Survey and audit of diabetes care in general practice in south London.

A survey was made of the diabetic care given by general practitioners in six family practitioner committee areas. Replies were received from 388 practices, representing 1034 principals (effective response rate 69%), serving over two million patients. Fourteen per cent of practices offered mini-clinic facilities for their diabetic patients, although a much greater proportion professed to give either full or shared care to patients in ordinary surgery time. One quarter of practices kept a diabetes register, but fewer had a system of recall for patients to ensure anticipatory care. The barriers which general practitioners most often perceived in the provision of adequate care for diabetics were: lack of time, absence of a recall system and deficiency in their own clinical skills. Seventy seven of the doctors responding to the initial questionnaire participated in an audit of the level of supervision provided for 378 of their diabetic patients. Better levels of supervision of non-insulin dependent diabetics were shown in those practices where diabetes registers were kept, and where special arrangements were made for caring for diabetes. The levels of care provided by those doctors setting aside specific clinic times were not demonstrably superior to those who did not. The findings suggest that provision of support services, particularly expertise in dietetics, would help to increase general practitioners' confidence and enable more of them to improve their care of diabetic patients.     

The outcome of hidden neurotic illness treated in general practice

One thousand patients attending a general practice surgery were asked to complete the general health questionnaire as the first stage of screening for hidden minor psychiatric disorders. Those who had an unexpectedly high score of 20 or more were randomly allocated to doctors or health visitors for treatment. After one year, these two groups were reinterviewed by the doctors and health visitors respectively and comparable rates of recovery were found. After five years, they were interviewed again and a second general health questionnaire completed. It was found that both groups had improved significantly, and that there was no significant difference between them.

Poor outcome was associated with problems with children, household or neighbours and with a previous history of psychiatric illness. Improvement was associated with physical treatment of the original disorder, resolution of the original problem and job satisfaction.

The implication of these findings for the comparative management of minor psychiatric disorders by general practitioners and non-medical health workers in primary care are discussed.

     

Clinical effect of computer generated physician reminders in health screening in primary health care--a controlled clinical trial of preventive services among the elderly

OBJECTIVES: To apply and evaluate the effects of a program for computer generated physician reminders, integrated with an electronic patient record (EPR) system, for opportunistic health screening in elderly patients. DESIGN: A pilot study designed as a 20-month clinical trial with a control group and a 20-month non-intervention follow-up using a computer reminder program that selects patients for screening in five intervention areas (diabetes, hypertension, cobalamin deficiency, hypothyroidism and anaemia). SETTING: Four primary health care (PHC) centres in suburban Stockholm. SUBJECTS: The intervention was designed for patients 70 years or older from one health care centre who visited a general practitioner (GP) during the first 20-month period. Patients from the three remaining centres served as controls. MAIN OUTCOME MEASURES: The number of patients who underwent the tests, who had pathological test results, new diagnoses and new pharmacological treatments in both patient groups. RESULTS: In total, 602 patients underwent screening and 1989 were controls. There was a statistically significant, moderate or marked increase (13-75%) in the number of patients who were tested in all five intervention areas. An increase in pathological test results (1-8%) was found in two areas: hypertension and cobalamin deficiency. There was an increase in the number of patients with the diagnosis of cobalamin deficiency during the study. At follow-up a decrease in new diagnoses for anaemia was found. CONCLUSION: The system seems to be associated with a moderate to large increase in laboratory and manual screening tests for both established and new screening areas. The effect on clinical outcomes was found mainly in a not-yet-established screening area (cobalamin deficiency), indicating that the system may be clinically useful when introducing new screening services.     

Minimum data set necessary to promote the care of the elderly in general practice

A preliminary data set was designed to allow uniform information collection, to initiate structured intervention and thereby to promote anticipatory care of the elderly. A questionnaire inviting comment on the data set was sent to 116 general practitioners in training practices and 40 consultants in geriatric medicine in the northern region and also to the 18 professors in general practice in the United Kingdom. The response rates from the three groups were 76%, 55% and 67% respectively.

There was good agreement between the three groups regarding the content of the data set suggesting that it may be possible to introduce uniform information collection which in turn would standardize records of the elderly and aid computerization.

The need for periodic screening of the elderly was considered necessary by 37% of general practitioners, 59% of consultants and 33% of professors. The cause of such low interest in screening and its effect on computerized care and surveillance of the elderly are discussed.

     

Will the future GP remain a personal doctor?

During the past three decades, general practice has evolved into a form of primary health care that provides a wide range of reactive, anticipatory, and preventive services, and now also purchases secondary care. As a result, practices now have more staff and more complex patterns of organization. However, most patients prefer smaller practices and personal list systems. There is a danger that a core feature of general practice--personal care--is gradually being eroded. If this trend is to be halted, the organization of general practices and the support available to them must be revised so that they can continue to provide personal care, yet also offer a wide range of effective services in the community.     

Risk factors for complex care needs in general medical inpatients: results from a European study

The authors linked admission risk factors to a series of indicators for complex care delivery to enable detection of patients in need of care coordination at the moment of admission to the general hospital. The authors found 13 risk factors to be predictive of more than one indicator of care complexity. An admission risk screening procedure to detect patients in need of care coordination should focus on these risk factors and should include predictions made by doctors and nurses at admission and information collected from the patient and the medical chart.     

A model to describe social performance levels in elderly people

In elderly patients illness clearly affects both their social activity and their ability to care for themselves. It is important in general practice to recognize this effect when managing old people with acute and chronic illness. A model is described which aims to facilitate estimations of social performance at various levels. By carrying out this estimation the type of `social' help needed can be better assessed. The model's usefulness in anticipatory care is also described.     

Antenatal screening for haemoglobinopathies in primary care: a whole system participatory action research project

BACKGROUND: The usual system for antenatal screening for haemoglobinopathies permits termination only late in the second trimester of pregnancy. AIM: To evaluate a system where pregnant women are screened in general practice, and to develop a model of care pathway or whole system research able to bring into view unexpected effects of health service innovation. DESIGN OF STUDY: A whole system participatory action research approach was used. Six purposefully chosen general practices screened women who attended with a new pregnancy. Data of gestational age of screening were compared with two control groups. Qualitative data were gathered through workshops, interviews and feedback to the project steering group. At facilitated annual workshops participants from all parts of the care pathway produced a consensus about the meaning of the data as a whole. SETTING: Six general practices in north London. METHOD: A whole system participatory action research approach allowed stakeholders from throughout the care pathway to pilot the innovation and reflect on the meaning and significance of quantitative and qualitative data. RESULTS: The gestational age of screening in general practice was 4.1 weeks earlier (95% confidence interval (CI) = 3.41 to 4.68) than in hospital clinics (P<0.001), and 2.9 weeks earlier (95% CI = 2.07 to 3.65) than in community midwife clinics (P <0.001). However, only 35% of pregnant women in the study were screened in the practices. Changes required throughout the whole care pathway make wider implementation more difficult than at first realised. The cost within general practice is greater than initially appreciated owing to a perceived need to provide counselling about other issues at the same time. Practitioners considered that other ways of early screening should be explored, including preconceptual screening. The research approach was able to bring into view unexpected effects of the innovation, but health workers were unfamiliar with the participatory processes. CONCLUSION: Antenatal screening for haemoglobinopathies in general practice lowers the gestational age at which an at-risk pregnancy can be identified. However, widespread implementation of such screening may be too difficult.     

Impact of hemochromatosis screening in patients with indeterminate results: the hemochromatosis and iron overload screening study.

PURPOSE: Assess the quality of life impact of receiving indeterminate test results for hemochromatosis, a disorder involving HFE genetic mutations and/or elevated serum transferrin saturation and ferritin. METHODS: The study sample was from the Hemochromatosis and Iron Overload Screening Study, a large observational study of hemochromatosis among primary care patients in the US and Canada using HFE genotype and serum transferrin saturation and ferritin screening. Study subjects included 2,304 patients found with hemochromatosis risk of uncertain clinical significance. Assessed was SF-36 general health and emotional well-being before screening and six weeks after participants received their test results. Health worries were assessed after screening. RESULTS: Of the study subjects, 1,268 participants (51.5%) completed both assessments. Compared to normal controls, those with HFE mutations or elevated serum transferrin saturation and ferritin levels of uncertain significance were more likely to report diminished general health and mental well-being, and more health worries. These effects were associated with participants' belief of having tested positive for hemochromatosis or iron overload. CONCLUSION: Notification of indeterminate results from screening may be associated with mild negative effects on well-being, and might be a potential participant risk in screening programs for disorders with uncertain genotype-phenotype.     

COMPRI--an instrument to detect patients with complex care needs: results from a European study

The authors developed a screening instrument to detect patients in need of complex care coordination at admission to a general hospital. On the basis of a series of risk factors for care complexity, the authors constructed a short, care complexity prediction instrument (COMPRI) and assessed its qualities. The COMPRI is an easily administered screening instrument that detects patients at risk for complex care needs for whom care coordination is indicated. COMPRI's predictive power exceeds all currently available case-mix instruments.     

Delta-9-tetrahydrocannabinol and cannabidiol, but not ondansetron, interfere with conditioned retching reactions elicited by a lithium-paired context in Suncus murinus: An animal model of anticipatory nausea and vomiting

Chemotherapy patients report not only acute nausea and vomiting during the treatment itself, but also report anticipatory nausea and vomiting upon re-exposure to the cues associated with the treatment. We present a model of anticipatory nausea based on the emetic reactions of the Suncus murinus (musk shrew). Following three pairings of a novel distinctive contextual cue with the emetic effects of an injection of lithium chloride, the context acquired the potential to elicit conditioned retching in the absence of the toxin. The expression of this conditioned retching reaction was completely suppressed by pretreatment with each of the principal cannabinoids found in marijuana, Delta(9)-tetrahydrocannabinol or cannabidiol, at a dose that did not suppress general activity. On the other hand, pretreatment with a dose of ondansetron (a 5-HT(3) antagonist) that interferes with acute vomiting in this species, did not suppress the expression of conditioned retching during re-exposure to the lithium-paired context. These results support anecdotal claims that marijuana, but not ondansetron, may suppress the expression of anticipatory nausea.     

Finding diabetics--a method of screening in general practice.

BACKGROUND: It is well known that many diabetic patients go undiagnosed until complications have started to develop. Screening can be expensive in time and money, and ineffective, and is therefore unpopular with general practitioners (GPs). AIM: This study aimed to develop a screening method that was cost-effective and practical within the setting of an ordinary general practice. METHOD: Urine-testing sticks for glucose were sent with an explanatory letter to all (1736) non-diabetic subjects over 50 years old in a general practice. At the same time, diabetic recall and care were audited and improved in the practice. RESULTS: Reply slips were received from 1204 patients (69.4%). Of these, 2.6% were positive and 97.4% were negative. Eight new diabetic patients were therefore found at a cost of 78.25 pounds each. CONCLUSION: This method of screening a selected part of a general practice population is practical and effective. Apart from the human cost, the financial cost of finding a new diabetic patient is small compared with that of caring for a diabetic patient who is blind or an amputee.     

Opportunistic and systematic screening for chlamydia: a study of consultations by young adults in general practice

BACKGROUND: Opportunistic screening for genital chlamydia infection is being introduced in England, but evidence for the effectiveness of this approach is lacking. There are insufficient data about young peoples' use of primary care services to determine the potential coverage of opportunistic screening in comparison with a systematic population-based approach. AIM: To estimate use of primary care services by young men and women; to compare potential coverage of opportunistic chlamydia screening with a systematic postal approach. DESIGN OF STUDY: Population based cross-sectional study. SETTING: Twenty-seven general practices around Bristol and Birmingham. METHOD: A random sample of patients aged 16-24 years were posted a chlamydia screening pack. We collected details of face-to-face consultations from general practice records. Survival and person-time methods were used to estimate the cumulative probability of attending general practice in 1 year and the coverage achieved by opportunistic and systematic postal chlamydia screening. RESULTS: Of 12 973 eligible patients, an estimated 60.4% (95% confidence interval [CI] = 58.3 to 62.5%) of men and 75.3% (73.7 to 76.9%) of women aged 16-24 years attended their practice at least once in a 1-year period. During this period, an estimated 21.3% of patients would not attend their general practice but would be reached by postal screening, 9.2% would not receive a postal invitation but would attend their practice, and 11.8% would be missed by both methods. CONCLUSIONS: Opportunistic and population-based approaches to chlamydia screening would both fail to contact a substantial minority of the target group, if used alone. A pragmatic approach combining both strategies might achieve higher coverage.     

Medical screening of 1500 patients in a dental surgery: a prospective study.

Communication between medical and dental practitioners about patients they have in common enhances total patient care, but such communication rarely occurs. This may be due to lack of appreciation by doctors of the medical risks to certain patients undergoing dental treatment. To ascertain a relevant medical history, prospective medical screening was performed on 1500 new patients attending a general dental practice using a standard health questionnaire followed by an interview between the patient and dentist. There were 382 (25.5%) patients with a current or past medical history of relevance to dentistry, 90 (6.0%) were taking medication of potential importance and 105 (7.0%) considered they had an intolerance to certain drugs. The screening provided a patient data base for medical and medico-legal purposes. A total of 376 (25.1%) questionnaires were filled out incorrectly and 63 of these (16.8%) had major misinformation about medical history. A small but important group deliberately misled the dentist either from fear of refusal of treatment or embarrassment about their medical history. Therefore interviews are an essential adjunct to written health questionnaires in eliciting accurate information. Formal screening of new patients is essential in general dental practice. Furthermore, general medical practitioners need to become aware of the common risks to patients undergoing dentistry. Better formal and informal communication between general medical and dental practitioners is recommended for the benefit of their mutual patients.     

Providing census data for general practice. 2. Usefulness

Computerized census data are described in relation to a general practice population. The previously published methods for scoring deprivation – underprivileged areas score and material deprivation score – are applied to the data. Wards and enumeration districts within a single practice area are ranked by both methods and examples show the wide variation in deprivation scores for enumeration districts within single wards. The value of these data to a general practice is discussed with particular reference to developing a profile of the practice and to planning prevention and anticipatory care.     

General practice screening clinic for Bangladeshi families.

AIM. A screening clinic for Bangladeshi families was established in order to improve the health care provided by one general practice to its Bangladeshi patients. METHOD. The clinic was run by a general practitioner, a health visitor and a Bangladeshi health worker. Patients were invited to attend household by household. The composition of each household was recorded using a genogram. Details of family illness, housing and employment were noted. A medical history was taken from each individual. Every adult was screened for diabetes and risk factors for coronary heart disease; cervical cytology was offered to women. The immunization status of all patients was recorded and adults were immunized. Children were referred to the child health clinic for immunizations. The clinic concluded with a health education session focusing on smoking, exercise and diet. RESULTS. Over a two year period, 58% of the Bangladeshi families registered with the practice attended the clinic, a total of 207 people. Meeting Bangladeshi patients household by household was an effective and apparently efficient way of providing basic screening and health education. It allowed the practice to learn about the structure of its Bangladeshi families, the social problems faced by their community, and the areas in which their health care could be improved. CONCLUSION. This clinic provides a model which could be adapted for use with other ethnic or 'hard-to-reach' groups. It may also prove an effective way of screening all families in general practice.     

Unexpected death and critical illness in Prader-Willi syndrome: report of ten individuals

Individuals with Prader-Willi syndrome (PWS) generally survive into adulthood. Common causes of death are obesity related cor pulmonale and respiratory failure. We report on a case series of eight children and two adults with unexpected death or critical illness. Our data show age-specific characteristics of PWS patients with fatal or life-threatening illnesses. Under the age of 2 years, childhood illnesses in general were associated with high fever and rapid demise or near-demise. Hypothalamic dysfunction likely plays a role in exaggerated fever response, but also perhaps in central regulation of adrenal function. Below average sized adrenal glands were found in three children, which raises the possibility of unrecognized adrenal insufficiency in a subset of individuals with PWS and emphasizes the vital role of autopsy. The tub drowning death of an adult patient could be related to central hypersomnia, which has been reported in PWS. We suggest that increased risk for critical illness be considered in the discussion of anticipatory guidance for the care of infants with PWS. Since a number of children died while hospitalized, particularly close observation of PWS children who are ill enough to warrant hospital admission is recommended.     

Alcohol consumption screening of newly-registered patients in primary care: a cross-sectional analysis

Background

Although screening and brief intervention is effective at reducing alcohol consumption in primary care and is recommended by guidelines, there are numerous barriers to its delivery. Screening newly-registered patients for alcohol-use disorders provides an opportunity for systematic collection of alcohol consumption data.

Aim

To examine how alcohol screening data are recorded in primary care, the extent to which they are recorded, and whether reported levels of consumption differ from general population data.

Design and setting

Cross-sectional analysis, with data collected from patients in the year after registration.

Method

Data on alcohol consumption were collected from The Health Improvement Network (THIN) primary care database from patients aged ≥18 years, newly registered with a general practice in 2007 to 2009, and compared with the Office for National Statistics Opinions (ONS Omnibus) survey.

Results

A total of 292 376 (76%) of the 382 609 newly-registered patients had entries for alcohol consumption (units a week, Read Codes for level of consumption, and/or screening test). Only 25 975 (9%) were recorded as completing a validated screening test, most commonly AUDIT/AUDIT-C (16 004, 5%) or FAST (9419, 3%). Alcohol-use disorders are underreported in primary care (for example, higher risk drinking 1% males, 0.5% females) in comparison with the Opinions survey (8% males, 7% females).

Conclusion

Alcohol screening data are collected from most patients within 1 year of registration with a GP practice; however, use of a validated screening test is rarely documented and alcohol-use disorders are underreported. Further efforts are needed to encourage or incentivise the use of validated tests to improve the quality of data collected.     

General practitioners' perceptions of private health screening: too much paper, anxiety, and reassurance.

There is no evidence to support the practice of screening consultations that include general physical examinations and batteries of tests; however, many patients may choose, or be sent by their employers, to have private full health screening (FHS). General practitioners (GPs) are routinely sent the results of these screening examinations and are expected to deal with any subsequent care required. GPs recognize some positive aspects of FHS, but in our survey there was a groundswell of dislike for these examinations because of uncertainty about patient benefit (raised anxiety or false assurance) and a potential to irritate the GP. The implications for workload were minimal but resented. GPs would welcome a precise summary of significant findings and for the screening doctor to take greater responsibility for follow-up.