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PubMed1997

Does a teaching programme improve general practitioners' management of depression in the elderly?

General Practitioners have a central role to play in the management of depression in their older patients. However, studies suggest that GPs tend to underdiagnose and undermanage depression in this age group. Continuing Medical Education is an important part of helping GPs keep up to date and improve their practice. We set out to see what effect a half a day postgraduate training course had on the views and knowledge of a group of local GPs on the management of depression in the elderly. Twenty-one general practitioners attended the course and of these fifteen completed a questionnaire with clinical vignettes before and six weeks after the course. Analysis of the questionnaire and vignette data showed significant improvements in a number of areas: in particular, GPs' knowledge about antidepressant treatment increased, as did their preference for cognitive behavioural therapy out of a range of psychological treatments. This study indicates that a teaching package on depression in the elderly can improve general practitioner's management knowledge. It also suggests that old age psychiatrists can play an important part in the education of their GP colleagues. Nevertheless, further studies are needed to ensure that educational programmes make an effective impact on the underdiagnosis and undertreatment of depression in the elderly.

Age Factors↗
PubMed1985

Sigmoidoscopy/proctoscopy service with open access to general practitioners.

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.

Adolescent↗
PubMed1989

Outcome of pregnancies referred to a general practitioner maternity unit in a district hospital.

OBJECTIVE: To audit the outcome of pregnancies booked for confinement in a general practitioner maternity unit in a district general hospital. DESIGN: Retrospective review of case records. SETTING: General practitioner maternity unit in a district general hospital. PATIENTS: 685 Women referred to a general practitioner unit in 1987. RESULTS: 315 Nulliparous women and 330 multiparous women were booked for confinement; 202 women transferred to consultant care before delivery and a further 104 during labour or after delivery. Recognised risk factors, other than nulliparity, rarely predicted the need for transfer. Confinement in the general practitioner unit was associated with low intervention and good fetal outcomes. CONCLUSIONS: The general practitioner maternity unit provides a safe alternative for confinement in low risk pregnancies. High rates of transfer deny this facility to many women who desire confinement in a low technology environment.

Apgar Score↗
PubMed2006

The feminization of the medical work force, implications for Scottish primary care: a survey of Scottish general practitioners.

BACKGROUND: The number of women working in general practice internationally has been steadily rising. In Scotland there have been concerns that such a change may lead to increased part-time working and subsequently to a fall in available general practice manpower despite an apparently rising overall number of general practitioners. However, there is very little information on the actual hours worked by men and women general practitioners or on the types of work they are undertaking. METHODS: Anonymous workload questionnaires of all Scottish general practitioner principals and non-principals RESULTS: Response rates for general practice principals and non-principals were 67.2% and 65.2% respectively. Male principals spent on average 18% more time on general medical services (GMS) and 50% more time on non-GMS activities (such as teaching, specialist sessions, administration and research) than women (both p <0.01). This difference was similar for non-principals. In no age group did the hours worked by women doctors approach that of male doctors. CONCLUSION: Women doctors in primary care in Scotland work fewer hours in all age groups than their male counterparts. The rapidly increasing proportion of women in general practice may lead to an increasing shortfall of medical availability in the future if current work patterns are maintained. Further longitudinal research is required to establish this and man-power planning is required now to address this. More worryingly auxiliary activities such as teaching and administrative duties are not being taken up by women. This may have serious implications for the future development of the specialty in Scotland.

Adult↗
PubMed1999

Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines.

OBJECTIVES: To examine the adherence by senior NHS medical staff to the BMA guidelines on the ethical responsibilities of doctors towards themselves and their families. DESIGN: Postal semistructured questionnaire. SETTING: Four randomly selected NHS trusts and three local medical committees in South Thames region. SUBJECTS: Consultants and principals in general practice. MAIN OUTCOME MEASURES: Personal use of health services. RESULTS: The response rate was 64% (724) for general practitioners and 72% (427) for consultants after three mailings. Most (1106, 96%) respondents were registered with a general practitioner, although little use was made of their services. 159 (26%) general practitioners were registered with a general practitioner in their own practice and 80 (11%) admitted to looking after members of their family. 73 (24%) consultants would never see their general practitioner before obtaining consultant advice. Most consultants and general practitioners admitted to prescribing for themselves and their family. Responses to vignettes for different health problems indicated a general reluctance to take time off, but there were differences between consultants and general practitioners and by sex. Views on improvements needed included the possibility of a "doctor's doctor," access to out of area secondary care, an occupational health service for general practitioners, and regular health check ups. CONCLUSION: The guidelines are largely not being followed, perhaps because of the difficulties of obtaining access to general practitioners outside working hours. The occupational health service should be expanded and a general practitioner service for NHS staff piloted.

Attitude of Health Personnel↗
PubMed2005

Economic evaluation of a general practitioner with special interests led dermatology service in primary care.

OBJECTIVE: To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care. DESIGN: Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial. SETTING: General practitioner with special interest dermatology service covering 29 general practices in Bristol. PARTICIPANTS: Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest. INTERVENTIONS: Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care. MAIN OUTCOME MEASURES: Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial. RESULTS: Costs to the NHS for patients attending the general practitioner with special interest service were 208 pounds sterling (361 dollars; 308 euro) compared with 118 pounds sterling for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were 48 pounds sterling and 51 pounds sterling, respectively; costs of lost production were 27 pounds sterling and 34 pounds sterling, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were 540 pounds sterling per one point gain in the dermatology life quality index and 66 pounds sterling per 10 point change in the access scale. CONCLUSIONS: The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes.

Ambulatory Care↗
PubMed1992

Relationship between the working styles of general practitioners and the health status of their patients.

The aim of this study was to relate the working style of general practitioners to the health status of a sample of their patients. From a large regional sick fund forming part of the national health insurance system in the Netherlands a stratified sample was taken of general practitioners with at least 1000 patients on their list, taking into account the degree or urbanization of the area in which they practised and their annual referral rates to specialists. These 75 general practitioners were observed for two days in their surgeries by trained doctors and rated according to criteria defined beforehand. Taking into account these ratings and the annual figures from the sick fund for prescribing selected drugs and referrals to specialists, the general practitioners were classified into styles of practice - integrated, interventionist or minimal diagnostic. Twenty randomly selected women, aged 50-65 years, from each general practitioner's list, were interviewed and examined by independent doctors. The patients of general practitioners with the integrated practice style appeared to feel more healthy and to have more realistic expectations about the possibilities of professional help for common ailments. They tended to visit their doctor less frequently and to have fewer symptoms. The results showed an association between the quality of general practitioners and patients' health, and it may therefore be concluded that good general practitioners can further the health and well being of their patients.

Aged↗
PubMed1999

Programme to improve the use of drugs in older people and involve general practitioners in community education.

As part of a multi-pronged approach to improving the quality of drug use in the elderly, a pharmacist was contracted by the Division of General Practice (Northern Tasmania) to develop educational material and implement two academic detailing sessions for general practitioners on the issues of adverse drug reactions and drug interactions in older people. The project aimed to involve general practitioners in community education after optimizing relevant therapeutic knowledge and standardizing prescribing practices. Sixteen general practitioners were involved in the project and 13 of these agreed to participate in academic detailing. The pharmacist developed prescribing guidelines for general practitioners and discussed these and illustrative case studies at the academic detailing sessions. General practitioner-conducted education sessions were completed by nine general practitioners to groups of carers, general practitioners, nurses and older people. Despite the relatively low numbers of general practitioners involved, the results of the project were encouraging. Academic detailing by the pharmacist was well received by the general practitioners, who indicated they would be willing to participate in further sessions. Pre- and post-project multiple-choice tests on therapeutic issues in the elderly indicated a strong trend for an increase in knowledge. Analysis of general practitioners' patient records found a statistically significant decline in the median number of medications prescribed per patient during the project. There was also a statistically significant decline in prescribing of 'indicator' medications, particularly psychoactive drugs and nonsteroidal anti-inflammatory drugs in patients resident in nursing homes. The project demonstrated that academic detailing by a pharmacist can be effective as part of a combined approach to improve the quality of drug use in older people.

Aged↗
PubMed1994

Training, skills and approach to potentially difficult anaesthesia in general practitioner anaesthetists.

Seventy-six of the 92 practising South Australian rural general practitioner anaesthetists responded to a questionnaire on anaesthetic training, skills and approach to potentially difficult anaesthesia. The mean training period in anaesthesia was 7.5 months, 24% at registrar level. Eight per cent had no training, and 40% had 3 months or less. Thirty-three per cent trained exclusively overseas and 13% hold a Diploma in Anaesthesia. A total of 11,400 anaesthetics were performed by 76 general practitioners in 1992 at an average of 152 (range 2 to 1500). The mean visual analog "comfort score" in performing anaesthesia was 6.6 and correlated best with the number of procedures per year (r = 0.32, P = 0.03). Forty-six per cent of general practitioners provided anaesthesia for the 0 to 12 month age group, and only 35% had regional skills to use in obstetric anaesthesia. Patients classified as ASA grade 3 to 5, disease states such as unstable angina, severe asthma, and risk factors such as skeletal myopathy, were avoided by most general practitioners. The failed intubation rate was 50/10,000. The conclusion is that South Australian general practitioner anaesthetists exhibit a generally safe approach to selection of patients for anaesthesia, although in some instances the approach to potentially difficult anaesthesia should be more conservative.

Adult↗
PubMed1993

An audit of general practitioner requests for pelvic ultrasound: analysis of referral patterns and outcome.

OBJECTIVES: 1. To assess the information supplied by general practitioners on the gynaecological ultrasound request form and to determine how this information influences the interpretation of scans; and 2. To examine the influence of scans on the subsequent management of patients both by general practitioners and, where relevant, by hospital gynaecologists. DESIGN: Retrospective analysis of gynaecological ultrasound requests made by general practitioners. Postal questionnaire and assessment of outcome according to general practitioners' records and, where appropriate, the hospital notes. SETTING: A London teaching hospital gynaecological ultrasound department and associated general practices. SUBJECTS: Four hundred ninety-eight women referred by general practitioners for a gynaecological ultrasound scan over a one year period (1990). RESULTS: The 498 requests for gynaecological ultrasound scans included 472 primary diagnostic referrals. Seventy-one percent of general practitioners replied to the questionnaires. Overall, 46% of the scans were normal, but the proportion of normal scans fell to 21% if the date of the last menstrual period and a pregnancy test result were included on the form. Forty per cent of women scanned subsequently were referred for hospital care. CONCLUSIONS: General practitioners would appear to use the ultrasound service in a rational way and therefore there can be no justification for not allowing them open access. The positive diagnostic yield can be further improved if time is taken to supply simple relevant information which may be facilitated by a specific request form.

Abortion, Threatened↗
PubMed2003

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial.

OBJECTIVE: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Primary care. PARTICIPANTS: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). MAIN OUTCOME MEASURES: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. RESULTS: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. CONCLUSIONS: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.

Absenteeism↗
PubMed1996

Assessing general practitioners' care of adult patients with learning disability: case-control study.

OBJECTIVE: To compare general practitioners' care of adult patients with learning disability with that of control patients in the same practice. DESIGN: Case-control study of patients and controls by a structured interview study of general practitioners. SETTING: Avon. PATIENTS: 78 adult patients with learning disability and 78 age and sex matched controls--cared for by 62 general practitioners. MAIN MEASURES: Number and content of consultations and opinions of the general practitioners. RESULTS: There were more consultations for diseases of the central nervous system and of the skin among the patients than the controls (15 v 3 for central nervous system disease and 15 v 4 skin disease). There were also significantly fewer recordings of blood pressure and cervical cytology tests (34 v 51 for blood pressure and 2 v 18 for cytology). Although more patients were taking drugs affecting the central nervous system (33 v 6), more controls were taking drugs for musculoskeletal complaints (17 v 7). CONCLUSION: Although adult patients with learning disability consult with their general practitioners at equivalent rates to other patients, they get less preventive care and consult for different types of problems than do other patients. The reasons for these differences in preventive care are not clear. Carers and general practitioners should be informed of these differences to ensure that appropriate care is given.

Adult↗
PubMed1991

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.

Adult↗
PubMed1993

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES: To identify those important characteristics of doctors' and patients' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners' performance in their own consultations. DESIGN: Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING: All vocational training schemes for general practice in the Northern region of England. SUBJECTS: First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES: Trainers' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS: 6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION: The instrument produced is reliable for assessing general practitioners' performance in their own consultations.

Adolescent↗
PubMed2002

[General medicine and general practitioner. The viewpoint of the teachers at the Department of Medicine of Tunis].

The general medicine remains a same survey subject in countries where the debate began since several years. We have led an investigation by questionnaire close to 50 chosen hospitalo-academic physicians by pull to the fate on the list of teachers of the faculty of medicine of Tunis. The majority of our investigated (90%) consider that the physician general practitioner is the physician of the individual in its totality, the counselor and the family's confidant. The formation that receives the future general practitioner currently doesn't prepare it to assure his role. To form the future physician better general practitioner, we think that it's necessary to define the general practitioner role, to adapt the formation to the role of the general practitioner and the specificity of the general medicine.

Adult↗
PubMed1995

Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors.

OBJECTIVE: To compare the process and outcome of "primary care" consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department. DESIGN: Prospective, controlled intervention study. SETTING: A busy, inner city accident and emergency department in south London. SUBJECTS: Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES: Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations. RESULTS: Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners. CONCLUSION: Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Adolescent↗
PubMed1992

Do access factors affect utilisation of general practitioner services in south Auckland?

AIMS: To describe basic features of access to general practitioner services in south Auckland, and to examine the effect of different factors on utilisation of general practitioner services with particular attention to access issues. METHODS: A random population survey of relatively established residents was undertaken with the sample drawn from electoral rolls. A questionnaire was administered face-to-face by trained interviewers. RESULTS: Ninety-eight percent of respondents claimed to have a regular family doctor. The median travelling time to a respondent's general practitioner was 10 minutes. Ninety-five percent of respondents' general practitioners operated appointment systems. The median waiting time was 20 minutes, 30% felt the doctors fees stopped them going to the doctor sometimes. The average reported visiting rate was 6.9 visits per year. Poor perceived health, longer times with a given doctor and long waiting times were associated with decreased utilisation. Demographic factors were not associated with utilisation. Patient fees were not associated with utilisation in the sample. Only 23% of the variation in utilisation could be explained by the model. CONCLUSIONS: Long waiting times are associated with decreased utilisation in this population. Although there is significant dissatisfaction with general practitioner fees, this does not manifest itself in decreased utilisation. Only a small proportion of the variation in utilisation can be explained by linear models of the variables studied.

Adolescent↗