Biomedical subjects
Publications and source records attributed to M O Roland.
Computers have gained rapid acceptance in general practice. A recent development has been the use of computers to run practice appointment systems. This study demonstrates the benefits of installing a computerized appointment system, with improved service for patients, and more efficient use of time by both doctors and receptionists.
OBJECTIVES: To study the number, demography, and clinical details of patients who agreed or refused to attend centralised primary care centres for out of hours medical care and to study the satisfaction with the service of those who attended. DESIGN: Data collected by telephonists and doctors. Satisfaction questionnaires given to patients who attended. SETTING: Five out of hours primary care centres in the United Kingdom. SUBJECTS: All patients contacting the deputising service to request medical help out of hours who were asked to attend a primary care centre. The study terminated when 1000 patients had agreed to attend (200 from each centre). 1000 patients not agreeing to attend were also sampled. RESULTS: The attendance rate varied from 8.9% to 52.3% in the five centres. The overall standardised attendance rate was 22.4%. The attendance rate was highest in children under 5 (465/2380, 19.5%) and fell with increasing age. Of the 1000 sampled non-attenders, 403 said that they had no transport and 345 said that they were too ill to attend. Those who attended were seen by the doctor more quickly. There was no significant difference between the groups in the number who received a prescription (810 attenders v 820 non-attenders, P = 0.57) or who were admitted to hospital (59 v 52, P = 0.5). Satisfaction with the service among those who attended was very high; 95% (694/731) said that they would be prepared to attend under similar circumstances in the future. CONCLUSION: Most patients are not able or prepared to attend a central facility for primary care out of hours. Substantial cultural change will be necessary and careful consideration given to planning if such centres are to provide a major part of out of hours care.
Zellweger syndrome, neonatal adrenoleukodystrophy, and infantile Refsum's disease are genetic disorders characterized by the virtual absence of catalase-positive peroxisomes and a general impairment of peroxisomal functions. Recent studies in these three disorders have provided morphologic evidence of peroxisomal "ghosts" of density 1.10 g/cm3 that contain membrane proteins but lack a majority of the matrix enzyme activities. We report here the biochemical studies in a female infant with clinical features of infantile Refsum's disease whose liver and fibroblasts contained cytosolic catalase but no catalase-positive peroxisomes. Oxidation of phytanic and pipecolic acids was severely impaired, whereas oxidation of very-long-chain fatty acids and dihydroxyacetone phosphate acyltransferase activity were only partially decreased. Immunoblot analysis showed that the three peroxisomal beta-oxidation enzymes (acyl-CoA oxidase, enoyl-CoA hydratase/3-hydroxyacyl-CoA dehydrogenase, and 3-ketoacyl-CoA thiolase) were detectable in liver tissues. The 3-ketoacyl-CoA thiolase was of the mature form (41 kD), in contrast with other peroxisomal disorders with multiple enzyme deficiencies. The majority of these peroxisomal enzyme activities were associated with two subcellular membrane vesicle fractions lacking catalase: one had the density of normal peroxisomes (1.17 g/cm3), the other, yet undescribed, a lower density (1.137 g/cm3). This suggests that peroxisomes (density = 1.17 g/cm3) and structures with lower density (density = 1.137 g/cm3) found in this patient's cultured skin fibroblasts, although lacking catalase, contained functional peroxisomal enzymes. This distinguishes this disorder from other disorders of peroxisome biogenesis.
General practitioners are often reluctant to administer brief cognitive tests, and to question the relatives of patients who appear to be demented, for fear of causing distress. Diagnoses of dementia are therefore often based on guesswork, and non-demented patients may be rated as cognitively impaired in error. A randomly selected sample of 174 general practice patients aged 80 years and over were asked to complete a simple test of orientation and information in order to assess the usefulness and acceptability of such a procedure. If patients scored 10 points or less out of 12, a relative or other knowledgeable informant was questioned about their changes in mental state and behaviour. Assessments proved acceptable to patients, relatives and doctors; diagnoses were revised in 29 cases; and practical initiatives were proposed in 15 cases. Open discussions with patients and their families proved innocuous and have much to commend them.
OBJECTIVE: To investigate the relation between general practitioners' referral rates to individual specialties and the individual areas of expertise of the referring doctors. DESIGN: Data collected on referral patterns in one group practice over nine months. SETTING: General practice in suburban Birmingham consisting of five partners and a trainee. RESULTS: In 395 referrals there were large differences in referral patterns among partners for otorhinolaryngology, ophthalmology, general surgery, and dermatology. The doctors with particular expertise in otorhinolaryngology and ophthalmology had high referral rates to those specialties, and these differences persisted after allowing for case mix. CONCLUSION: A high referral rate does not necessarily imply a high level of inappropriate referral.
OBJECTIVE: To identify aspects of outpatient referral in which general practitioners', consultants', and patients' satisfaction could be improved. DESIGN: Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING: Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS: 628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES: Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS: Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients' and doctors' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.
Twenty-two patients with skin problems were identified on the basis that their general practitioner was satisfied with their management and had no intention of referring them to hospital. These patients were reviewed by one of two dermatologists who made treatment recommendations in 14 cases, and these suggestions were taken up by 11 patients. Six patients reported definite subjective improvement in their skin condition six weeks later. The general practitioners found the consultation valuable in 17 cases. Although these patients might have improved without the dermatologists' intervention, a group of patients may exist who would benefit from specialist advice, even though that advice has not been sought. Restriction on hospital referrals could therefore be detrimental to patient care. Controlled trials could be conducted to determine the benefit of specialist advice on patients not currently seen in hospital.
Detailed referral information from one practice was used to investigate the effect of calculating referral rates in several different ways. Referral rates for individual general practitioners should be related to the number of consultations carried out and not to the number of registered patients; for whole practices list size may be used as the denominator. Most doctors will not need to control for age and sex of patients when comparing referral rates but may need to control for case mix when comparing referral rates to individual specialties. In addition, a method is described for distinguishing systematic variation between the referral rates of individual doctors from the random variation that may arise from data based on fairly small numbers of referrals. The method indicates whether systematic variation is greater than would be expected by chance, and it can be extended to indicate whether variability in referral rates is greater in one specialty than another. Because of random variation with time a year's data may not be sufficient to allow reliable interpretation of referral rates to individual specialties, except for the largest. At present there is no known relation between high or low referral rates and quality of care. Nevertheless, if doctors are to interpret their own rates of referral they need those rates to be reliable and valid. Use of the 10 guidelines described in this paper will help to prevent unwarranted conclusions being drawn from information on general practitioners' rates of referral to hospital.
In an attempt to develop a measure of the referral behaviour of general practitioners, 21 simulated case histories were constructed which presented between three and six stages at which a decision was required whether or not refer a 'patient' to hospital. Twenty general practitioners completed the case histories and their responses were compared with their referral rates to outpatient departments. No significant correlations were found between the doctors' responses to the vignettes and their actual referral rates, and the repeatability of the vignettes was disappointing. The fact that the case histories appeared realistic to the doctors who completed them was not reflected in objective measures of their validity. Simulated case histories should not be used as a method of measuring doctors' behaviour without establishing their validity and reliability.
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A 20-fold variation in referral rates from general practitioners to hospital outpatient departments has been shown in studies published to date. Most of the hypotheses proposed to account for this variation have not been supported by these studies. A simple model was constructed, which showed that a significant part of the variation may be due to the fairly small numbers of referrals in most studies. Real differences may have been swamped by random variations in the small numbers of referrals. The statistical power of the studies may not have been high enough to determine which factors were significant in describing the variation and how much of the variation was due to differing clinical practice. There remains a substantial part of the variation that cannot be accounted for.
In a study of referrals to East Anglian hospitals 737 referrals in six specialties from three general practices were examined to see how accurately the hospital computer master index had identified the referring practice, the referring general practitioner and the doctor with whom the patient was registered. Although the practice was accurately identified by the hospital computer in 97% of referrals, the identification of the referring doctor and the patient's registered general practitioner were less reliable (72% and 49% respectively). It is concluded that at present the practice rather than the individual doctor may be the appropriate unit of analysis for studies of general practitioners' referral rates. This may be true for other performance indicators where information on a doctor's case mix and workload is not available. The results of this study emphasize that problems may arise if data relating to individual general practitioners are interpreted out of context of the practice and the way in which it is organized.
Concern is growing about the number of elderly people dying of hypothermia. A register was compiled of patients over 75 on a general practitioner's list who were identified from their medical records as being at risk of hypothermia, having two or more established risk factors. Twenty four patients from this register were visited early in winter by a doctor to discuss how hypothermia could be prevented. They were then revisited during very cold weather to see whether they had made any changes. Several improvements to heating arrangements were noted, but the median temperature in the bedrooms of houses with no central heating was 10 degrees C below the World Health Organisation's recommended temperature. In addition, eight patients were not visited daily. Even with media publicity and visits from carers and a doctor, 17 of the 24 elderly people studied continued to live in an environment in which they were at risk of developing hypothermia.
It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government's recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.
An experiment was carried out in which patients who were seeking appointments for a consultation in a general practice in south London attended consulting sessions booked at 5, 7.5, or 10 minute intervals. The particular session that the patient attended was determined non-systematically. The clinical content of the consultation was recorded on an encounter sheet and on audio-tape. At the end of each consultation patients were invited to complete a questionnaire designed to measure satisfaction with the consultation. The stress engendered in doctors carrying out surgery sessions booked at different intervals of time was also measured. At surgery sessions booked at 5 minute intervals, compared with 7.5 and 10 minute intervals, the doctors spent less time with the patients and identified fewer problems, and the patients were less satisfied with the consultation. Blood pressure was recorded twice as often in surgery sessions that were booked at 10 minute intervals compared with those booked at 5 minute intervals. There was no evidence that patients who attended sessions booked at shorter intervals received more prescriptions, were investigated or referred more often to hospital specialists, or returned more often for further consultations within four weeks. There was no evidence that the doctors experienced more stress in dealing with consultations that were booked at 5 minute intervals than at consultations booked at 7.5 and 10 minute intervals, though they complained of shortage of time more often in surgery sessions that were booked at shorter intervals.
In a study in which patients were allocated non-systematically to surgeries booked at 5, 7.5, and 10 minute intervals 623 consultations were taperecorded. In surgeries booked at longer intervals doctors used the extra time to take a fuller history from their patients. In surgeries booked at 10 minute intervals doctors spent more time explaining the patient's problem, explaining the proposed management, and in discussing prevention and health education, these increases not being evident in surgeries booked at 7.5 minute intervals.
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After introducing a computer assisted repeat prescribing programme into a south London practice improvements were made in several aspects of practice organisation. Time was saved by doctors and receptionists; prescriptions were produced more rapidly; information in the records about drugs that were available for repeat prescription was improved; and queries from chemists about prescriptions were reduced. The costs of the system in terms of computer operator time were estimated. Computerising prescribing data provides a source of data that may be used to enable doctors to audit their own prescribing.