PubMed · 4275720
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A S Emel'ianov. 1974. [Sumac dermatitis].. https://pubmed.ncbi.nlm.nih.gov/4275720/
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OBJECTIVE: To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the NHS reforms in April 1991. DESIGN: Prospective collection of data on general practitioners' referrals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases--October 1990 to March 1991 (phase 1), October 1991 to March 1992 (phase 2), and October 1993 to January 1994 (phase 3). SETTING: 10 first wave fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS: Patients referred to consultant out-patient clinics. RESULTS: NHS referral rates increased in fundholding practices in phase 2 and phase 3 of the study by 8.1/1000 patients a year (95% confidence interval 5.7 to 10.5), an increase of 7.5% from phase 1 (107.3/1000) to phase 3 (115.4/1000). Non-fundholders' rates increased significantly, by 25.3/1000 patients (22.5-28.1), an increase of 26.6% from phase 1 (95.0/1000) to phase 3 (120.3/1000). The fundholders' referral rates to private clinics decreased by 8.8%, whereas those from non-fundholding practices increased by 12.2%. The proportion of referrals going outside district boundaries did not change significantly. Three of the four practices entering the third and fourth wave of fundholding increased their referral rates significantly in the year before becoming fundholders. CONCLUSIONS: No evidence existed that budgetary pressures caused first wave fundholders to reduce referral rates, although the method of budget allocation may have encouraged general practitioners to inflate their referral rates in the preparatory year. Despite investment in new practice based facilities, no evidence yet exists that fundholding encourages a shift away from specialist care.
OBJECTIVE: To evaluate different methods for community based screening for sight threatening diabetic eye disease. DESIGN: Prospective study. SETTING: Mobile screening unit visiting inner city community clinics; hospital assessment clinic (tertiary centre). SUBJECTS: 395 diabetic patients registered with four general practices in an inner city location. INTERVENTIONS: Community based photography with mydriasis and direct ophthalmoscopy through dilated pupils by an experienced ophthalmologist, both compared with reference standard of slit lamp biomicroscopy by a consultant specialist in medical retinal disease. MAIN OUTCOME MEASURES: Sensitivity and specificity of screening method and prevalence of sight threatening diabetic eye disease (moderate preproliferative retinopathy, circinate maculopathy, exudate within 1 disc diameter of fixation, other diabetes related eye disease). RESULTS: 358 subjects underwent photography, 326 attended hospital clinic for ophthalmoscopy, and six were ungradable on photographs and biomicroscopy, leaving 320 for analysis. Of these 295 (91%) attended clinic within four months of photography. Sensitivity of detection of eye disease by photography was 89% (95% confidence interval 80% to 98%), significantly better than for direct ophthalmoscopy (65% (51% to 79%)). Analysis of patients with false negative results indicated possible improvement of photographic sensitivity to 93% by addition of stereoscopic macular pair photographs. Specificity of detection of sight threatening eye disease was 86% (82% to 90%) for photography and 97% (95% to 99%) for direct ophthalmoscopy. CONCLUSIONS: Since high sensitivity is essential for an effective screening programme, a photographic method should be considered as preferred option in national, community based screening programmes. Even in the hands of an experienced ophthalmologist, direct ophthalmoscopy is limited by weaknesses inherent to the instrument.
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