Organization of care for diabetic patients in general practice: influence on hospital admissions.

The aim of this study was to determine whether there is a relationship between the structure of care for diabetes in general practice and the corresponding admission rates for diabetic patients to hospital. A questionnaire was sent to 350 group or single handed practices in the Oxford region and a retrospective analysis was made of admission rates using hospital activity analysis. Admission rates were adjusted for the age structure of the practices. The degree of organization of care was determined by drawing up a composite score from the answers to the questionnaire and comparing practices with few, average and many facilities. There was a significant trend in the rates of admission across the groups of practices: those with few facilities made 16.2 admissions per 10,000 population over two years, those with average facilities 13.8 admissions, and those with many facilities 14.0 admissions (chi-squared trend = 6.88, 1 df, P less than 0.01). These findings support the hypothesis that organized general practice care reduces the rate of hospital admissions, although there are many other influences on the admission rate from any one practice.     

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.

     

Systematic care of diabetic patients in a general practice

A diabetic clinic looking after 21 patients in a single-handed practice of 2,000 is described. It appeared that systematic care of these diabetics led to earlier detection and treatment of complications, and may have prevented or postponed serious disability. In the long term, a clinic such as this may help reduce practice work-load. Many clinic duties were carried out by a nurse, so that the clinic took up little doctor time. It is concluded that running a diabetic clinic is within the scope of general practice, provided the necessary support is given.     

Care complexity in the general hospital: results from a European study

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.     

How effective is systematic care of diabetic patients? A study in one general practice.

A method of systematic diabetic care compatible with personal lists, the 'diabetic day', was introduced into a seven partner inner city general practice. The effect on glycosylated haemoglobin levels and the recording of six process measures (fundoscopy, visual acuity, weight, blood glucose levels, glycosylated haemoglobin levels and blood pressure) was assessed. Of the 111 known registered diabetic patients, 64 entered the diabetic day and fulfilled the eligibility criteria. General practice records were analysed retrospectively over a period of four years--the two years before entry into the diabetic day were compared with the subsequent two years. Mean glycosylated haemoglobin levels fell from 10.52% in the year before entry to the diabetic day to 9.71% in the second year after entry (P < 0.01, 95% confidence intervals 0.19 to 1.39). There was a significant increase in all process measures recorded in the general practice notes after entry into the diabetic day. The introduction of systematic care for diabetic patients led to an improvement in recorded process measures and a reduction in patients' glycosylated haemoglobin levels in a general practice which had made previous efforts to improve diabetic care and was already well staffed, organized and motivated.     

Nocturnal asthma: a study in general practice.

Symptoms of nocturnal asthma were studied using questionnaires returned by 1199 general practitioners throughout the United Kingdom. Of 7729 asthmatic patients seen consecutively and prescribed a bronchodilator aerosol, 73% woke with asthma at least once a week and 39% woke nightly. The percentage of asthmatics waking at night at least once a week in this population, where 48% were prescribed corticosteroid aerosols, was very similar to the 74% found to have asthma attacks at night in an earlier study of new hospital referrals at a time when such medication was not available. While sampling bias cannot be excluded, the clinical characteristics and profile of medications found in this study are similar to other reports and the evidence suggests that the general practitioners were managing these patients carefully. There was an overall association between the patients' perception of the severity of their asthma and frequency of waking at night (P less than 0.001). However, 26% of 2928 patients waking every night regarded their asthma as mild. These patients were taking significantly less medication than those also waking nightly but assessing their asthma as severe (P less than 0.001). The seriousness of nocturnal symptoms may be underestimated by asthmatics and they should be asked specifically about the frequency of nocturnal waking. Those with nocturnal asthma had a generally higher frequency of allergic and non-allergic provoking factors, but no single factor distinguished these patients from those without nocturnal symptoms. There was a strong correlation between the frequency of nightly waking and the number of medications used (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Disinfection methods in general practice and health authority clinics: a telephone survey

Concern about the epidemic of the acquired immune deficiency syndrome led to discussions in one health district about the dangers of cross-infection from instruments in general practice and health authority clinics. In order to establish what current disinfection practices were in use a telephone survey was adopted as a quick and easy method of data collection. Information was collected on who was responsible for disinfection as well as details of how each instrument was disinfected. Results from 69 general practices and 21 health authority clinice in one health district are reported.

Some form of sterilizer was used in 63 general practices. These included water boilers (49%), dry heat sterilizers (41%), autoclaves (5%) and pressure cookers (5%). Sixty one practices were using metal vaginal specula and of these 29 were disinfecting by boiling, three were using pressure cookers, 18 dry heat, seven chemical methods, three autoclaves and one the central sterile department of the local hospital. Of those who were boiling after simple washing, three practices boiled for five to 10 minutes and reused instruments during the same clinic. Of the 29 using simple boiling 20 (69%) were boiling for less than 20 minutes.

The study highlights the fact that no formal advice has been given on disinfection practice by the DHSS, the health authorities or the family practitioner committees. The need to set up local guidelines and develop practical steps for their introduction are discussed.

     

Care of schizophrenia in general practice: the general practitioner and the patient.

BACKGROUND. The transfer of patients with chronic schizophrenia from large mental hospitals into the community has had an impact on the role of the general practitioner in the effective delivery of primary care services to these patients. AIM. A study was undertaken to assess the care available in general practice for patients with schizophrenia, the attitudes of general practitioners and patients to the care provided and the factors influencing patients' use of services. METHOD. Eighty three patients with a diagnosis of schizophrenia and 26 doctors in 13 London practices registered on the VAMP research bank took part in a series of structured and semi-structured interviews. This was followed by a systematic examination of the patients' case notes. RESULTS. Only 14 patients (17%) had no active symptoms according to the present state examination interview and 52 (63%) were currently taking antipsychotic medication. Fifty three patients were in contact with a psychiatrist. Approximately one quarter of patients were visited by a community psychiatric nurse; in 18 of these 19 cases, the main reason for contact was reported to be for administration of medication by depot injection. In all but one case, patients seeing a community psychiatric nurse were also being seen by a psychiatrist. Sixteen doctors reported having had a consultation in the previous month with a patient's relative, friend or member of hostel staff. There were considerable differences between patients and their doctors in their attitudes to the use of services. Of the 26 general practitioners, 23 were enthusiastic about the possibility of introducing shared care records. Of the 54 patients in contact with a mental health professional, only 18 favoured the use of shared care records. Most of the doctors (19, 73%) reported they would welcome a psychiatric liaison service in their practice; 40% of 53 patients said they would not. Patients receiving antipsychotic drugs and patients registered with inner city practices attended their general practitioners more frequently than those not taking antipsychotic medication and those registered with suburban practices. Use of antipsychotic medication (adjusted odds ratio (OR) 8.2, 95% confidence interval (CI) 2.2 to 30.7, P < 0.01), male sex (OR 5.8, 95% CI 1.5 to 22.1, P < 0.01) and active symptoms on the present state examination (OR 4.1, 95% CI 1.0 to 17.5, P = 0.06) were all predictive of current contact with mental health professionals. CONCLUSION. Family doctors were closely involved with the care of patients with schizophrenia and their relatives and were eager for increased liaison with secondary care services. Although patients were more resistant than doctors to management innovations this may reflect lack of familiarity with changes in community services. Greater input is needed by mental health professionals, particularly community psychiatric nurses, and some consideration of the burden of care in inner city practices is necessary in health service planning.     

Comparison of anticoagulant control among patients attending general practice and a hospital anticoagulant clinic.

Management of patients receiving oral anticoagulant therapy was assessed in general practice and a dedicated hospital anticoagulant clinic. The demographic characteristics of patients in both groups were similar, as were the indications for anticoagulation therapy and the duration of treatment. General practice patients were reviewed significantly more frequently, with a median interval of 16 days compared with 42 days for hospital patients (P < 0.001). Twenty four per cent of general practice visits and 26% of hospital attendances resulted in an alteration to the warfarin dosage. Overall, 52% of general practice thrombotest results lay within the ranges recommended by the British Society for Haematology, compared with 45% of hospital results (P < 0.001). There was no difference in the rate of complications in general practice and the hospital clinic. In this study, the anticoagulant control achieved in a general practice setting was superior to that in a dedicated hospital outpatient clinic, although control was far from ideal in either setting.     

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

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

Epidemiology of Pseudomonas aeruginosa in a general hospital: a four-year study.

A retrospective study was done to determine the epidemiology of infection and/or colonization due to Pseudomonas aeruginosa in a Brazilian general hospital. In 1966, 1968, and 1969, there were only two instances where probable cross-contamination was shown; the remaining isolates were unrelated. In late 1971 the hospital experienced a marked increase in P. aeruginosa isolation. Contaminated dextrose solutions used in the infant feeding were the apparent cause of the problem which occurred in the premature and special care nurseries. A contaminated oxygen humidifying bottle was the source of a different outbreak in surgery. There was also evidence in four instances that cross-infection and/or contamination had occurred. Pyocin and serological typing revealed that many strains were involved and led to a clear understanding of the complex epidemiological relationships among all the strains.     

The inflammatory cervical smear: a study in general practice.

This study set out to determine whether the term 'inflammatory' in a cervical smear report implies underlying infection or whether it could be masking cancerous or precancerous changes. Of 826 smears taken in one practice over one year, 42 demonstrated some degree of inflammatory change. Thirty four of these women presented for swabs and almost half (47%) had a microbiologically proven infection. This group was further subdivided, and of those whose smears were reported as simple 'inflammation', just over one third (35%) were infected but of those whose smears were reported as 'severe inflammation', over two thirds were infected (73%). The commonest organisms isolated were Gardnerella vaginalis and Candida albicans. It would therefore appear to be worthwhile to treat patients who report severe inflammation with metronidazole and with anti-fungal pessaries before the smear is repeated. Following treatment two women went on to show dyskaryosis within five months. On colposcopy one of these women was found to have invasive cervical squamous cell carcinoma. It is concluded that whether women with inflammatory smears are treated or not, it is mandatory to repeat the smear, ideally within five months.     

Lay beliefs of patients using domiciliary oxygen: a qualitative study from general practice.

BACKGROUND: Oxygen, given for 15 hours a day to certain patients with chronic obstructive pulmonary disease, is known to reduce mortality and improve morbidity. There is, however, an apparent mismatch in provision--some patients who would potentially benefit are not receiving it and, conversely, other patients may be receiving it 'inappropriately'. AIM: To investigate lay beliefs about oxygen therapy of patients receiving domiciliary treatment. METHOD: Twenty-four patients receiving domiciliary oxygen therapy from three general practices in Middlesbrough were interviewed using qualitative, semi-structured interviews. RESULTS: There were two contradictory approaches to oxygen use. On the one hand, oxygen helped the individual maintain mastery and self-control over illness by relieving symptoms, thus enabling daily activities and roles to continue, and by the reassurance that it was available, even if not used. In addition, self-control over the illness was maintained by individual experimentation with the best ways to use oxygen, which increased personal involvement in treatment. On the other hand, there were concerns that oxygen should not master the individual through inducing dependency on its use. CONCLUSIONS: These ambivalent ideas about oxygen should be considered when assessing patients for use of domiciliary oxygen and by general practitioners maintaining treatment. Some patients who according to medical criteria would benefit from domiciliary oxygen may wish to restrict its use because of worries about dependency and these worries may need addressing. Other patients using domiciliary oxygen who do not meet medical criteria for long-term use may nevertheless gain benefits, including improved self-control over their illnesses.