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.

     

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

     

A comparison of hospital and general practice blood pressure readings using a shared-care record card

Shared-care blood pressure record cards were issued to 149 consecutive hypertensive patients attending our hospital clinic. In 108 (72.5 per cent), general practitioners entered readings they had obtained onto the cards. The use of the record card has proved helpful in the management of patients, and we are encouraged by the co-operation of the family doctors.

A comparison of blood pressures measured in hospital and in general practice showed that general practitioners found systolic pressures to be an average of 5.5 mm Hg lower than hospital doctors, but there were no differences in diastolic pressure. In many cases, wide discrepancies were found both in hospital and general practice. We conclude that it is a myth that patients' blood pressures are lower when they consult their family doctor, or that outpatient blood pressure readings are falsely elevated by the stress of hospital attendance.

     

Family therapy in general practice: views of referrers and clients.

Family therapy is being used in a variety of settings, including general practice. To assess the views as to the effectiveness and acceptability of a family therapy clinic in a north London surgery, questionnaires were given to general practitioners referring patients, and to clients. Replies were received from seven doctors and 20 clients, representing 11 families. There was a high level of satisfaction among general practitioners referring patients. The clinic proved to be highly acceptable for clients, with 90% agreeing that it was easier to attend a clinic at the practice than at a hospital; and only one patient thought that knowing the general practitioner worked in the practice made it harder to talk openly. Eighty per cent of patients felt the problem had improved at the time of follow up. Where the problem had not improved, 60% felt that they were dealing with it better. Almost all of the patients felt that the family therapy clinic should become a permanent part of local services. The family therapy clinic in general practice has been shown to be effective and popular with users of the service.     

A comparison of blood pressure control in hypertensive patients treated in hospital clinics and in general practice

Two thousand and twenty hypertensive patients of 45 years and over were treated and followed up for either 6 months, 12 months, 18 months or 2 years. Seventeen hundred and forty of these patients were seen in hospital outpatient clinics, 280 in general practice.

The patients followed in general practice had an average blood pressure of 182/111 mmHg prior to treatment. The blood pressure after follow-up for 18-24 months averaged 156/97 mmHg. The corresponding results for the patients followed in hospital clinics were 195/115 mmHg untreated and 150/92 mmHg after follow-up.

The untreated blood pressures were higher in the hospital patients (p < 0·001 for systolic, p < 0·05 for diastolic pressure) and the treated diastolic pressures at 18-24 months were lower in the hospital than the general practice group (p < 0·001). The hospital patients did not receive a greater variety of drugs but were prescribed them in higher doses. Blood pressure control was considered to be inadequate in many patients in both groups. At 18-24 months, 26 per cent of the general practice group had diastolic pressures of 105 mmHg or more, as had 13 per cent of the patients followed in the hospital clinics.

     

A follow-up of self-poisoned patients

Over half the patients who were admitted to hospital after self-poisoning had seen their general practitioner in the previous month, and in half of those discharged from hospital no definite after-care arrangements were made. Opportunities for prevention of occurrences are being missed. Thorough follow-up of 135 such patients identified many non-medical problems, and over 80 per cent were helped by appropriate referral. Although only five of these patients made a further attempt during the period of review, the method of selection of patients does not allow definite conclusions to be made.     

Adolescent patients in an Inner London general practice: their attitudes to illness and health care

A postal questionnaire was sent to 121 patients aged 16-20 years identified from the age-sex register of an Inner London practice; 87 replied. Information was sought about adolescents' perceptions and experience of illness and health care, and their attitudes to preventive medicine. Few of the girls reported that they were in good health; 59 per cent of girls and 23 per cent of boys had visited their general practitioner in the previous three months. Thirty per cent of girls and 15 per cent of boys felt that there was something wrong with their health and in particular that they were overweight. Smoking and drinking were common. Adequate contraception was being practised by most girls.

Detailed interviews with 18 of the respondents identified a number of family problems and difficult relations with staff in hospitals. Most of them considered that good health was not merely a matter of luck.

Adolescents are usually described as being a most healthy group, but this study of an inner city practice suggests that adolescents themselves do not share this view.

     

Long-surviving hypertensives—a 15-year follow-up

In a London suburban general practice 87 hypertensives have been followed up for more than 15 years. These represented one third of all those (270) aged 30-59 diagnosed as being hypertensive. Females outnumbered males by 2·5: 1. Most (85 per cent), had mild or moderate high blood pressure at first diagnosis with a diastolic blood pressure less than 120mm Hg.

At assessment 15-25 years from first diagnosis, 58 (78 per cent) were still alive and of these 51 (58 per cent) were well and had no obvious ill effects; 17 (20 per cent) had complications from their high blood pressures. Deaths occurred in 19 (22 per cent) after more than 15 years of observation.

I suggest that within the condition which we label as hypertension there are many in whom the condition is relatively benign and may be left untreated with hypotensives. These tend to be women rather than men, the older rather than the younger, and those with lower diastolic blood pressures.

Once diagnosed, high blood pressure is not necessarily a progressive condition. In one third (30 per cent) of this group the diastolic blood pressures fell during the period of observation, in 18 per cent it remained unchanged and in 52 per cent it rose.

     

A coronary screening programme in general practice

All male patients between the ages of 37 and 43 were selected from an age-sex register and invited to attend the surgery for coronary screening, which included medical history, family history, occupation, smoking habits, blood pressure, examination of the urine, measurement of weight and height, the taking of an electrocardiogram and chest x-ray, plus fasting blood levels of cholesterol, sugar, triglycerides, lipid electrophoresis, urea, and full blood picture. Sixty-four per cent responded to the invitation and of those, avoidable risk factors were found in 52 per cent.

Forty per cent of those reporting had not previously had their blood pressure recorded. Fifty-eight per cent had not had their urine examined, and 71 per cent had never had a chest x-ray.

Twenty per cent were found to have atypical electrocardiograms (mainly T-wave changes and ectopics) and 20 per cent had sufficiently elevated plasma lipids to justify further electrophoresis. Forty-four per cent of patients admitted to smoking more than 10 cigarettes daily.

Follow-up of the smokers one year later showed that 27 per cent had stopped smoking completely, 12 per cent had reduced their smoking by more than half, 54 per cent had not changed their smoking habits at all, five per cent had given up smoking but started again, and two per cent had either moved away or could not be traced.

I believe such a programme can readily be undertaken in the average general practice and can yield much useful information, such that it is possible to influence patients' smoking habits by advice.

     

Psychiatric services in primary care: specialized or not?

We compare referrals made to a psychiatric service by two comparable general practices. One practice made its referrals through conventional channels; the other referred patients to a multi-professional team who saw patients at a clinic held on the practice premises. The members of the team and the general practitioners in the second practice also met regularly to discuss matters of mutual interest. More patients were referred by this method, which also made greater use of the multiple disciplines involved in psychiatric care.

Patients referred through conventional channels were more likely to have had previous contact with the psychiatric service, were more likely to be admitted to hospital and spent 70 per cent more time as inpatients.

These results confirm the findings of other workers in demonstrating that there are tangible benefits in a multidisciplinary specialist team working in primary care.

     

Reluctance to seek medical advice about breast symptoms

A third of a sample of women with breast symptoms referred by general practitioners to a hospital clinic said they had been reluctant to consult their doctor. Fear, being a nuisance to the doctor, and embarrassment were the three most frequently mentioned reasons for their reluctance. Nearly half of those questioned were prompted to seek medical advice either solely, or partly, because of the thought of breast cancer.     

The diagnosis of pregnancy in general practice

In 1,631 pregnancies presenting to general practitioners, the reliability of three proprietary slide tests for the diagnosis of pregnancy was assessed both against the outcome and against the results of hospital tests done at the same time. When all patients were considered the reliability of such tests done in the surgery was 85 per cent against a 90 per cent for hospital tests and when only patients who were more than 42 days pregnant were included, the accuracy figure rose to 87 per cent in general practice and 91 per cent in hospital.

The time delay before the results of the hospital test was assessed showed a mean of three days which is considered unacceptable if there are urgent clinical reasons for the test being done. The doctors participating listed their reasons for doing tests and in 54 per cent of cases urgent confirmation or otherwise of the pregnancy was considered essential by either doctor or patient. In the remaining 46 per cent this confirmation was considered simply helpful rather than essential. The study showed that the accuracy of the test, when delegated to a nurse, was acceptable and that in a proportion of three to one the participating doctors considered that the test was of value and worthwhile in patient care.

     

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.

     

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.

     

Home and hospital: a comparison of the experiences of mothers having home and hospital confinements

A survey of women delivered in 24 different districts compared the patients' reports of their experiences of delivery in hospital with delivery at home.

Among the findings were that labour lasted a significantly shorter time at home, significantly fewer women were left alone at home, and significantly fewer had episiotomies at home.

Husbands played much more of a role at home and 76 per cent were present at the birth compared with 30 per cent in hospital.

Of the mothers at home 57 per cent held their baby “as long as they wanted” compared with 29 per cent in hospital.

These and other factors suggest that more needs to be done to improve the qualitative aspects of delivery in hospital and especially to promote warmer human relationships within the patient's family.

     

Elderly peoples' experiences of discharge from hospital.

In a study of patients' perceptions of the transition from hospital to the community, 115 elderly people registered with a central London group practice were interviewed shortly after they arrived home. Many patients received little notice of discharge, a third being told on the day they left the hospital. A third felt they had been discharged too soon and those living alone were significantly less likely to return to a heated home containing basic items of food. Seventy-seven patients, including 80% of those living alone were visited by family, friends or professionals within three days of coming home. Eighty-six per cent of non-professional visitors were women. Several of the elderly couples appeared to be under considerable stress and not all individuals were receiving the help they considered most appropriate to their needs. Many of the problems identified were due to poor communication between practice, hospital and patients. We suggest several measures aimed at improving the quality of that communication, so as to ensure that available resources can be mobilized to support this vulnerable group of people.     

Diabetes and its care--what do patients expect?

A sample of 77% of the non-insulin dependent diabetics aged 30-70 years from two urban practices offering no structured diabetic care were interviewed. The 55 patients (mean age 60 years) were asked about their experiences and expectations of diabetes and the health professionals involved in their care. Twenty-six patients attended the hospital diabetic clinic regularly but 13 patients received no review at all; 46 patients wanted their general practitioner to be involved in future care and only six wanted to continue with hospital review alone. Patients gave hospital doctors and general practitioners similar high ratings for knowledge of diabetes and its management but general practitioners and practice nurses were rated more highly for communication and accessibility. The aspect of care valued most was being given clear information about diabetic management. Twenty two patients thought that diabetes would have a significant impact on their future health and 35 rated regular diabetic review as extremely important in keeping themselves healthy. Most patients felt it likely that they would have a high blood glucose level most of the time and develop diabetic complications. Little difference was found between the views of clinic attenders and non-attenders, and there was no evidence that non-attenders had actively rejected review. These non-insulin dependent diabetics considered diabetes to be a serious disorder warranting regular care and expressed confidence in the primary care team's ability to provide such care.     

High blood pressure: public views and knowledge

After completing a screening for hypertension among patients aged between 45 and 54 in a group practice, a sample of both responders and non-responders to screening were surveyed to determine their attitude to screening and knowledge of hypertension.

The reasons for non-response were various, and 18 per cent felt screening to be unnecessary. There was little difference between responders (both hypertensive and non-hypertensive) and non-responders in their knowledge of hypertension, and they were well informed about related conditions and illnesses caused by hypertension. The majority were aware of some likelihood of the disease being symptomless, and 38 per cent thought no symptoms were likely to be caused by hypotensive drugs. They seemed aware that the treatment was long term, but only 14 per cent thought it would be life-long.

     

Evaluation of the RCGP report on the prevention of arterial disease

For this pilot study 349 patients aged between 20 and 64 years were seen following their consultations with their own general practitioners. The recommendations of the recent RCGP report on the prevention of arterial disease in general practice were carried out. An average of seven minutes was spent with each patient. A considerable number of patients had risk factors for arterial disease; 25 per cent of the sample were smokers, 32 per cent were obese and 15 per cent had a single blood pressure reading greater than 150/90. Two new cases of diabetes were discovered.

Case-finding for risk factors for arterial disease, as recommended in the RCGP report, was considered worthwhile but might be most effectively carried out by a suitably trained practice nurse.

     

Problem drug users known to Bristol general practitioners

A 12-month prospective survey was undertaken of all 239 problem drug users known to general practitioners in Bristol and the doctors' attitudes towards them. The drug users were predominantly young, aged 15-35 years, and males outnumbered females by approximately two to one. Seventy-eight per cent had problems associated with opiates, almost invariably heroin, 10% had problems with stimulants (mainly amphetamine powder), and others had problems with hallucinogens, cannabis, barbiturates and solvents. Opiate dependence was the commonest single problem but ill health, hepatitis, psychiatric illnesses, relationship problems, work and financial difficulties were also frequently mentioned.

There was a wide variation in the numbers of problem drug users seen by individual practices, which related both to the situation of the practice and the widely varying attitudes of the partners towards drug users and drug problems. General practitioners were aware of the grapevine that transmits news of their treatment to other users, and individual practices had typically evolved a general strategy for all drug users, to minimize arguments. General practitioners were asked their views about specialist services: they thought that services in the area for drug users were inadequate to help them and their patients in 58% of cases. Several suggestions were made for additional services which were needed.