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PubMed1993

Sex differences among recipients of benzodiazepines in Dutch general practice.

OBJECTIVE: To analyse sex differences among recipients of benzodiazepines in Dutch general practice. DESIGN: Study of consultations and associated interventions as recorded in the Dutch national survey of general practice. SETTING: Practices of 45 general practitioners monitored during 1 April to 30 June 1987. SUBJECTS: 61,249 patients (29,035 (47.4%) men in the age groups 19-44, 45-64, and 65 years and over. MAIN OUTCOME MEASURES: Symptoms among recipients of repeat as well as new benzodiazepine prescriptions stratified by sex and age. RESULTS: Prescriptions for benzodiazepines were found to be significantly more common among women than among men, (a) after correcting for the sex distribution of the total patient population, and (b) in the two oldest age groups after correcting for the number of consultations. Of all prescriptions for benzodiazepines, 89% (6055/6777) were repeats and 70% (4759/6777) requests. Only 9% (439/4759) of these were authorized by the general practitioner, the rest being issued by the general practitioner's assistant after he or she had referred to the diagnosis in the patient's record. In contrast, only three (1%) of the 492 first time recipients of benzodiazepines had requested a prescription and were not seen by the general practitioner. Women (43/96; 45%) aged 45-64 years received their first prescription for benzodiazepines almost twice as often as men (15/63; 24%) without symptoms or a diagnosis being an indication (female to male relative risk 1.88 (95% confidence interval 1.15 to 3.08)). CONCLUSIONS: The sex difference among first time recipients of benzodiazepines seems to be due to general practitioners being less stringent when prescribing this drug for women. The difference continues in repeat prescriptions, physicians failing to check adequately the need for these.

Adult↗
PubMed1993

General practitioners' attitudes to professional reaccreditation.

OBJECTIVE: To determine the views of general practitioners about professional reaccreditation. DESIGN: Postal questionnaire. SUBJECTS: All 278 general practitioner principals working in Cleveland. MAIN OUTCOME MEASURES: General practitioner characteristics; attitudes to reaccreditation; and views on the development, conduct, content, and format of reaccreditation. RESULTS: 210 out of 278 (76%) general practitioners responded to the questionnaire. 128 (61%) agreed that general practitioners should undergo reaccreditation. 149 (72%) thought the General Medical Services Committee and local medical committees were appropriate bodies to lead its development. 120 respondents suggested that reaccreditation should be carried out by assessors appointed by the doctor's own local medical committee. The most favoured interval between reaccreditation episodes was 10 or more years. 152 doctors thought that doctors who failed reaccreditation should be advised on education and reassessed soon afterwards. Clinical knowledge (82%), clinical skill (82%), prescribing practices (67%), standards of medical record keeping (60%), and consultation behaviour (58%) were the most popular subjects for scrutiny. 138 (67%) respondents felt that reaccreditation should be part of continuing medical education. CONCLUSION: Most general practitioners support professional reaccreditation. They believe the process should be led by the profession, be educational, and take account of a range of professional activities.

Accreditation↗
PubMed1994

Specialist outreach clinics in general practice.

OBJECTIVES: To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists' and general practitioners' views on outreach clinics. DESIGN: Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. SETTING: 50 hospitals in England and Wales. SUBJECTS: 50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. MAIN OUTCOME MEASURES: Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. RESULTS: 28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. CONCLUSIONS: Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.

Appointments and Schedules↗
PubMed1996

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN: Multicentre randomised controlled trial. SETTING: 51 general practices linked to nine Scottish maternity hospitals. SUBJECTS: 1765 women at low risk of antenatal complications. INTERVENTION: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES: Comparisons of health service use, indicators of quality of care, and women's satisfaction. RESULTS: Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.

Clinical Protocols↗
PubMed1996

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost.

OBJECTIVE: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost. DESIGN: A randomised controlled trial. SETTING: A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis. PATIENTS: All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion. MAIN OUTCOME MEASURES: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences. RESULTS: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively. CONCLUSION: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.

Adult↗
PubMed1999

Questionnaire study and audit of use of angiotensin converting enzyme inhibitor and monitoring in general practice: the need for guidelines to prevent renal failure.

OBJECTIVES: To determine the current pattern of use of angiotensin converting enzyme inhibitor and monitoring of renal function in general practice and to audit all admissions to a regional renal unit for uraemia related to use of these drugs. DESIGN: Postal questionnaire sent to 400 general practitioners; audit of clinical notes of all patients receiving these drugs in one large general practice; audit of all cases of uraemia (creatinine concentration >500 micromol/l) related to treatment presenting to hospital renal services over 12 months. SETTING: General practices in the North Wales health authority and one in central Manchester. Regional renal unit in Salford. MAIN OUTCOME MEASURES: Proportion of general practitioners who regularly monitored renal function before and after initiation of angiotensin converting enzyme inhibitors. Indications for treatment and details of monitoring of renal function in patients receiving these drugs. Incidence of related uraemia and evidence of comorbid disease, other aetiological factors, delayed detection, and patient outcome. RESULTS: 277 (69%) general practitioners replied; 235 (85%) checked renal function before but only 93 (34%) after the start of treatment, and 42 (15%) never checked renal function. Angiotensin converting enzyme inhibitors were prescribed for 162 patients from a total of 3625 aged >35 years (mean age 66.4 (SD 15.9) years). Monitoring of renal function occurred before treatment in 55 (45%) and after start of treatment in 35 (29%) of the 122 patients treated in general practice. Angiotensin converting enzyme inhibitors could be causally implicated in 9 (7%) of 135 admissions for uraemia (mean age 74.2 (7. 2) v 62.1 (2.1) years; P<0.01). 3 patients had renovascular disease and 6 had congestive cardiac failure with another intercurrent illness. Renal function had not been checked in any patient after the start of treatment; mean duration of illness before admission was 10.5 (3.2) days. Mean length of hospital stay was 20.9 (10.4) days; there were 8 survivors. CONCLUSION: Cases of uraemia related to treatment with angiotensin converting enzyme inhibitors are still encountered and are often detected late because of lack of judicious monitoring of renal function in vulnerable, often elderly, patients, especially at times of intercurrent illness. Guidelines for appropriate monitoring of renal function may help to minimise the problem.

Acute Kidney Injury↗
PubMed1999

Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance. The Infectious Intestinal Disease Study Executive.

OBJECTIVE: To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners. Comparison with incidence and aetiology of cases reaching national laboratory based surveillance. DESIGN: Population based community cohort incidence study, general practice based incidence studies, and case linkage to national laboratory surveillance. SETTING: 70 general practices throughout England. PARTICIPANTS: 459 975 patients served by the practices. Community surveillance of 9776 randomly selected patients. MAIN OUTCOME MEASURES: Incidence of infectious intestinal disease in community and reported to general practice. RESULTS: 781 cases were identified in the community cohort, giving an incidence of 19.4/100 person years (95% confidence interval 18.1 to 20.8). 8770 cases presented to general practice (3.3/100 person years (2.94 to 3.75)). One case was reported to national surveillance for every 1.4 laboratory identifications, 6.2 stools sent for laboratory investigation, 23 cases presenting to general practice, and 136 community cases. The ratio of cases in the community to cases reaching national surveillance was lower for bacterial pathogens (salmonella 3.2:1, campylobacter 7.6:1) than for viruses (rotavirus 35:1, small round structured viruses 1562:1). There were many cases for which no organism was identified. CONCLUSIONS: Infectious intestinal disease occurs in 1 in 5 people each year, of whom 1 in 6 presents to a general practitioner. The proportion of cases not recorded by national laboratory surveillance is large and varies widely by microorganism. Ways of supplementing the national laboratory surveillance system for infectious intestinal diseases should be considered.

Adolescent↗
PubMed1999

General practitioners' experiences of patients' complaints: qualitative study.

OBJECTIVE: To examine how general practitioners experience patients' complaints. SETTING: General practices in Lambeth, Southwark, and Lewisham health authority. PARTICIPANTS: Representative sample of 30 general practitioners who had had complaints made against them under either the old or new complaints system. DESIGN: Qualitative study with detailed interviews. RESULTS: Participants described their experiences of patients' complaints in three stages: initial impact, conflict, and resolution. The first stage described being out of control, feelings of shock and panic, and a sense of indignation towards patients generally. The second stage described the many conflicts generated by the complaint: emotional conflicts such as feelings of anger, depression, and even suicide, conflicts around aspects of professional identity including doubts about clinical competence, conflicts with family and colleagues, and conflicts arising from the management of the complaint. The third stage described a sense of resolution. For many this meant practising defensively, for others it meant planning to leave general practice, and for a minority no resolution was achieved. Not all participants, however, reported such a negative experience. Some described how they had become immune to complaints, and a small minority described the complaint as a learning experience. CONCLUSION: The initial impact stage and conflict stage may be necessary aspects of the experience that general practitioners endure when they have a complaint made against them. Support structures should, however, be in place to help general practitioners through these stages.

Attitude of Health Personnel↗
PubMed1999

Tensions between policy makers and general practitioners in implementing new genetics: grounded theory interview study.

OBJECTIVE: To explore general practitioners' perceptions of their role in implementing genetic technology. DESIGN: Grounded theory interview study. SETTING: Primary care. SUBJECTS: Purposive sample of 30 general practitioners with a further theoretical sample of 14. RESULTS: Inconsistencies were identified between policy makers' and general practitioners' definitions of general practitioners' role in implementing the new genetics. General practitioners emphasised the need to build on current practice, whereas policy makers focused on transforming practice to include the new specialised roles and skills. Two core themes were identified: genetics in a generalist context, which included appropriate generalist intervention, the ethical dilemmas implicit in the "therapeutic gap," the familial-hereditary distinction in primary care, and the implications for generalist identity, including the potential marginalisation of generalism. CONCLUSION: New technologies such as genetics that require implementation in general practice should be integrated within existing generalist frameworks.

Ethics, Medical↗
PubMed2000

Cross sectional study of reporting of epileptic seizures to general practitioners.

OBJECTIVE: Comparison of reporting of recent epileptic seizures by patients to a doctor and anonymously. DESIGN: Cross sectional study of patients with epilepsy by comparison of paired questionnaires. SETTING: Rural and urban general practices in Norfolk. PARTICIPANTS: 122 patients aged over 16 years and able to self complete a questionnaire who were recruited by 31 general practitioners when attending for review of their epilepsy. MAIN OUTCOME MEASURE: The difference in reported occurrence of seizure to general practitioners and in a linked anonymous questionnaire. RESULTS: 18 patients failed to report a seizure in the past year to their general practitioner (uncontrolled epilepsy). 40% (24/60) of people with epilepsy who anonymously reported a seizure in the past year held a driving licence, but only six revealed this to their general practitioner. The unemployment rate was 34%, substantially higher than the 9% in the general population. Measures of anxiety, depression, and stigmatization were higher in patients with uncontrolled epilepsy. CONCLUSIONS: A significant proportion of patients with epilepsy under-report their seizures. Recognition of underreporting is important if patients are to benefit from adequate and appropriate treatment. General practitioners' ability to treat epilepsy is hampered by their role in regulating the rights of epileptic patients to hold a driving licence or access certain occupations.

Adolescent↗
PubMed2000

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: clinical effectiveness.

OBJECTIVE: To compare the clinical effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients. DESIGN: Prospective, controlled trial with randomised and patient preference allocation arms. SETTING: General practices in London and greater Manchester. PARTICIPANTS: 464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion. INTERVENTIONS: Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists. MAIN OUTCOME MEASURES: Beck depression inventory scores, other psychiatric symptoms, social functioning, and satisfaction with treatment measured at baseline and at 4 and 12 months. RESULTS: 197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. All groups improved significantly over time. At four months, patients randomised to non-directive counselling or cognitive-behaviour therapy improved more in terms of the Beck depression inventory (mean (SD) scores 12.9 (9.3) and 14.3 (10.8) respectively) than those randomised to usual general practitioner care (18.3 (12.4)). However, there was no significant difference between the two therapies. There were no significant differences between the three treatment groups at 12 months (Beck depression scores 11.8 (9.6), 11.4 (10.8), and 12.1 (10.3) for non-directive counselling, cognitive-behaviour therapy, and general practitioner care). CONCLUSIONS: Psychological therapy was a more effective treatment for depression than usual general practitioner care in the short term, but after one year there was no difference in outcome.

Adult↗
PubMed2003

Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial.

OBJECTIVE: To assess the long term effectiveness of the "green prescription" programme, a clinician based initiative in general practice that provides counselling on physical activity. DESIGN: Cluster randomised controlled trial. Practices were randomised before systematic screening and recruitment of patients. SETTING: 42 rural and urban general practices in one region of New Zealand. SUBJECTS: All sedentary 40-79 year old patients visiting their general practitioner during the study's recruitment period. INTERVENTION: General practitioners were prompted by the patient to give oral and written advice on physical activity during usual consultations. Exercise specialists continued support by telephone and post. Control patients received usual care. MAIN OUTCOME MEASURES: Change in physical activity, quality of life (as measured by the "short form 36" (SF-36) questionnaire), cardiovascular risk (Framingham and D'Agostino equations), and blood pressure over a 12 month period. RESULTS: 74% (117/159) of general practitioners and 66% (878/1322) of screened eligible patients participated in the study. The follow up rate was 85% (750/878). Mean total energy expenditure increased by 9.4 kcal/kg/week (P=0.001) and leisure exercise by 2.7 kcal/kg/week (P=0.02) or 34 minutes/week more in the intervention group than in the control group (P=0.04). The proportion of the intervention group undertaking 2.5 hours/week of leisure exercise increased by 9.72% (P=0.003) more than in the control group (number needed to treat=10.3). SF-36 measures of self rated "general health," "role physical," "vitality," and "bodily pain" improved significantly more in the intervention group (P<0.05). A trend towards decreasing blood pressure became apparent but no significant difference in four year risk of coronary heart disease. CONCLUSION: Counselling patients in general practice on exercise is effective in increasing physical activity and improving quality of life over 12 months.

Adult↗
PubMed2003

Patients' accounts of being removed from their general practitioner's list: qualitative study.

OBJECTIVE: To explore patients' accounts of being removed from a general practitioner's list. DESIGN: Qualitative analysis of semistructured interviews. SETTING: Patients' homes in Leicestershire. PARTICIPANTS: 28 patients who had recently been removed from a general practitioner's list. RESULTS: The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were "good" patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services "appropriately," were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These "bad" general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner's list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising. CONCLUSIONS: Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with "difficult" patients.

Adolescent↗
PubMed2003

Proactive asthma care in childhood: general practice based randomised controlled trial.

OBJECTIVES: To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children. DESIGN: Randomised controlled trial with cluster sampling by general practice. SETTING: General practices in the northern region of the Australian Capital Territory. PARTICIPANTS: 174 children with moderate to severe asthma who attended 24 general practitioners. INTERVENTION: System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner. MAIN OUTCOME MEASURES: Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge. RESULTS: Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7); P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores. CONCLUSIONS: Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.

Asthma↗
PubMed2004

An investigation into general practitioners associated with high patient mortality flagged up through the Shipman inquiry: retrospective analysis of routine data.

OBJECTIVE: To identify a credible explanation for the excessively high mortality associated with general practitioners who were flagged up by the Shipman inquiry. DESIGN: Retrospective analysis of routine data. SETTING: Primary care. PARTICIPANTS: Two general practitioners in the West Midlands who were associated with an unacceptably high mortality of patients during 1993-2000. MAIN OUTCOME MEASURES: Observed and expected number of deaths and deaths in nursing homes. RESULTS: Preliminary discussions with the general practitioners highlighted deaths in nursing homes as a possible explanatory factor. No relation was found between the expected number of deaths and deaths in nursing homes in each year during 1993-2000 for either general practitioner. In contrast, the magnitude and shape of the curves of a cumulative sum plot for excess number of deaths (observed minus expected) in each year were closely mirrored by the magnitude and shape of the curves of the number of patients dying in nursing homes; and this was reflected in the high correlations (R2 = 0.87 and 0.89) between excess mortality and the number of deaths in nursing homes in each year for the general practitioners. These findings were supported by administrative data. CONCLUSIONS: The excessively high mortality associated with two general practitioners was credibly explained by a nursing home effect. General practitioners associated with high patient mortality, albeit after sophisticated statistical analysis, should not be labelled as having poor performance but instead should be considered as a signal meriting scientific investigation.

Cause of Death↗
PubMed1999

What makes the dyspeptic patient feel ill? A cross sectional survey of functional health status, Helicobacter pylori infection, and psychological distress in dyspeptic patients in general practice.

BACKGROUND: Dyspepsia is prevalent in about 30% of the general population in Europe, but only 25% of people with complaints consult their general practitioner. AIMS: To study the relation between the severity of dyspeptic complaints and the health status of patients presenting to the general practitioner; and the relation with patient characteristics, Helicobacter pylori infection, and psychological distress. METHODS: A cross sectional, general practice based survey of 360 unselected primary care dyspeptic patients from 92 general practices in The Netherlands was conducted. Symptom severity was measured using a validated symptom score, H pylori using a whole blood test, and psychological distress using the GHQ-12 test. Functional health status was assessed using the COOP/Wonca charts. RESULTS: Symptoms lasting more than three months and presence of relevant psychological distress were both associated with higher levels of dyspepsia. H pylori infection, frequency of symptoms, and age had no influence on dyspepsia severity. Severity of dyspepsia and psychological distress, but not H pylori infection or duration of symptoms, affected health status univariately. Dyspepsia correlated with general health, daily activities, and social activities. In logistic modelling, health status was far better predicted by psychological distress than by dyspepsia severity. CONCLUSION: The relation between dyspeptic symptom severity and health status is limited. H pylori infection relates neither to functional health status, nor to intensity of dyspepsia. Psychological distress is a major determinant of impaired health of dyspeptic patients in general practice and may be the clue to improvement of health status in many dyspeptic patients.

Adult↗
PubMed1996

Use of oral pathology services by general histopathologists and their attitudes to training of oral pathologists.

AIMS: (1) To determine whether general histopathologists are aware of oral pathology as a specialist discipline and whether they use oral pathologists to identify lesions of the dental and orofacial tissues which pose diagnostic difficulties to general histopathologists. (2) To establish whether consultant histopathologists would consider dentally qualified applicants for salaried training posts within their department so that they may fulfil College accreditation requirements. METHODS: A questionnaire was sent to a consultant histopathologist in each of 226 general histopathology departments in England and Wales. RESULTS: In total, 167 (74%) consultant histopathologists completed the questionnaire, of whom 98% (163/167) were aware of the specialty and 92% (153/167) perceived a need for it. Oral biopsy specimens formed less than 5% of the workload in 76% (126/167) of departments, but 80% (134/167) of the consultants had referred at least one case to an oral pathologist during 1993. The most common sources of diagnostic difficulty were identified as salivary gland pathology, odontogenic tumours and lesions of oral mucosa. Only 22% (36/167) of consultants were aware that trainees in oral pathology are obliged to spend a year in accredited general histopathology training, but 40% (67/167) said they would consider a dentally qualified applicant for a training post in their department. CONCLUSIONS: General histopathologists are aware that oral pathologists exist and most will at some time call on their services; thus there is a need for specialists in oral pathology. Consultant histopathologists have a supportive attitude to the problem of providing the necessary general experience for oral pathology trainees, which will continue to be obtained through secondment to a histopathology department outside the trainee's main institution in most cases. Central funding would help the problem of providing cover for trainees spending a year out to complete general pathology training.

Attitude of Health Personnel↗
PubMed1990

General practitioners and completeness of cancer registry.

STUDY OBJECTIVE: The aim of the study was to evaluate the role of the general practitioner as a source of information for a cancer registry. DESIGN: The study involved a random sample of respondents to a letter inviting participation which was sent to all general practitioners in a specific area. Participating doctors were visited to maximise cooperation. Data collection consisted of setting up a retrospective (prevalence) registry of cancer patients diagnosed over a 20 month period, and a prospective (incidence) register over a subsequent 12 month period. The general practitioner cancer file was then linked to the total cancer registry data base to estimate missed cases. SETTING: The study took place in the catchment area of the Comprehensive Cancer Centre Middle-Netherlands (IKMN). PARTICIPANTS: Of 448 general practitioners in the IKMN region, 152 were willing to participate and of these 52 were randomly selected to take part (11% of all general practitioners in the region). MEASUREMENTS AND MAIN RESULTS: A total of 1637 tumours were identified from the general practitioners, of which 252 (15.4%) were not included in the cancer registry. Of these, only 22 (1.3%) were not included in the registry because they had tumours diagnosed clinically in outpatients and therefore had been omitted from the usual sources of information available to the cancer registry (pathology reports, hospital discharge letters). The missed cases were mostly older patients with digestive tract tumours. CONCLUSIONS: On cost-benefit grounds it was not considered feasible to initiate an active cancer registration system among general practitioners, provided that notification of pathological examinations to the registry is complete. Limited under-registration will occur when death certificates cannot be used as an additional source of information.

Catchment Area, Health↗