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Biomedical subjects

D M Fleming

Publications and source records attributed to D M Fleming.

At least 109 records · Page 6Linked to original sources
PubMed1988

The case for differential capitation fees based on age in British general practice.

A study was performed to assess whether the existing differential capitation fees for general practitioners accurately assess differential workloads. Data from the third morbidity study in general practice were used to compare capitation fees with relative workload in differing age and sex groups. The population mix which determined the payment by capitation for the 143 principals in the study provided the basis for examining the advantage or disadvantage the general practitioner got from the existing system. Capitation fees for the elderly underestimated the increased workload by 21% for those aged 65-74 and by 54% for those aged 75 or over but overestimated the workload for male adults aged up to 65. Nevertheless, 60% of the participating general practitioners were not advantaged or disadvantaged by more than 2.5% of their capitation fees (450 pounds a year for the average practitioner with a list of 2000 patients). Similarly 88% were not advantaged or disadvantaged by more than 5%; none were advantaged or disadvantaged by more than 10%. A three scale capitation fee for the age groups 0-64, 65-74, and 75 or over should be applied in the ratio of 3:5:7 rather than in the present ratio of 3:4:5, but given the present population mix in practices there is no case for differential capitation fees by sex or differential fees for the age group 0-4 years.

Adolescent↗
PubMed1988

Hematologic bone marrow disorders: quantitative chemical shift MR imaging.

Twenty-one in vivo studies of bone marrow of the lumbar spine were performed with a 0.6-T commercial MR imager and proton chemical shift imaging techniques. Six healthy volunteers served as controls. Multiple measurements in the volunteers demonstrated reproducibility within errors of 5% for fat fraction and 6% for T1 of water. Ten patients who had histologically proved leukemia or aplastic anemia were then examined. The data show that changes in fat fraction represent the underlying reason for many of the changes observed in conventional spin-echo (SE) images of these disorders. Although both conventional and chemical shift images showed differences among the pathologic groups and healthy volunteers, fat fraction determined with chemical shift imaging was the single best discriminator among them. A two-point estimate of fat fraction was also evaluated. This rapid imaging protocol performed almost as well as the complete quantitative analysis in discriminating between pathologic and healthy tissue and showed improved discrimination compared with conventional SE techniques.

Adipose Tissue↗
PubMed1988

General practitioner referrals to hospital: the financial implications of variability.

The emergency and outpatient referral rates of practices taking part in the 2nd and 3rd National Morbidity Studies (NMS-2, NMS-3) were studied. Variation in referral rate between individual practices was contrasted with variation between different practice and patient sub-groups. Variability in referral rates between practices to outpatient departments was shown greatly to exceed variability of these rates associated with different practice locations (urban/rural), and between sexes, age-groups or social groups of patients. A similar contrast was seen when exploring rates for inpatient referrals (with exception made for rates in patients aged 75+). There were strong correlations present between individual practice referral activity in the first two years of NMS 2 (R = 0.72, n = 43, P = less than .001), and between NMS-2 and NMS-3 for those practices which participated in both studies (R = 0.80, n = 18, P = less than .001), indicating a high degree of consistency of referral behaviour. In the 3rd study total referrals from general practice were 10.6 per 100 population compared with 20.7 per 100 reported in hospital statistics. Direct access to Accident and Emergency (A and E) Departments and internal hospital referrals between specialist departments account for the bulk of the difference. The cost implications of variability in referral rates among practitioners are considerable. More data about referral are required.

Data Collection↗
PubMed1988

Comparison between the weekly returns service and the Oxford regional sentinel practice scheme for monitoring communicable diseases.

Weekly data for seven conditions reported to the weekly returns service of the Royal College of General Practitioners' Birmingham research unit over a 52-week period have been compared with those reported to the Oxford regional sentinel practice scheme. The mean weekly recorded rates for otitis media, asthma and intestinal infectious disease were similar in both systems; in the weekly returns service, mean weekly rates for common cold, acute bronchitis and influenza/influenza-like illness were approximately twice and for sore throat/tonsillitis slightly higher than rates in the Oxford scheme.In the weekly returns service no recommendations are made about criteria for diagnosis but in the Oxford scheme diagnostic criteria agreed by the participants are used. Where rates in both monitoring systems are the same, agreed criteria are likely to be conventional clinical practice and therefore superfluous. Where rates are different, the use of criteria enhances specificity of the information content but results in an underestimation of the total incidence of - respiratory disease presented to general practitioners.For common cold, acute bronchitis, otitis media and influenza/ influenza-like illness the associations between the rates in the two systems were high (R>/=O. 79), as might be expected, but these high values cross validate both recording systems in their monitoring of trends. For the remaining (non-epidemic) conditions the associations were low. There were no significant associations between the rates for asthma and the upper respiratory infectious diseases in either recording system, which suggests there was effective discrimination of asthma.

Communicable Disease Control↗
PubMed1988

Diagnosis and patterns of incidence of influenza, influenza-like illness and the common cold in general practice.

The incidence of influenza, influenza-like illness and the common cold during the influenza epidemics of 1972 and 1976 as reported to the weekly returns service of the Royal College of General Practitioners was examined by three regional areas and by age group. The results of a postal questionnaire concerned with diagnostic criteria used by participating doctors were also analysed. These two analyses were used to explore the validity of these diagnostic terms as reported in the weekly returns service.The two influenza epidemics peaked at about the same time throughout the country and in all age groups simultaneously, although the severity of the epidemic seemed to wane from south to north in 1976. The reported incidence of influenza-like illness and of the common cold was less in the central region than in the north and south during both the two epidemic years. Influenza incidence was maximal in age groups 15-44 and 45-64 years, whereas the reported incidence of influenza-like illness and the common cold was maximal in pre-school children.Additionally, influenza-like illness and the common cold appeared to a fairly uniform extent every winter whereas influenza was truly epidemic.From the questionnaire to general practitioners, the symptoms of rigors, malaise and myalgia and the recognition of an epidemic were the important criteria which differentiated influenza from influenza-like illness.We conclude that in general practice the distinction between influenza and influenza-like illness is reliably made and has validity in the clinical context and meaning of these diagnostic terms.

Cohort Studies↗
PubMed1987

Prognosis in adult asthma: a national study.

Although one million people consult their general practitioners for asthma each year, data on the prognosis of this disease are scarce, particularly in adults. Mortality was studied among 2547 adult asthmatics attending a national sample of 60 general practices between 1970 and 1976; they were compared with a matched group of non-asthmatic patients. Mortality from all causes was significantly raised in the asthmatic cohort (189 deaths v 112 among controls; relative risk 1.61, 95% confidence interval 1.3 to 2.0), especially in women (92 v 42 deaths; relative risk 2.2 (1.5 to 3.1)), and in the oldest age group (55-59 years). In both sexes the predominant cause of excess mortality was respiratory disease, particularly asthma (25 v 0 deaths) and chronic obstructive airways disease (37 v 4 deaths; relative risk 8.8 (2.8 to 23)). Overall, 94% of the asthmatic cohort survived the mean follow up period of eight years compared with 96% of the controls. In contrast to previous findings, the risk of death due to malignant neoplasms was not significantly reduced overall (34 v 36 deaths), though the risk was significantly reduced among those aged under 45 years (2 v 10 deaths; relative risk 0.2 (0.02 to 0.9)) and there was a significant trend of lowering of relative risk with younger age (p less than 0.01).

Adult↗
PubMed1987

Prevalence of asthma and hay fever in England and Wales.

The results concerned with the prevalence of asthma and hay fever in the large surveys of morbidity in general practice in 1970-1 and 1981-2 were compared. In data standardised for age the prevalence of asthma in men increased from 11.6 to 20.5 people consulting per 1000 population (p less than 0.001) and in women from 8.8 to 15.9 per 1000 population (p less than 0.001). Similar increases were also evident in data analysed from the 19 practices contributing to both surveys. The prevalence of asthma increased in each age group examined. Increases of similar magnitude were reported for hay fever--the prevalence in men increased from 10.8 to 19.8 people consulting per 1000 population (p less than 0.001) and in women from 10.3 to 19.7 per 1000 population (p less than 0.001) and occurred in all age groups. The prevalence of acute bronchitis was reduced significantly in the age group 5-14 and increased among the elderly. The prevalence of chronic bronchitis was reduced substantially in 1981-2. The reported increased prevalence of both asthma and hay fever represented a real increase and was not accounted for by changes in diagnostic preference. Only in the age group 5-14 was there any likelihood that some of the increased prevalence of asthma might have resulted from a reduction in the prevalence of acute bronchitis.

Acute Disease↗
PubMed1987

A simple scoring system for evaluating symptoms, history and urine dipstick testing in the diagnosis of urinary tract infection.

Patients presenting with symptoms suggestive of urinary tract infection were recruited in a general practice survey aimed at measuring the predictive value of symptoms, history and urine dipstick testing for diagnosing the presence of bacterial infection. Urine specimens were obtained from 87% of the 521 patients recruited. A diagnosis of infection was established by urine culture producing a colony count in a pure culture exceeding 100 000 organisms per ml or between 10 000 and 100 000 organisms per ml plus a minimum of 100 leucocytes per mm(3).Occurrence rates for symptoms and other items of information in infected and non-infected groups were used to derive their positive and negative predictive values in making the diagnosis. The predictive value of volunteered symptoms was compared with that of elicited and volunteered symptoms combined. The positive predictive value of symptoms was increased where elicited symptoms were included but this was achieved at the cost of diminishing the negative predictive value. The occurrence rates were used to derive a mathematical model for diagnosing infection. The symptoms-history-urinalysis (SHU) score generated in this model compared well with a computer predicted probability. Both were substantially better than the assessment and action (decision to prescribe an antibiotic) of the recording doctor.The scoring method described has been demonstrated in urinary tract infection but may be applied to any symptom combination related to a diagnosis for which there is an agreed definition.

Adolescent↗
PubMed1986

Comparison of Second National Morbidity Study and General Household Survey 1970-71.

We present a comparison of data from two morbidity surveys conducted in 1970-71--the Second National Morbidity Study (subsequently referred to as NMS) and the General Household Survey (GHS). In the NMS 115 general practitioners recorded for one year details of the utilization of services by and the morbidity in their patients; and in the GHS the same sort of information was obtained from interviewing members of approximately 15,000 households. Differences in consultation and home visiting rates are examined. For this purpose, data in the NMS which were based on the verified population (population linked to the National Census for 1971) are contrasted with findings from the GHS (with telephone contacts excluded). Apart from small differences in home visiting rates especially among old people, the overall consultation rates are extremely close. We suggest that the losses to both studies, which occur especially among young mobile people in urban populations, need to be considered carefully when interpreting the data. Nevertheless, the doctor-generated NMS data matches well with the patient-generated GHS. Ways are suggested whereby the surveys might be more closely linked.

Adolescent↗
PubMed1986

A comparison of the practice activities of trainees and principals.

The practice activities of trainees are compared with those of principals using a large data base to provide a factual basis for the discussion of the workload and activities of trainees.Trainees undertook an average of 187 consultations including 32 home visits over two weeks compared with 301 consultations and 50 home visits for principals. These values show that trainees are seeing sufficient patients for adequate learning and are not being exploited. There were relatively more children and more patients with acute respiratory disorders among the patients consulting trainees compared with those consulting principles.However, trainees saw fewer elderly patients, fewer patients presenting for preventive care and fewer patients with cardiovascular disorders than principals. These deficiencies in the range of patients that trainees are seeing are undesirable. Antibiotics were prescribed more frequently by trainees than by principals but trainees prescribed fewer psychotropic drugs especially as repeat prescriptions and their referral rates and investigation rates were both lower. This probably reflects a consulting profile in which there are more young patients with acute than chronic problems.

Adolescent↗
PubMed1985

List size, screening methods, and other characteristics of practices in relation to preventive care.

Twenty eight practices carried out a review of patient records for information about preventive procedures on two occasions in 1980 and 1982. We have now undertaken a survey of certain characteristics of the practices in an attempt to demonstrate features associated with effective preventive care. Significant favourable factors are a small list size, the setting up of a formal screening programme for cervical cytology and measuring blood pressure, and few registered patients in social classes IV and V. More successful practices also tend to be training practices, have principals with higher qualifications, and have developed good records organization. Opportunistic screening for cervical cytology and measuring blood pressure was not shown to be more effective than no policy of screening at all.

Adolescent↗
PubMed1985

Disability as identified from general practice records.

Thirty eight doctors who attended a postgraduate educational course provided information about disabled patients identified in a search of 7000 records. Disablement was defined as a major disruption to the normal lifestyle of patients in appropriate age and sex groups. Altogether 242 people were identified as disabled, equivalent to 32 per 1000 population, which is closely similar to that published by Harris, who identified patients by postal questionnaire. Among adults aged 15 to 64 more men were identified than women, and we suggest that a higher rate of disablement might be expected in men. Disablement among women may be underestimated because of underrecognition by doctors of disability in housewives. Fifty two per cent of all disabled people were able to attend the doctor's surgery, and 72% were receiving regular medication; 79% were dependent on relatives, but only 30% were dependent on statutory services. In the opinion of the recording doctors medical and nursing needs were well met, though not the social needs, where the importance of living alone is noteworthy.

Adolescent↗
PubMed1985

The denominator for audit in general practice.

Different denominators for morbidity studies were compared from two large studies in Britain. From the second national morbidity survey, data from 24 single-handed doctors showed a close correlation between the denominators 'persons consulting' and 'list size' (r greater than 0.9) in both years of the survey, but a weaker correlation between 'consultations' and 'list size' (r = 0.6). However, when examining rank order statistics for visiting and out-patient referral rates, it was immaterial for most doctors which denominator was chosen. Only for recorders with a consultation rate at the extremes of the range was the choice of denominator critical to the interpretation of the data. In the practice activity analysis study, based on 47 doctors and a mean of 284 consultations in two weeks, the correlation between 'persons consulting' and 'total consultations' was 0.99. Thus the number of consultations provided a satisfactory proxy for persons consulting in a two-week study. These results justify the use of 'consultations' over two weeks as a denominator in general practice audit in circumstances where rank order is appropriate for the interpretation of data.

Family Practice↗
PubMed1985

Prescribing activity during a period of self-audit.

Prescription forms were obtained for 34 doctors who had been involved in a self-audit of psychotropic prescribing using the practice activity analysis method during the last week of February and the first of March, 1980. The forms were provided by the UK Prescription Pricing Authority after the consent of the participating doctors had been obtained. For 11 of the recorders (group 1) prescription forms were available for February and for the remaining 23 (group 2) for March. For group 1 recorders the two control weeks in the study preceded the observation week and for group 2 recorders they followed it. The total number of prescription forms issued, the number including a psychotropic drug and the number including an antibiotic were compared in the respective observation and control weeks. In group 1 there were uniform reductions of all prescribing during the observation period as compared with the controls. The reduction was attributed to a shortfall in prescription forms identified in the last week of the month. In group 2 there were no differences. The pattern of prescribing indicated by the proportions of drugs in the various categories was consistent throughout. Thus the task of undertaking self-audit did not appear to influence the underlying activity audited.

Ampicillin↗