). RESULTS: 258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group D < or = 9 and 62 (24%) to the group D > 9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D > 9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D > 9 had consulted more than one GP vs 14% (p < 0.05). Diagnosis management by the GE was the same in both groups. Patients of group D < or = 9 had more often perceived their symptoms as serious (p < 0.05). CONCLUSIONS: Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.     

Medical care-seeking and health-risk behavior in patients with head and neck cancer: the role of health value, control beliefs and psychological distress

Health behavior plays an important role in the development, detection and course of cancer of the head and neck. Relevant health behavior includes prompt medical care seeking, and smoking and drinking cessation after diagnosis. This study examines the relationship between these health behaviors and health value and control beliefs, as well as psychological distress. Two hundred and sixty-four recently diagnosed head and neck cancer patients were interviewed about their health behavior, and they filled in a questionnaire on health beliefs and psychological distress. The results showed that one-quarter (25%) of the patients had waited more than 3 months before seeking medical care, 50% had continued to smoke and 80% had continued to drink after the diagnosis. The patients, particularly those who smoked and drank before diagnosis, reported lower levels of health value and perceived health competence than a general population sample with which they were compared. Patients who engaged in patient delay reported a lack of perceived health competence. Psychological distress and lack of perceived health competence were found to be more common among patients who continued to smoke. The implications of these findings are discussed with regard to interventions aimed at promoting these specific health behaviors.     

Let's get physical! A study of general practitioner's referral letters to general adult psychiatry--are physical examination and investigation results included?

BACKGROUND/AIM: The authors previously conducted a survey of psychiatrists' attitudes to physical examination and investigations of out-patients. The most common reason for not performing such investigations was the expectation that they had already been undertaken by the general practitioner (GP). We decided to test this theory. METHOD: A series of GP out-patient referral letters to general psychiatry was examined to establish whether findings from physical examination and investigations had been included. RESULTS: One hundred and three letters were examined. None of the letters contained information relating to a physical examination. Only one in twenty had information on investigations despite 4 out of 10 patients in the sample presenting to the GP with somatic symptoms. CONCLUSION: Details of physical examination and blood tests are not routinely included in referral letters to general psychiatry. This may lead to missed diagnoses of primary or secondary physical illness in psychiatric presentations. Unless it is clearly stated in the GP referral letter, it is unwise to assume that necessary investigations to exclude physical causes of presenting symptoms have been performed. Suggestions are made to improve communication between GPs and psychiatrists.     

Isolated headache in general practice: Determinants for delay in referral in patients with subarachnoid haemorrhage

Abstract Background: A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom. Objective: To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP). Methods: For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (>?2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Results: Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral. Conclusion: In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.     

Patient Factors Related to the Presentation of Fatigue Complaints: Results from a Women's General Health Care Practice

ABSTRACT

The aim of this study was to examine which patient-related factors predicted: (1) fatigue, (2) the intention to discuss fatigue and (3) the actual discussion of fatigue during consultation with a GP in a women's general health care practice. Patients were asked to complete two questionnaires: one before and one after consultation. The patient-related factors included: social-demographic characteristics; fatigue characteristics; absence of cognitive representations of fatigue; nature of the requests for consultation; and other complaints. Some 74% of the 155 respondents reported fatigue. Compared to the patients that were not fatigued, the fatigued patients were more frequently employed outside the home, had higher levels of general fatigue, and a higher need for emotional support from their doctor. A minority (12%) intended to discuss fatigue during consultation. Of the respondents returning the second questionnaire (n = 107), 22% reported actually discussing their fatigue with the GP while only 11% had intended to do so. In addition to the intention to discuss fatigue during consultation, the following variables related to actually discussing fatigue: living alone, caring for young children, higher levels of general fatigue, absence of cognitions with regard to the duration of the fatigue, and greater psychological, neurological, digestive, and/or musculoskeletal problems as the reason for consultation. Fatigue was found to be the single reason for consultation in only one case. It is concluded that fatigue does not constitute a serious problem for most patients and that discussion of fatigue with the GP tends to depend on the occurrence of other psychological or physical problems and the patient's social context.     

How will the two-weeks-wait rule affect delays in management of urological cancers?

The UK National Health Service has now specified a maximum interval of two weeks between general practitioner (GP) referral and specialist assessment for patients with suspected cancer. We examined progress through the cancer pathway in 160 patients with potentially curable cancers of the prostate, bladder, kidney and testis before implementation of this rule. Median intervals with interquartile ranges were quantified from the first GP consultation to hospital referral, then to the first hospital consultation, confirmation of diagnosis and definitive surgery. 34% of patients were seen at the hospital within two weeks of referral. The overall median interval from GP consultation to radical surgery was 137 days, the longest being for prostate cancer (median 244). For prostate, bladder and renal cancers the principal element of delay was from the time of diagnosis to surgery (76, 73 and 26 days respectively). These results indicate that, under the two-weeks-wait rule, 2 out of every 3 patients achieve earlier initial assessment. However, the overall delay will not be substantially reduced without concomitant increases in diagnostic facilities, theatre time and human resources.     

Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities

BACKGROUND: Colorectal cancer can present in a variety of ways, and with any of several symptoms. Different referral routes from primary to secondary care cater for these different presentations. The route that has received most investment in the UK National Health Service is the 2-week clinic, but the proportions of patients taking this and other routes to diagnosis are largely unknown. METHODS: We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified. RESULTS: Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short. CONCLUSION: Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources-the 2-week clinic-is used by a minority of patients.     

Delay in starting treatment for tuberculosis in east London

In the United Kingdom there is little information about the delay between the onset of symptoms in patients with tuberculosis and the time it takes for them to be correctly diagnosed and treatment started. We have examined the duration and possible causes of such delay in our own district. The records of 93 patients were examined. Total delay in starting treatment was estimated as the time from the start of symptoms to commencement of chemotherapy. Patient delays were estimated from the time between the start of symptoms to the time taken to first attend their general practitioner (GP) with symptoms. Healthcare system delays were estimated from the interval between first being assessed by their GP and starting anti-tuberculosis treatment. Median total delay was 18 weeks (0-219). The time when patients first presented to their GP was determined for 64 patients: median patient delay was then estimated as nine weeks (range 0-104 weeks), and median healthcare delay five weeks, with a very wide range (0.5-210). Prolonged delay was seen in three patients with cervical lymph node disease. Patient delay was significantly longer than healthcare system delay (p = 0.019). Pulmonary disease was associated with shorter total delay in starting treatment compared with extra-pulmonary disease (p = 0.035). In patients with tuberculosis there were considerable delays in first presentation to medical services, in diagnosis and in starting treatment. Patient delays were longer than healthcare system delays. There is a need to improve awareness of the symptoms of tuberculosis both on the part of the general population and of health professionals, especially in areas of high incidence.     

Do patients want to disclose psychological problems to GPs?

BACKGROUND: GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored. OBJECTIVES: To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care. METHODS: A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity. RESULTS: Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%). CONCLUSIONS: Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.     

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.     

Cluster randomized trial of a multifaceted primary care decision-support intervention for inherited breast cancer risk

BACKGROUND: GPs are increasingly expected to meet the needs of patients concerned about their risk of inherited breast cancer, but may lack skills or confidence to use complex management guidelines. We developed an evidence-based, multifaceted intervention intended to promote confidence and skills in this area. OBJECTIVE: To evaluate the effectiveness of the intervention in improving GP confidence in managing patients concerned about genetic risk of breast cancer. METHODS: DESIGN: Cluster randomized controlled trial. SETTING: General practices in the Grampian region of Scotland. SUBJECTS: GPs and the patients they referred for genetic counselling for risk of breast cancer. MAIN OUTCOME MEASURES: GPs' self-reported confidence in four activities related to genetics; rates of referral of patients at elevated genetic risk; and referred patients' understanding of cancer risk factors. RESULTS: No statistically significant differences were observed between intervention and control arms in the primary or secondary outcomes. A possible effect of the intervention on the proportion of referred patients who were at elevated risk could not be discounted. Only a small proportion of intervention GPs attended the educational session, were aware or the software, or made use of it in practice. CONCLUSIONS: No convincing evidence of the effectiveness of the intervention was found, probably reflecting barriers to its use in routine practice.     

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals

BACKGROUND: Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals. OBJECTIVE: The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s). METHODS: Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups. RESULTS: For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40). CONCLUSIONS: Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.