SEARCH · Search PubMed

Results for “generalization”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

SourceResearch connectionFrom yearThrough year

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,369 records · Page 76Linked to original sources

PubMed1990

Rectal examination in general practice.

OBJECTIVE: To investigate factors influencing a general practitioner's decision to do a rectal examination in patients with anorectal or urinary symptoms. DESIGN: Postal questionnaire survey. SETTING: General practices in inner London and Devon. SUBJECTS: 859 General practitioners, 609 (71%) of whom returned the questionnaire. MAIN OUTCOME MEASURES: Number of rectal examinations done each month; the indication score, derived from answers to a question asking whether the respondent would do a rectal examination for various symptoms; and the confidence score, which indicated the respondent's confidence in the diagnosis made on rectal examination. RESULTS: 279 General practitioners did five or fewer rectal examinations each month and 96 did more than 10 each month. Factors significantly associated with doing fewer rectal examinations were a small partnership and being a female general practitioner, and the expectation that the examination would be repeated. Lack of time in the surgery, and a waiting time of less than two weeks for an urgent outpatient appointment were also important. General practitioners were deterred from doing rectal examinations by reluctance of the patient (278), the expectation that the examination would be repeated (141), and lack of time (123) or a chaperone (39). Confidence in diagnosis was significantly associated with doing more rectal examinations, the perception of having been well taught to do a rectal examination at medical school, and being a male general practitioner. CONCLUSIONS: Factors other than clinical judgment influence the frequency of rectal examination in general practice. Rectal examination may become commoner with the trend towards larger group practices and if diagnostic confidence is increased and greater emphasis put on rectal examination in undergraduate and postgraduate teaching.

Attitude of Health Personnel↗

PubMed1992

Workload of general practitioners before and after the new contract.

OBJECTIVE: To assess changes in general practitioners' workload associated with the new contract introduced in April 1990. DESIGN: Weekly workload diary completed during four weeks in February-March 1990 and during the same period in 1991. SETTING: Sheffield, United Kingdom. SUBJECTS: All 300 general practitioners on Sheffield Family Health Services Authority list as principals in 1990 and 1991. MAIN OUTCOME MEASURES: Mean number of hours worked per week, number of patients seen each week, and mean time spent per patient. RESULTS: 181 (60%) general practitioners responded in 1990 and 163 (54%) in 1991. Of these, 18 (10%) were not working in 1990 and 14 (7%) in 1991. General medical service work increased during a "normal working week" from a mean of 38.6 hours a week in 1990 to 40.6 hours in 1991, and non-general medical service work decreased from 5.4 hours a week to 4.5 hours. Hours spent on call were similar before and after the contract. For the 99 general practitioners who responded in both years, time spent on general medical service duties increased significantly (40.5 h in 1990 v 42.5 h [corrected] in 1991; p = 0.033), mainly due to more time being spent in clinics. Significantly more patients were being seen in clinics (9 v 14; p = 0.001); the average time spent per patient remained at about 8 1/2 minutes during surgeries and 16 minutes for a home visit, and rose from 13 to 14 minutes for patients seen in clinics. The time spent on practice administration fell but not significantly. CONCLUSION: Since the new contract there has been a significant increase in general medical services work, mainly due to more patients being seen in clinics, with no reduction in the time spent per patient.

Contract Services↗

PubMed1992

Study of diagnostic accord between general practitioners and an ophthalmologist.

OBJECTIVES: To identify diagnostic accord and disagreement between general practitioners and an ophthalmologist and thereby determine how undergraduate and non-specialist postgraduate ophthalmic training could be improved. DESIGN: Comparison of diagnosis of presenting conditions by general practitioners and one ophthalmologist in patients consulting general practitioners for ophthalmic problems during March 1989 to February 1990. SETTING: 12 general practices in west Nottingham. PATIENTS: 1474 patients presenting to the study general practitioners with new ophthalmic conditions or new episodes of recurrent conditions. MAIN OUTCOME MEASURES: Diagnoses of general practitioners and ophthalmologist. RESULTS: 1121 (76%) of patients with eye problems agreed to see the ophthalmologist and most were seen within three days. Sufficient data for comparison were available on 1103 patients. Diagnostic agreement was found in 638 cases (58%), but potentially serious misdiagnosis was found in only 15 cases; management in three of these cases would have ensured later identification. Most commonly confused conditions were infective and allergic conjunctivitis, blepharitis, and dry eyes. General practitioners assessed visual acuity in only 114 cases yet eight of the 15 patients seriously misdiagnosed had reduced acuity, an important diagnostic sign. CONCLUSIONS: Most ophthalmic disease seen in general practice does not require specialised equipment for diagnosis. Most cases of misdiagnosis have no serious consequences for the patient. Undergraduate and postgraduate training in ophthalmology should ensure that common conditions can be easily differentiated and more serious conditions identified and referred.

Clinical Competence↗

PubMed1992

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91.

OBJECTIVE: To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this. DESIGN: A retrospective case-control study. SETTING: South east Scotland. SUBJECTS: All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91. OUTCOME MEASURES: Demographic details of patients; Breslow thickness, clearance of excision. RESULTS: 42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis. CONCLUSIONS: General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.

Adult↗

PubMed1993

The views of singlehanded general practitioners: a qualitative study.

OBJECTIVES: To examine the concerns of singlehanded general practitioners working in an inner London area and to compare the views of general practitioners in partnerships. DESIGN: Qualitative analysis of semistructured interviews with a random sample of singlehanded general practitioners and a sample of general practitioners from partnerships matched for age and sex. SETTING: The area covered by Lambeth, Southwark, and Lewisham Family Health Services Authority. RESULTS: The singlehanded general practitioners were more likely to be older, male, and first qualified abroad than general practitioners in partnerships. Their major concerns were inadequate premises, maintaining their singlehanded status, and coping with recent changes to their contract. Most were very satisfied with their solo status and did not see the provision of 24 hour care as stressful. CONCLUSION: Singlehanded general practitioners saw themselves as providing a unique service for patients, and their status as an alternative for general practitioners who were unhappy in partnerships. Such practices are unlikely to wither away as a pattern of provision. Any comprehensive development of primary care must take their needs into account.

Attitude of Health Personnel↗

PubMed1993

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

OBJECTIVES: To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines. SETTING: Practices within Cambridge Health Authority and Addenbrooke's Hospital, Cambridge. MAIN OUTCOME MEASURES: Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice. RESULTS: There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral). CONCLUSION: The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.

Decision Making↗

PubMed1994

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE: To gain insight into decisions made in general practice about the end of life. DESIGN: Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS: Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION: Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.

Aged↗

PubMed1994

Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers.

OBJECTIVE: To study stress, anxiety, and depression in a group of senior health service staff. DESIGN: Postal survey. SUBJECTS: 81 hospital consultants, 322 general practitioners, and 121 senior hospital managers (total 524). MAIN OUTCOME MEASURES: Scores on the general health questionnaire and the hospital anxiety and depression scale. RESULTS: Sixty five (80%) consultants, 257 (80%) general practitioners, and 67 (56%) managers replied. Of all 389 subjects, 183 (47%) scored positively on the general health questionnaire, indicating high levels of stress. From scores on the hospital anxiety and depression scale only 178 (46%) would be regarded as free from anxiety, with 100 (25%) scoring as borderline cases and 111 (29%) likely to be experiencing clinically measurable symptoms. The findings for depression were also of some concern, especially for general practitioners, with 69 (27%) scoring as borderline or likely to be depressed. General practitioners were more likely to be depressed than managers (69 (27%) v 4 (6%) scored > or = 8 on hospital anxiety and depression scale-D; P = 0.004) with no significant difference between general practitioners and consultants. General practitioners were significantly more likely to show suicidal thinking than were consultants (36 (14%) v 3 (5%); P = 0.04) but not managers (9 (13%)). No significant difference could be found between the three groups on any other measure. CONCLUSIONS: The levels of stress, anxiety, and depression in senior doctors and managers in the NHS seem to be high and perhaps higher than expected.

Anxiety↗

PubMed1994

Careers in academic general practice: problems, constraints, and opportunities.

Changing priorities in the NHS have underlined the crucial importance of academic general practice in providing quality training and research to underpin developments in general practice. Unfortunately, several problems and constraints mean that the full potential of general practitioners to make a contribution to teaching and research has not been realised. These issues are examined and recommendations for improvements are made. Obstacles to career development for academics in general practice should be removed. The funding of academic general practice should be the same as for other medical disciplines. Vocational training for general practice should be extended to include research and audit methods, particularly for doctors interested in an academic career. Above all, the long term objective should be to integrate undergraduate and post-graduate general practice to increase the overall effectiveness of teaching and research and hence the quality of service general practice.

Academic Medical Centers↗

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↗

PubMed1996

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars.

OBJECTIVES: To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN: Prospective intervention study which was later costed. SETTING: Inner city accident and emergency department in south east London. SUBJECTS: 4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES: Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS: Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor's manner (434/492 (88%)). Patients' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION: Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.

Consultants↗

PubMed1998

General practitioner's perceptions of the route to evidence based medicine: a questionnaire survey.

OBJECTIVES: To determine the attitude of general practitioners towards evidence based medicine and their related educational needs. DESIGN: A questionnaire study of general practitioners. SETTING: General practice in the former Wessex region, England. SUBJECTS: Randomly selected sample of 25% of all general practitioners (452), of whom 302 replied. MAIN OUTCOME MEASURES: Respondents' attitude towards evidence based medicine, ability to access and interpret evidence, perceived barriers to practising evidence based medicine, and best method of moving from opinion based to evidence based medicine. RESULTS: Respondents mainly welcomed evidence based medicine and agreed that its practice improves patient care. They had a low level of awareness of extracting journals, review publications, and databases (only 40% knew of the Cochrane Database of Systematic Reviews), and, even if aware, many did not use them. In their surgeries 20% had access to bibliographic databases and 17% to the world wide web. Most had some understanding of the technical terms used. The major perceived barrier to practising evidence based medicine was lack of personal time. Respondents thought the most appropriate way to move towards evidence based general practice was by using evidence based guidelines or proposals developed by colleagues. CONCLUSION: Promoting and improving access to summaries of evidence, rather than teaching all general practitioners literature searching and critical appraisal, would be the more appropriate method of encouraging evidence based general practice. General practitioners who are skilled in accessing and interpreting evidence should be encouraged to develop local evidence based guidelines and advice.

Attitude of Health Personnel↗

PubMed1999

General practitioners' perceptions of effective health care.

OBJECTIVES: To explore general practitioners' perceptions of effective health care and its application in their own practice; to examine how these perceptions relate to assumptions about clinicians' values and behaviour implicit in the evidence based medicine approach. DESIGN: A qualitative study using semistructured interviews. SETTING: Eight general practices in North Thames region that were part of the Medical Research Council General Practice Research Framework. PARTICIPANTS: 24 general practitioners, three from each practice. MAIN OUTCOME MEASURES: Respondents' definitions of effective health care, reasons for not practising effectively according to their own criteria, sources of information used to answer clinical questions about patients, reasons for making changes in clinical practice. RESULTS: Three categories of definitions emerged: clinical, patient related, and resource related. Patient factors were the main reason given for not practising effectively; others were lack of time, doctors' lack of knowledge and skills, lack of resources, and "human failings." Main sources of information used in situations of clinical uncertainty were general practitioner partners and hospital doctors. Contact with hospital doctors and observation of hospital practice were just as likely as information from medical and scientific literature to bring about changes in clinical practice. CONCLUSIONS: The findings suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic. The promotion of effective care in general practice requires a broader vision and a more pragmatic approach which takes account of practitioners' concerns and is compatible with the complex nature of their work.

Adult↗

PubMed1999

Explaining variation in hospital admission rates between general practices: cross sectional study.

OBJECTIVES: To quantify the extent of the variation in hospital admission rates between general practices, and to investigate whether this variation can be explained by factors relating to the patient, the hospital, and the general practice. DESIGN: Cross sectional analysis of routine data. SETTING: Merton, Sutton, and Wandsworth Health Authority, which includes areas of inner and outer London. SUBJECTS: 209 136 hospital admissions in 1995-6 in patients registered with 120 general practices in the study area. MAIN OUTCOME MEASURES: Hospital admission rates for general practices for overall, emergency, and elective admissions. RESULTS: Crude admission rates for general practices displayed a twofold difference between the 10th and the 90th centile for all, emergency, and elective admissions. This difference was only minimally reduced by standardising for age and sex. Sociodemographic patient factors derived from census data accounted for 42% of the variation in overall admission rates; 45% in emergency admission rates; and 25% in elective admission rates. There was a strong positive correlation between factors related to deprivation and emergency, but not elective, admission rates, raising questions about equity of provision of health care. The percentage of each practice's admissions to different local hospitals added significantly to the explanation of variation, while the general practice characteristics considered added very little. CONCLUSIONS: Hospital admission rates varied greatly between general practices; this was largely explained by differences in patient populations. The lack of significant factors related to general practice is of little help for the direct management of admission rates, although the effect of sociological rather than organisational practice variables should be explored further. Admission rates should routinely be standardised for differences in patient populations and hospitals used.

Cross-Sectional Studies↗

PubMed1999

General practice and the care of children with HIV infection: 6 month prospective interview study.

OBJECTIVES: To describe the use of primary care services by children infected with HIV and to explore the attitudes of their parents to the role of general practitioners in their children's care. DESIGN: A 6 month prospective study. Quantitative analysis of "contact diaries" kept by parents; qualitative analysis of face to face interviews with parents. PARTICIPANTS: Parents of children receiving care at a regional referral centre in London. RESULTS: Twenty four families (80% response rate) were recruited to the study. In 19 families the mother was black African. Half the children had been diagnosed with symptomatic HIV infection, half with AIDS. All the children were registered with a general practitioner who knew of the child's HIV infection. In five families there had initially been tensions in their relationship with their general practitioner but by the time of the study all but one family had established at least an "acceptable" relationship. Children with symptomatic HIV infection saw their general practitioner a mean of 7.5 times per patient year; for children with AIDS the figure was 5.8. Parents regarded the paediatric HIV team at the hospital as their primary source of medical care. Three factors constrained their use of general practice: their own anxieties about distinguishing "normal" symptoms from those related to HIV infection; their view that their general practitioner did not feel competent to treat HIV infected children; and their concerns about maintaining confidentiality in the surgery. CONCLUSIONS: Parents remain oriented towards the paediatric HIV team as their primary source of medical care and use general practice largely for routine prescriptions for their children. Any further development of the general practitioner's role will need to build on existing relationships with specialist providers and take account of parents' concerns.

Child↗

PubMed2000

Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care.

OBJECTIVE: To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care. DESIGN: Multicentre randomised controlled trial of patients requesting an appointment the same day. SETTING: 20 general practices in England and Wales. PARTICIPANTS: 1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations). MAIN OUTCOME MEASURES: Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs. RESULTS: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4. 20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37. 2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner 18.ll pound sterling v general practitioner 20.70 pound sterling adjusted difference 2.33 pound sterling - 1.62 pound sterling to 6.28 pound sterling). CONCLUSIONS: The clinical care an health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners.

Adolescent↗

PubMed2002

General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial.

OBJECTIVES: To evaluate the impact of an intervention based in general practice on the incidence of repeat episodes of deliberate self harm. DESIGN: Cluster randomised controlled trial in which 98 general practices were assigned in equal numbers to an intervention or a control group. The intervention comprised a letter from the general practitioner inviting the patient to consult, and guidelines on assessment and management of deliberate self harm for the general practitioner to use in consultations. Control patients received usual general practitioner care. SETTING: General practices within Avon, Wiltshire, and Somerset Health Authorities, whose patients lived within the catchment area of four general hospitals in Bristol and Bath. PARTICIPANTS: 1932 patients registered with the study practices who had attended accident and emergency departments at one of the four hospitals after an episode of deliberate self harm. MAIN OUTCOME MEASURES: Primary outcome was occurrence of a repeat episode of deliberate self harm in the 12 months after the index episode. Secondary outcomes were number of repeat episodes and time to first repeat. RESULTS: The incidence of repeat episodes of deliberate self harm was not significantly different for patients in the intervention group compared with the control group (odds ratio 1.2, 95% confidence interval 0.9 to 1.5). Similar findings were obtained for the number of repeat episodes and time to first repeat. Subgroup analyses indicated that there was no differential effect of the intervention according to patient's sex (P=0.51) or method used to cause deliberate self harm (P=0.64). The treatment seemed to be beneficial for people with a history of deliberate self harm, but it was associated with an adverse effect in people for whom the index episode was their first episode (interaction P=0.017). CONCLUSIONS: An invitation to consult, sent by the general practitioner of patients who have deliberately harmed themselves, and the use of management guidelines during any subsequent consultation did not reduce the incidence of repeat self harm. A subgroup analysis that indicated that patients who had previously harmed themselves benefited from the intervention was inconsistent with previous evidence and should be treated with caution. More research is needed on how to manage patients who deliberately harm themselves, to reduce the incidence of repeat episodes.

Adolescent↗

PubMed2004

Impact of nurse practitioners on workload of general practitioners: randomised controlled trial.

OBJECTIVE: To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team. DESIGN: Randomised controlled trial with measurements before and after the introduction of nurse practitioners. SETTING: 34 general practices in a southern region of the Netherlands. PARTICIPANTS: 48 general practitioners. INTERVENTION: Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse. MAIN OUTCOME MEASURES: Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention. RESULTS: The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload. CONCLUSION: Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.

Family Practice↗