Factors identifying higher risk rectal bleeding in general practice

BACKGROUND: Rectal bleeding is a common symptom. The ability to distinguish those patients having serious underlying pathology from those with self-limiting conditions is a continuing dilemma in general practice. AIM: To determine the factors affecting the predictive and diagnostic value of rectal bleeding for bowel cancer in primary care. DESIGN OF STUDY: One-year prospective observational study. SETTING: Three large general practices. METHOD: Three hundred and nineteen consecutive patients over the age of 34 years consulting their GPs with rectal bleeding were included in the study. Investigation was by flexible sigmoidoscopy or a questionnaire and review of all patients took place after 18 months. The main outcome measures were consultation rates; the prevalence of cancer, colitis and significant polyps in patients presenting with rectal bleeding; its diagnostic value when occurring with or without a change in bowel habit, perianal symptoms and abdominal pain. RESULTS: The consultation rate for rectal bleeding in patients over the age of 34 years was 15 per 1000 per year; 3.4% had colorectal cancer. The prevalence of cancer increased to 9.2% when the rectal bleeding was associated with a change in bowel habit, and to 11.1% when it was without perianal symptoms. Thirty-six per cent of cancer patients had a palpable rectal mass. CONCLUSION: Over 96% of the patients who present to their GPs with rectal bleeding do not have cancer. Greater awareness of the diagnostic value of the different symptom combinations of rectal bleeding could help GPs adopt different management strategies for patients at higher and very low risk of cancer.     

Cluster randomised controlled trial of the effectiveness of primary care mental health workers

BACKGROUND: Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable. AIM: To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England. METHOD: Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial. RESULTS: Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector. CONCLUSION: For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.     

Outcome of general practitioner referrals to specialist outpatient clinics for back pain.

In 1983-84 general practitioners in the Oxford region kept records of their referrals to outpatient clinics over a period of six months. Five years later in 1988-89 the general practice notes of 182 patients referred for back pain were studied to determine the outcomes of their referral. The actions initiated in the outpatient clinics were compared with the general practitioners' main reason for referral recorded at the time of referral. Of the 182 patients 136 (74.7%) received specialist treatment following the outpatient referral despite the fact that general practitioners had given treatment as the main reason for referral in only 28.6% of cases. Patients' mean consultation rate for back pain declined from 4.2 consultations per annum to 0.9 (P less than 0.001) over the five year period, but there was a small but significant increase in consultations for other problems. Five years after the referral 33.3% of patients were still consulting their general practitioner for back pain. The referral system for patients with chronic back pain could be rationalized to reduce the need for re-referrals and multiple follow-up outpatient consultations. There is a need to improve communications between general practitioners, specialists and patients about the purpose of referral, the likely effects of treatment and the scope for prevention. A survey of the outcome of referrals for common conditions, such as back pain, is a useful first step in the development of referral guidelines.     

Workload in a general practice 1950-85

Annual patient consultation rates have been recorded continuously for 36 years in a stable National Health Service practice in a south-east London suburb. Four phases in consultation rates were noted: rising rates from 1950 to 1956; peak rates from 1957 to 1963; falling rates from 1964 to 1970 and low stable rates from 1971 to 1985. Thus workload fell by almost 50%, from a peak of 3.81 to a low of 1.93 consultations per patient per year. The reduction of 91% in home visits was much greater than the 43% reduction in surgery (office) consultations.Certain questions are raised by the study: why are the consultation rates of this practice so low (one half the national rates); why have consultation rates in the practice fallen; and how many general practitioners are needed by the NHS? More studies are needed which compare practices, their processes and outcomes, and which analyse cost benefits in the health service.     

Diagnostic work-up of rectal bleeding in general practice

BACKGROUND: GPs have many patients with gastrointestinal discomfort. Among bowel-related complaints, the sign of rectal bleeding is of particular importance in patients aged 50 years and above, as it can be an early sign for serious bowel diseases such as colon carcinoma. Despite many guidelines offered to GPs for screening and early detection of colorectal carcinomas, there is very little information about the actual diagnostic approach to the sign of rectal bleeding. AIM: The aim of the study was to collect data concerning treatment strategies used by GPs who treat patients presenting with rectal bleeding. DESIGN OF STUDY: Prospective data collection. SETTING: General practices in Germany. METHOD: Over the course of a year, GPs recorded their treatment strategies in patients presenting with rectal bleeding and associated symptoms. Using a digital practice patient file, physicians participating in the study were able to continuously transmit data electronically to the researchers of the study about diagnostics, referrals, hospital admissions, and final diagnoses. RESULTS: During the course of 1 year, 94 participating physicians collected data on 1584 patients. Information about treating rectal bleeding was recorded for 422 patients; 60% of the patients were referred to specialists in internal medicine or gastroenterologists for further diagnostics. A colonoscopy was the most frequently performed diagnostic procedure (46.2%). Twenty-two per cent (n = 93) of the patients--54 of them aged 50 years and above--were exclusively treated by their GP without conducting a colonoscopy or cooperating with specialists. For these patients, GPs diagnosed less severe diseases like haemorrhoids or other proctologic diseases. CONCLUSION: By using a study that allows GPs to transmit electronically their findings and data, it is possible to draw a picture of treatment strategies of GPs in patients presenting with rectal bleeding. The high percentage of patients who received medical treatment in consultation with specialists underscores the significance of the sign of rectal bleeding in general practice. The need for further diagnostic measures in patients who have been treated exclusively by GPs has to be discussed.     

Patients'' experiences of GP consultations for psychological problems: a qualitative study

BACKGROUND: The vast majority of patients with psychological problems are seen solely by their GP, but little is known about patients' perspectives regarding the variety of consultation skills that may be used in routine GP consultations with these patients. AIM: To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful. DESIGN: Qualitative study. SETTING: Nine general practices in north central London. METHOD: Twenty patients, who had discussed psychological problems as a significant part of their index GP consultation, were asked in detail using the tape-assisted recall (TAR) method, about aspects of the consultation they had experienced as helpful or unhelpful. RESULTS: All patients described how the relationship with the GP helped or hindered them in discussing their problems; this was central to their experience of the consultation. An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients also described how the GP helped them make sense of, or resolve their problems, and supported their efforts to change. CONCLUSION: These patient accounts suggest that routine GP consultations for psychological problems can have a powerful impact, at least short-term. The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated, particularly in the mental health context. Further research is required to investigate the longer-term impact of different GP behaviours on patient health outcomes. The TAR method has potential applications in primary care research and in the training of GPs and other health professionals.     

Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications.

OBJECTIVE: To assess the viability of telemedicine as a vehicle for offering mental health consultations to primary-care patients. METHODS: Satisfaction ratings from 34 mental health encounters were compared with ratings from a convenience sample of 59 non-mental health encounters on four aspects of satisfaction: self-reported ability to speak freely; probability of further use of telemedicine; perceived experience of telemedicine personnel; and relative preference for a telemedicine visit compared with a face-to-face visit. The study was conducted in the context of the Telemedicine Program at the University of California, Davis. RESULTS: No significant differences in satisfaction were found between mental health and non-mental health encounter groups for any of the four aspects of satisfaction. CONCLUSIONS: Ratings from patients receiving mental health consultation using telemedicine yielded levels of satisfaction similar to those found in telemedicine consultations in non-mental health medical areas. The results support telemedicine as a means to extend mental health consultation to rural primary-care patients.     

Prioritising referrals to a community mental health team.

BACKGROUND: Current national policies encourage prioritisation of people with severe mental illness (SMI) as well as the development of a primary care-led National Health Service. Where resources for mental health are limited, there is a potential conflict between the needs of people with SMI and the much more common depressive and anxiety disorders that form the bulk of the mental health workload in primary care. AIM: To describe the re-organisation of a community mental health team in order to prioritise people with SMI. METHOD: The number and type of referrals received in the 12 months before and after re-organisation were compared, and general practitioners' (GP) views on the changes sought. RESULTS: There was a significant reduction in GP referrals of patients with less severe disorders in the second year. In both years the proportion of patients with a possible psychotic diagnosis or risk of self-harm was much higher among referrals from within the psychiatry department (92% of referrals) than among GP referrals (20% of referrals). Using data from a postal survey, 46% of referring GPs reported a significant improvement in the service provided to patients with SMI, but 34% reported a deterioration in services for other patient groups. GPs were more likely to be satisfied with the service for people with SMI than with the service for other patient groups. CONCLUSIONS: Improvements in the service provided for those with SMI can be achieved, but this may be at the expense of services for other patient groups. Primary care groups will need to consider this potential conflict in setting priorities for mental health.     

Characteristics of patients referred to psychiatrists for competency evaluations

Requests for inpatient psychiatric consultations at a general hospital over a three-year period were reviewed. Of 2,423 referrals, 79 (3.3%) were specifically for evaluation of competency, and 78.5% of those cases resulted in a diagnosis of an organic mental disorder. The proportion of referrals with organic mental disorder was significantly greater than it was in a control population of patients referred for consultation for any reason. Patients with organic mental disorder who were referred for competency evaluation had greater cognitive impairment than did control subjects.     

Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations.

BACKGROUND: There are many reasons why people frequently consult their general practitioner (GP). Although loneliness is increasingly recognized as a problem affecting well-being for elderly people, it has rarely been addressed as a predictor of frequency of consultation. AIM: To examine whether loneliness is associated with rates of GP consultations (home and surgery visits). METHOD: Analysis of data collected in face-to-face interviews at the second wave of a longitudinal health survey of two adult age cohorts living in four socially contrasting urban localities in Glasgow City. There were a total of 691 subjects: 142 males and 176 females aged 40 years at interview; and 167 males and 206 females aged 60 years at interview. Frequency of reported GP consultations in the past 12 months at home or in the surgery was examined. RESULTS: After controlling for sociodemographic and socioeconomic variables and health, loneliness was significantly associated with frequency of consultation at the surgery but not with the frequency of home visits. CONCLUSION: Loneliness may still be underestimated as a factor related independently to frequency of consultations with a GP at the surgery.     

Case-control study of GP attendance rates by suicide cases with or without a psychiatric history.

BACKGROUND: Targets for reduction in suicide deaths have been set against a background of an increasing number of people committing suicide. It is often assumed that a reduction can be effected by increasing the detection in primary care of patients at risk. This presupposes that there are indicators that enable suicide risk to be detected reliably. AIM: To compare the characteristics of those who commit suicide with an age- and sex-matched control group in terms of level of general practitioner attendance, diagnosis and pharmacological treatment of mental illness, and to compare those suicides with and without a psychiatric history in terms of general practitioner attendance and history of pharmacological treatment. METHOD: From a total of 48 deaths attributed to suicide and undetermined causes in the Forth Valley in 1993, general practice case notes were located for 41. Live controls were matched to index cases by age, sex and practice. Information on consultations, referrals to secondary care, medication and diagnoses in the previous 10 years was extracted from general practice and, for suicides, psychiatric case notes. RESULTS: Over the 10-year period, suicide patients attended their general practitioner at a higher level than control subjects. However, the number of suicide patients who attended their general practitioner in the month before their death did not differ in comparison with control subjects over a similar period. Suicide cases, in comparison with control subjects, were more likely to have received a psychiatric diagnosis from their general practitioner, been prescribed psychotropic medication and received referral to specialist mental health services. Those suicide patients with a psychiatric history had a significantly higher number of general practitioner consultations than those without a psychiatric history in four out of the five years preceding death. Those suicide patients without a psychiatric history did not differ significantly from control subjects on any of the variables assessed. CONCLUSION: For those people committing suicide who do not have a psychiatric history and whose consultation patterns do not differ from the norm, it is difficult to suggest how general practitioners might improve their detection of relevant suicidal risk factors. For those patients with a psychiatric history who commit suicide, until we have more detailed information regarding the specific content of general practitioner's consultations before death and how these differed from other consultations of the deceased, then it is premature to assume that general practitioners are failing to identify indicators of impending suicide.     

Allergic Rhinitis in Danish General Practice

The prevalence rate of allergic rhinitis and the consultation rate caused by this disease were studied in 131 general practices covering a population of 450,000 persons in Denmark. During a 1-year period starting June 1977 all consultations with or without symptoms were recorded.
Allergic rhinitis was defined as paroxysmal sneezing and rhinorrhoea with or without conjunctivitis, and without signs of infection.
Results are presented from three groups of practices classified by self-estimated completeness of reporting. 11–15 per thousand of the total population contacted a practice during the 1-year period (males: 12–17%, females: 10–13%). The highest prevalence rate occurred at 10–19 years of age, and allergic rhinitis was common from five to 44 years of age. The prevalence rate was higher among males up to the age of 30, after which age it was a little higher among females. About two-thirds of the patients consulting had at least one consultation per year with symptoms present.
The number of contacts came to 4.4 per patient per year and 20–25% of these were with symptoms.     

Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study

Background

In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity.

Aim

To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care.

Design of study

Retrospective cohort study.

Setting

Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database.

Method

Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models.

Results

Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity.

Conclusion

Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it.     

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.     

Provider–patient interaction in rural Cameroon—How it relates to the patient's understanding of diagnosis and prescribed drugs,the patient's concept of illness,and access to therapy

Objective

This cross-sectional survey examines the relation between provider–patient interaction and several patient-outcomes in a rural health district in Cameroon.

Methods

We used structured patient interviews and the Roter Interaction Analysis System (RIAS) for analysis of audio-recorded consultations.

Results

Data from 130 primary care consultations with 13 health-care providers were analysed. 51% of patients correctly named their diagnoses after the consultation; in 47% of prescribed drugs patients explained correctly the purpose. Patients’ ability to recall diagnoses was related to the extent of clarity a provider used in mentioning it during consultation (recall rates: 87.5% if mentioned explicitly, 56.7% if mentioned indirectly and 19.2% if not mentioned at all; p < 0.001). Two thirds of patients were able to describe their concept of illness before the consultation, but only 47% of them mentioned it during consultations. On average patients who mentioned their disease concept were faced with more remarks of disapproval from providers (1.73 vs 0.63 per consultation; p < 0.01). Although 41% of patients admitted problems with financial resources to buy prescribed drugs, discussion about financial issues was very rare during consultations. Providers issued financial questions in 32%, patients in 21% of consultations.

Conclusion

This study shows that provider–patient interaction in primary health care in a rural Cameroon district deserves more attention. It might improve the patients’ knowledge about their health condition and support them in beneficial health behaviour.

Practice implications

Our findings should encourage providers to give more medical explanation, to discuss patients’ health beliefs in a non-judgemental manner, and to consider financial issues more carefully.     

Psychiatric diagnoses and behaviour problems from childhood to early adolescence in young people with severe intellectual disabilities

BACKGROUND: While general population studies indicate an increase in the rate of psychiatric disorder in adolescence, little is known about the course of mental health and behaviour problems between childhood and adolescence in young people with severe intellectual disabilities. METHOD: From a sample of 111 children with severe intellectual disability who had been identified from the registers of six special schools at 4-11 years of age, 82 were traced and reassessed 5 years later at the age of 11-17 years. Behaviour problems were assessed by means of parental interviews conducted in the family home and parent and teacher questionnaires. Parental reports of psychiatric diagnoses were checked against health records. RESULTS: With most behaviour problems, including aggression, destructive behaviour and self-injury, there was little difference in rates between the two assessment occasions. However, in spite of this overall pattern of stability, the rates of some behaviour problems, including overactivity, showed significant reductions between childhood and early adolescence. Persistence rates for most behaviour problems appeared comparable to those reported for similar behaviours in general population studies of children. There was no significant difference in the proportion of cases with psychiatric diagnoses between the two assessment occasions, although brief psychotic episodes emerged in three cases in adolescence. CONCLUSIONS: The findings suggest that the prevalence of mental health and behavioural problems in young people with severe learning disabilities remains relatively stable between childhood and adolescence, although some specific behaviour problems diminish. However, a small minority of children may develop severe psychiatric disorders in adolescence.     

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.