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PubMed1992

The problem of diagnostic variability in general practice.

STUDY OBJECTIVE: The aim was to examine the scale, source, and relevance of variation between general practices in respect of the rates with which patients consulted with illnesses falling in each of several diagnostic groups. DESIGN: This study involved a general practice morbidity survey conducted over two years, 1970-72. All patients who consulted their general practitioners were identified and the number of these who consulted with diagnoses attributable to each of the 18 main chapters of the International classification of diseases were counted. Patients who consulted for more than one diagnosis within a chapter were counted once only; those who consulted for one or more diagnoses in each of several chapters were counted once for each chapter. SETTING: This was a national survey involving general practitioners in England and Wales. SUBJECTS: The study involved 214,524 patients from 53 selected general practices (115 doctors) who were registered with their general practitioners for the whole of the year 1970-71 and for whom their morbidity data had been linked with their social data from the 1971 census. MEASUREMENTS AND MAIN RESULTS: Using the numbers of patients on the practice lists as denominators, practice patient consulting rates (PPCR) were calculated for each practice and for each ICD chapter. Variability in chapter PPCR was examined by calculating coefficients of variation and, after allowance for random variation, coefficients of residual variation. There were large interpractice (doctor) variations in all chapter rates. These variations were only marginally attributable to: chance; different age, sex and social class mixes of practice populations; geographical locations; and practice organisation. The rates were, however, consistent from one year to the next for any one practice. Approximately half of the interpractice (doctor) diagnostic variability was associated with overall patient consulting behaviour. When the effects of this behaviour were discounted, any major residual diagnostic variability was confined largely to ICD chapters I-V, XVI, and XVII, ie, those chapters where aetiology forms the basis of classification. CONCLUSION: Variations in recorded diagnostic rates are mainly due to the consistent but idiosyncratic and selective exclusion by practitioners of some components from the total set which often coexist in a new diagnosis. Because of the scale of interpractice diagnostic variability, the use of algorithms and information technology is largely precluded from outcome studies, auditing procedures, and studies of practice work loads in general. However, (1) the consistency of any individual doctor's pattern of diagnostic recording from one year to another permits studies of trends; and (2) given a reasonable number of recording practices, the population mean practice consulting rates can be estimated with sufficient accuracy for many epidemiological research and administrative uses.

Age Factors↗
PubMed1995

Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings.

STUDY OBJECTIVES: To describe mathematically the relationship between patterns of sexual mixing in the general population and those of people with gonorrhoea infection, and hence to estimate the sexual mixing matrix for the general population. DESIGN: Integration of data describing sexual behaviour in the general population, with data describing sexual behaviour and mixing among individuals infected with gonorrhoea. Use of these data in a simple mathematical model of the transmission dynamics of gonorrhoea infection. SETTING: The general population of London and a genitourinary medicine (GUM) clinic in west London. PARTICIPANT: These comprised 1520 men and women living in London who were randomly selected for the national survey of sexual attitudes and lifestyles and 2414 heterosexual men and women who presented to the GUM clinic with gonorrhoea. MAIN RESULTS: The relationship between sexual mixing among people with gonorrhoea and sexual mixing in the general population is derived mathematically. An empirical estimate of the sexual mixing matrix for the general population is presented. The results provide tentative evidence that individuals with high rates of acquisition of sexual partners preferentially select other individuals with high rates as partners (assortative mixing). CONCLUSIONS: Reliable estimates of sexual mixing have been shown to be important for understanding the evolution of the epidemics of HIV infection and other sexually transmitted diseases. The possibility of estimating patterns of sexual mixing in the general population from information routinely collected in gonorrhoea contact tracing programmes is demonstrated. Furthermore, the approach we describe could, in principle, be used to estimate the same patterns of mixing, using contact tracing data for other sexually transmitted diseases, thus providing a way of validating our results.

Adolescent↗
PubMed1992

Audit in general practice: students and practitioners learning together.

OBJECTIVES: To describe and evaluate the use of medical audit in general practice as an educational activity shared by undergraduate medical students and general practitioners. DESIGN: A descriptive study, evaluated by a questionnaire survey of all participating practices and by results of completed student projects on general practice audit topics during three weeks in the first year of completed projects (1990-1). SETTING: One university department of general practice, collaborating with 18 general practices in contract with Liverpool Family Health Services Authority. PARTICIPANTS: 150 medical students, working in groups of two to six, and the general practitioners with whom they worked in 18 practices. MAIN MEASURES: The nature of topics proposed by practices and chosen by the students; methods of audit used by students; reported effects of the audits on the practices; general practitioners' opinions of the projects' usefulness to the practice. RESULTS: The range of topics was wide, and both quantitative and qualitative methods were used. Fifteen of the 18 questionnaires sent out were completed. Six practices reported that the final project had changed substantially after joint planning with the students. Two thirds (10) attached high value to the audits and were making changes in the delivery of care as a result. CONCLUSIONS: Medical audit "project work" by medical undergraduates is an effective tool for motivating students to learn and can lead to change in the clinical setting in which it occurs. IMPLICATIONS: By meeting the learning needs of both undergraduates and established practitioners audit project work has wider application within medical education.

Education, Medical, Undergraduate↗
PubMed1993

Psychiatric comorbidity in patients with generalized anxiety disorder.

OBJECTIVE: The goal of this study was to test the validity of generalized anxiety disorder as an independent diagnostic entity and to evaluate the prevalence and type of other psychiatric disorders coexisting with generalized anxiety disorder. Although a few published studies have addressed the subject, this study presents data from a larger group of subjects and excludes concurrent major depression as a potential confound. METHOD: The authors studied patients with a primary diagnosis of generalized anxiety disorder assigned after evaluation with the Structured Clinical Interview for DSM-III-R. Patients with a concurrent major depressive episode were excluded. All diagnoses for which the patient met criteria were determined, including lifetime occurrence of major depressive episode and substance use. RESULTS: One hundred nine patients with generalized anxiety disorder were included in the analysis. Twenty-eight (26%) of these patients were not given any other lifetime psychiatric diagnosis. The most prevalent comorbid diagnoses were social phobia (25 [23%] of the patients) and simple phobia (23 [21%] of the patients). Forty-six (42%) of the patients with generalized anxiety disorder had experienced at least one major depressive episode during their lifetime. CONCLUSIONS: These results support previous findings of high rates of psychiatric comorbidity in generalized anxiety disorder and validate the usefulness of generalized anxiety disorder as a separate diagnostic entity.

Adult↗
PubMed1995

Clinical correlates of early-onset and late-onset poststroke generalized anxiety.

OBJECTIVE: The authors' goal was to determine if generalized anxiety diagnosed while a patient was hospitalized for stroke (early onset) had the same clinical correlates as anxiety beginning 3 months or more after the stroke (late onset). METHOD: Patients with acute stroke (N = 142) were examined while they were in the hospital and 3, 6, 12, and 24 months later for the presence of anxiety symptoms. Patients underwent a structured psychiatric interview as well as assessment of cognitive, physical, and social function at each visit. Patients with early-onset and late-onset poststroke generalized anxiety were identified and compared to patients without poststroke generalized anxiety. RESULTS: The frequency of early-onset poststroke generalized anxiety was 27% and that of late-onset poststroke generalized anxiety was 23%. Three-quarters of the anxious patients had comorbid major or minor depression. Patients who developed early-onset or late-onset poststroke generalized anxiety were no more socially, cognitively, or physically impaired than patients who did not develop anxiety. Early-onset but not late-onset anxiety was associated with a previous history of psychiatric disorder. The median duration of late-onset anxiety was 3.0 months, and that of early-onset anxiety was 1.5 months. The presence of anxiety was significantly associated with depression; onset of depression and onset of anxiety occurred at approximately the same time. CONCLUSIONS: These findings suggest that although early-onset and late-onset poststroke generalized anxiety are phenomenologically similar, they may be the result of different pathophysiological mechanisms.

Anxiety Disorders↗
PubMed2004

Monitoring mortality in general practice in Grampian, Scotland.

Information on the distribution of mortality and morbidity in general practice is scarce, and not easily accessible either by health authorities or individual general practices. Although the assessment of population mortality is a standard public health measure, colleagues in public health, information sciences and general practice rarely undertake such activity related to general practice populations. Mortality information can be used for various purposes. Examples are providing background data for clinical audits or alerting practitioners to quality issues in the healthcare industry or even suggesting environmental hazards. We measured the experience of mortality in all generally practices in Grampian in the years 1991 to 1999. All practices were notified of their actual and expected mortality over this period of time and asked for comment. Only three general practices had excess mortality experience in both the periods 1991 to 1995 and 1996 to 1999. Only a minority of practices commented on the results. It appears that a high presence of nursing homes in a practice might skew the results; this phenomenon will be central to further inquiry. Future methodology for recording death in general practice should take account of this, as well as providing an account of the qualitative aspects of patients' need for a dignified satisfactory death.

Adolescent↗
PubMed1991

Are patients in favour of general health screening?

In order to determine whether patients are in favour of general health screening, two sex-matched groups of patients of similar age from a general practice were studied; a group of 315 consecutive patients who attended the practice and 93 individuals who had not attended the practice for at least 12 months were studied. Individuals in both groups were provided with a short, anonymous questionnaire about their desire for general health screening. Although roughly equal proportions of the attenders (93%) and non-attenders (88%) indicated that general health screening was a 'good idea', a significantly greater proportion of the attenders (83%) indicated that they would make an appointment and attend the practice for health screening compared to the non-attenders (66%) (P less than 0.002). Similarly, a significantly greater proportion of the attenders (33%) indicated that they would seek general health screening, even if not contacted by their doctor, when compared with the non-attenders (16%) (P less than 0.001). Thus patients in this study were greatly in favour of general health screening. However, patients who attended the general practice infrequently may represent a population who are relatively resistant to health screening.

Adolescent↗
PubMed2006

Factors influencing general practitioner referral of patients developing end-stage renal failure: a standardised case-analysis study.

BACKGROUND: To understand why treatment referral rates for ESRF are lower in Ireland than in other European countries, an investigation of factors influencing general practitioner referral of patients developing ESRF was conducted. METHOD: Randomly selected general practitioners (N = 51) were interviewed using 32 standardised written patient scenarios to elicit referral strategies. MAIN OUTCOME MEASURES: General practitioner referral levels and thresholds for patients developing end-stage renal disease; referral routes (nephrologist vs other physicians); influence of patient age, marital status and co-morbidity on referral. RESULTS: Referral levels varied widely with the full range of cases (0-32; median = 15) referred by different doctors after consideration of first laboratory results. Less than half (44%) of cases were referred to a nephrologist. Patient age (40 vs 70 years), marital status, co-morbidity (none vs rheumatoid arthritis) and general practitioner prior specialist renal training (yes or no) did not influence referral rates. Many patients were not referred to a specialist at creatinine levels of 129 micromol/l (47% not referred) or 250 micromol/l (45%). While all patients were referred at higher levels (350 and 480 micromol/l), referral to a nephrologist decreased in likelihood as scenarios became more complex; 28% at 129 micromol/l creatinine; 28% at 250 micromol/l; 18% at 350 micromol/l and 14% at 480 micromol/l. Referral levels and routes were not influenced by general practitioner age, sex or practice location. Most general practitioners had little current contact with chronic renal patients (mean number in practice = 0.7, s.d. = 1.3). CONCLUSION: The very divergent management patterns identified highlight the need for guidance to general practitioners on appropriate management of this serious condition.

Age Factors↗
PubMed1993

General information tapes inhibit recall of the cancer consultation.

PURPOSE: Studies of tape recordings of cancer consultations have produced conflicting results. At the same time, audiotapes containing general information about cancer are poorly evaluated and are distributed to patients in an ad hoc manner. We compared the effects of both interventions on patient satisfaction, psychologic adjustment, and recall of information following their first consultation with a medical oncologist. PATIENTS AND METHODS: Patients (n = 142) were randomized to receive (1) an audiotape of their consultation, (2) an audiotape describing cancer in general terms, or (3) no tape. Recall of information was assessed in a structured interview 4 to 20 days after the consultation. RESULTS: Satisfaction with the consultation increased linearly from no tape to general tape to consultation tape. Satisfaction with the tape itself was higher in patients who received the consultation tape (satisfaction score, 61%) compared with those who received the general tape (43%). Average recall for all groups was 6.4 of the 25 items of information presented, and 2.4 of the six points identified as particularly important by the oncologist. The consultation tape did not improve recall over the no tape control, but the general tape caused a decrease of almost two items in total recall. Spontaneous (ie, unprompted) recall was significantly poorer with the general information tape. Psychologic adjustment to cancer was unaffected. CONCLUSION: We conclude that individual audiotapes have a limited potential to increase recall of information from the oncology consultation. General information tapes about cancer appear to inhibit recall actively.

Adolescent↗
PubMed1979

The universality of generalized personality statements.

Researchers for three decades have assumed that generalized personality statements are nearly universally valid. In this study, undergraduate students indicated whether generalized personality statements were "true" or "false" as applied to themselves; then these same students and a group of graduate students estimated the percentage of college students who would answer each generalized statement "true." Only 7 of the 12 commonly-used, generalized personality statements were found to be nearly universally valid among the undergraduates; the other 5 were answered "true" by fewer than two-thirds of the undergraduates. Both groups undergraduates and graduate students were very accurate in estimating the percentage of students who would respond "true" to each statement. Thus, many supposed generalized statements are not nearly universally valid, and students are cognizant of the degree of universality of generalized statements. Results of prior research based on inappropriate assumptions about generalized statements must be viewed cautiously.

Journal Article↗
PubMed2000

Increased secondary generalization of partial seizures after temporal lobectomy.

OBJECTIVE: This study tests the primary hypothesis that secondary generalization of partial seizures is more likely after anterior temporal lobectomy (ATL) than before ATL, and the secondary hypothesis that antiepileptic drug withdrawal accounts for increased generalization of seizures postoperatively. BACKGROUND: The authors observed that some patients had generalized tonic-clonic (GTC) seizures after but not before ATL, by using a new classification of outcome that compares preoperative and postoperative seizure frequencies by seizure type. METHODS: Twenty patients with refractory temporal lobe epilepsy had postoperative GTC seizures or nongeneralizing complex partial (CP) seizures in a consecutive ATL series. All had reduced seizure frequency postoperatively and more than 2 years of follow-up on antiepileptic drugs. The authors calculated a generalization fraction, as (number of GTC seizures)/(number of CP and GTC seizures), for 2 years before and 2 years after surgery. RESULTS: Postoperative generalization fractions were greater than preoperative generalization fractions (Wilcoxon signed-rank test, p < 0.01). Most postoperative GTC seizures were not associated with antiepileptic drug withdrawal, and postoperative GTC seizures were not more associated with drug withdrawal than were postoperative CP seizures. Patients with more than two GTC seizures per year preoperatively were more likely than other patients to have postoperative GTC seizures. CONCLUSIONS: Patients with reduced seizure frequency after ATL have a greater tendency for partial seizures to secondarily generalize postoperatively. This phenomenon is not explained by antiepileptic drug withdrawal.

Anticonvulsants↗
PubMed1982

Telencephalic theory of generalized epilepsy: observations in split-brain patients.

The anatomical structures involved in the origin and spread of generalized seizures in humans have not been fully elucidated. Cortical, centrencephalic, and corticoreticular theories have been proposed to explain the clinical and electroencephalographic findings in patients with primary, generalized epilepsy or secondarily generalized seizures. Our observations in patients undergoing forebrain commissurotomy for intractable, generalized seizures lead us to propose a telencephalic theory of generalized epilepsy. This theory stresses the importance of the cerebral cortex as the site of origin of seizure discharge and the function of the forebrain commissures in the rapid propagation and bilateral synchronization of such discharge. These observations plus a review of the data generated from animal models of epilepsy are presented as evidence for such a theory. Although none of our patients had classical petit mal epilepsy, our findings suggest a secondary role of the brain stem reticular formation in generalized seizures and may be cogent to the discussion of primary, generalized epilepsy.

Adolescent↗
PubMed2006

Ethnicity, socioeconomic deprivation and consultation rates in New Zealand general practice.

OBJECTIVES: To explore the relationship between ethnicity, socioeconomic deprivation and utilization of general practice. METHODS: Data routinely collected by New Zealand general practices in 2001 were analysed using generalized linear regression. RESULTS: The mean number of doctor consultations for registered individuals was 3.7 and the median 2. After adjusting for age, gender and area socioeconomic deprivation, people from Maori, Pacific, Asian and other-unspecified ethnic groups consulted general practitioners at similar rates or less frequently than European people. There was a significant positive trend between increasing deprivation and increasing rates of general practitioner (GP) consultation. The most-deprived groups had an approximately 30% higher rate of consultation than the least-deprived groups. There was a significant negative trend between nurse consultations and deprivation, with people from the most-deprived groups having a 29% lower frequency of nurse consultation. There was a different pattern of doctor consultation in the under-six age group, where a higher rate of patient subsidy was available, suggesting cost may be a barrier to doctor consultation for other age groups. CONCLUSIONS: In the general practices, in this study, the increasing rate of doctor consultations with increasing socioeconomic deprivation is consistent with increased need. However, the fact that adjusted Maori and Pacific utilization rates were not higher than those for people of European ethnic identity is a cause for concern in light of evidence that Maori health status is poorer than European, even after adjusting for deprivation. Further research is required to explore potential barriers to general practice consultation.

Adolescent↗
PubMed1991

Differences in leading causes of death, hospitalization and general practice visits among Dutch women and men.

Mortality differences between Dutch women and men were compared to differences in hospitalization and general practitioner visits. Ranks for the top fifteen diagnoses per sex as well as absolute and relative (to total of sex-specific diagnoses per group) sex ratio's were computed for the age groups 15-44 years, 45-64 years and over 65 years. To enhance comparability all procreative and contraceptive management data were excluded. Twice as many men compared to women die in all age groups, resulting in a surviving excess of women in the oldest age group (male/female ratio: 0.67). As expected from these mortality figures relatively more men than women are hospitalized, in particular in the oldest age group, 26.4 versus 19.5/100,000 (relative male/female ratio: 1.35). In a study population of twelve general practices, representative of the total Dutch population, more women sought medical care from the general practitioner than men and the individual women visited the general practitioner more frequently than men, resulting in a relative male/female ratio of 0.6 for general practice visits. Men visit the general practitioner for diseases for which they are also hospitalized and also often die from. Women visit the general practitioner for a wide range of ailments only in part representative of diseases for which they are hospitalized or die from. During aging, women tend to visit primary health care facilities more frequently for chronic, non-fatal disease, which can be explained partly by the absolute longer lifespan of women than men.

Adolescent↗
PubMed2006

Generalization of motor learning depends on the history of prior action.

Generalization of motor learning refers to our ability to apply what has been learned in one context to other contexts. When generalization is beneficial, it is termed transfer, and when it is detrimental, it is termed interference. Insight into the mechanism of generalization may be acquired from understanding why training transfers in some contexts but not others. However, identifying relevant contextual cues has proven surprisingly difficult, perhaps because the search has mainly been for cues that are explicit. We hypothesized instead that a relevant contextual cue is an implicit memory of action with a particular body part. To test this hypothesis we considered a task in which participants learned to control motion of a cursor under visuomotor rotation in two contexts: by moving their hand through motion of their shoulder and elbow, or through motion of their wrist. Use of these contextual cues led to three observations: First, in naive participants, learning in the wrist context was much faster than in the arm context. Second, generalization was asymmetric so that arm training benefited subsequent wrist training, but not vice versa. Third, in people who had prior wrist training, generalization from the arm to the wrist was blocked. That is, prior wrist training appeared to prevent both the interference and transfer that subsequent arm training should have caused. To explain the data, we posited that the learner collected statistics of contextual history: all upper arm movements also move the hand, but occasionally we move our hands without moving the upper arm. In a Bayesian framework, history of limb segment use strongly affects parameter uncertainty, which is a measure of the covariance of the contextual cues. This simple Bayesian prior dictated a generalization pattern that largely reproduced all three findings. For motor learning, generalization depends on context, which is determined by the statistics of how we have previously used the various parts of our limbs.

Adult↗
PubMed2006

Asthma hospitalizations among American Indian and Alaska Native people and for the general US population.

STUDY OBJECTIVES: Asthma is one of the most common chronic diseases in the United States. High rates of asthma hospitalization have been reported for some ethnic minorities; however, asthma hospitalization rates for American Indian/Alaska Native (AI/AN) populations of all ages have not been studied. In this study, we examined and compared hospitalization rates for AI/AN populations and the general population in the United States. DESIGN: Hospital discharge records with a first-listed diagnosis of asthma were evaluated for AI/AN populations and the US general population of all ages from 1988 to 2002. RESULTS: The asthma hospitalization rate for AI/AN populations decreased from 17.8/10,000 per year in 1988 to 1990 to 12.9/10,000 per year in 2000 to 2002. The overall age-adjusted rate for 2000 to 2002 was slightly lower than that for the general US population (12.9/10,000 and 16.4/10,000, respectively). However, AI/AN populations living in the Southwest region (17.6/10,000) had the highest asthma hospitalization rate among the Indian Health Service regions and the rate from 2000 to 2002 was similar to that for the general US population. The 2000 to 2002 asthma hospitalization rate for AI/AN populations < 1 year of age (infants) was higher than that in US infants, and the rates for AI/AN age groups > or = 1 year were similar to or lower than those for the general US population. CONCLUSIONS: While asthma was rarely reported among AI/AN populations before 1975, the average annual age-adjusted asthma hospitalization rate was only slightly lower for AI/AN populations than that for the US general population from 2000 to 2002. Furthermore, the asthma hospitalization rates for AI/AN populations living in the Southwest and East regions were similar to the rate for the general US population. Efforts to further increase asthma awareness and symptom recognition among AI/AN populations should be implemented to help to reduce asthma hospitalizations.

Adolescent↗
PubMed2004

The general pediatrician: projecting future workforce supply and requirements.

OBJECTIVE: Trends affecting both the supply and requirements of child health physicians call into question earlier assessments about the adequacy of the general pediatric workforce. To understand the effects of these trends over time, we developed a model that projects the national supply of practicing general pediatricians over a 20-year period (2000-2020). DESIGN: The model incorporates current data on the practicing pediatrician workforce in the United States, pediatric residency graduates entering general pediatrics, and gender- and age-specific measures of productivity and of retirement or death. In addition, it accounts for projected changes in the size and ethnicity of the child population and the proportion of children currently receiving outpatient care from family practitioners. MAIN OUTCOME MEASURES: Time trend of the supply of general pediatricians and the number of children in the population per practicing pediatrician. RESULTS: The baseline model projects that the number of general pediatricians will expand by nearly 25 000 by the year 2020, a 64% increase from the year 2000, whereas the child population is projected to expand by only 9%. The increase was robust to sensitivity analyses measuring the impact of each of the model's variables on the future supply of pediatricians. In all probable scenarios, the general pediatrician workforce will expand significantly more rapidly than the child population. In addition, the trend in pediatrics is in marked contrast to the other primary care specialties. CONCLUSIONS: Despite a number of factors that might attenuate the growth of the general pediatrician workforce, none seems sufficient to slow its expansion in relation to the pediatric population. To maintain practice volumes comparable to today, pediatricians of the future may need to provide expanded services to the children currently under their care, expand their patient population to include young adults, and/or compete for a greater share of children currently cared for by nonpediatricians.

Education, Medical, Graduate↗
PubMed1977

An implicit technology of generalization.

Traditionally, discrimination has been understood as an active process, and a technology of its procedures has been developed and practiced extensively. Generalization, by contrast, has been considered the natural result of failing to practice a discrimination technology adequately, and thus has remained a passive concept almost devoid of a technology. But, generalization is equally deserving of an active conceptualization and technology. This review summarizes the structure of the generalization literature and its implicit embryonic technology, categorizing studies designed to assess or program generalization according to nine general headings: Train and Hope; Sequential Modification; Introduce to Natural Maintaining Contingencies; Train Sufficient Exemplars; Train Loosely; Use Indiscriminable Contingencies; Program Common Stimuli; Mediate Generalization; and Train "To Generalize".

Journal Article↗