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OBJECTIVE: To determine the prevalence of atrial fibrillation in England and Wales, and examine trends in its treatment with warfarin and aspirin between 1994 and 1998. DESIGN: Analysis of data from the general practice research database. SETTING: England and Wales. PATIENTS: 1.4 million patients registered with 211 general practices. MAIN OUTCOME MEASURES: Age and sex specific prevalence rates of atrial fibrillation; percentage of patients with atrial fibrillation treated with oral anticoagulants or aspirin. RESULTS: The prevalence of atrial fibrillation in 1998 was 12.1/1000 in men and 12.7/1000 in women. Prevalence increased from less than 1/1000 in under 35 year olds to over 100/1000 in those aged 85 years and over. There was a 22% increase in the age standardised prevalence of atrial fibrillation in men and a 14% increase in women between 1994 and 1998. The percentage of patients prescribed oral anticoagulants increased from 20% to 34% in men and from 17% to 25% in women. The percentage of men with atrial fibrillation prescribed aspirin increased from 26% to 36%, and the percentage of women increased from 24% to 36%. Applying the age and sex specific prevalence and treatment rates to the population gives an estimate of around 650 000 cases of atrial fibrillation in England and Wales. The greatest number of cases occurs in the 75-84 year old age group. CONCLUSIONS: The number of patients in the community with identified atrial fibrillation is increasing. There has also been a pronounced increase in the percentage of patients with atrial fibrillation prescribed oral anticoagulants or aspirin.
A self-administered questionnaire, the Health Survey Questionnaire (HSQ) was distributed to patients registered with 47 group general practices. The HSQ assesses alcohol consumption using a quantity frequency scale and includes the four CAGE questions and a question on whether respondents think they have an alcohol problem. A random stratified sample of those patients who returned an HSQ (2666 men and 1537 women) were subsequently invited to attend their general practice for an interview with the practice nurse, where weekly alcohol consumption was estimated using both a quantity frequency scale and a systematic enquiry about alcohol consumption for the week immediately preceding the interview. The latter method was taken as the 'gold standard'. Excessive drinkers were defined as men whose weekly consumption by this method was not less than 35 units per week and women drinking at least 21 units per week. After weighing the results to take account of the sampling bias in favour of the excessive drinkers, 11.7% of men and 2.9% of women were excessive drinkers according to the estimate of alcohol consumption at interview. This compares with the 7.6% of men and 2.7% of women who were heavy drinkers by the HSQ quantity frequency scale. The two interview estimates were comparable but in general the HSQ tended to underestimate consumption compared with these estimates. The questionnaire was found to be most effective in screening for excessive drinkers if all the patients who indicated concern about their drinking (i.e. those who were with CAGE positive or had a self-assessed drinking problem), as well as all of those who were above the limits for the trial on the quantity frequency scale, were selected as being potentially excessive drinkers. In the weighted sample, 14.8% of men and 6.9% of women were in this group. Using these selection criteria and taking the interview as the standard for determining the excessive drinkers a sensitivity of 58.6% and specificity of 91.08% was obtained for men, with a positive predictive value of 46.1% and a negative predictive value of 94.3%. For women the test was more sensitive (69.7%) and more specific (95.0%) and had a better negative predictive value (99.1%) than for men. The positive predictive value for women at 29.6% was not as good as that obtained for men. This analysis shows that the HSQ is a fairly effective tool for detecting excessive drinkers in general practices with a small proportion of false positive results. It is both economical and acceptable to patients in a wide range of practice settings.
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The 9-year practice histories of 100 working-aged residents of the rural municipality of Kaavi in Finland were analysed. Based upon an analysis of these histories, an interview of the 81% who participated and the personal patient knowledge of the author from his work as a general practitioner for 7 years in the community, 78% of the persons studied could be classified into six categories in a qualitative typology of consulting patterns. The descriptive names of the categories, together with their proportionate sizes and the mean annual consultation rates within the categories were: (1) 'Healthy and competent' (16%; 1.03); (2) 'Contented returners' (12%; 3.28); (3) 'Information seekers' (8%; 4.08); (4) 'Support seekers' (15%; 4.62); (5) 'Drifters' (21%; 2.21) and (6) 'Those hard to convince' (6%; 3.59). The rest (22%; 1.15) could not be classified. The implications of the typology are discussed from two standpoints: (1) In view of the current Finnish debate on the need for fee deterrents for the use of public general practitioner's services. (2) The potentials and limitations of different broad strategies suggested for general practice.
The practice of routinely following-up breast cancer in hospital clinics is of widespread concern: studies have shown that it is not an effective way of detecting recurrent disease and it places great strain on cancer services which are already overstretched. A general practice centred system of routine follow-up may be a solution to this problem in those countries which have a strong primary care base. Such a system would have other benefits such as continuity of care for the patient. The objective of this study was to determine the views of general practitioners and specialists on follow-up of patients with breast cancer in remission, with special emphasis on their views on the transfer of routine follow-up from the hospital to general practice. A postal questionnaire survey of British breast cancer specialists (response rate 77.0%) and a personal interview survey of British general practitioners (response rate 81.8%) were conducted. The results show that British general practitioners are willing to take on greater responsibility for the routine follow-up care of their patients with breast cancer. However, there was frequently a mis-match between specialists' and general practitioners' views on this subject.
A project was carried out to study the usefulness of ordinary data from computer-based journals for comparing practices. 20 general practitioners from four municipalities participated for four months in 1992. The computer-based journal provides accurate information on the number and kind of contacts with patients, and on who visits the general practitioner. It also tells what is done at each contact, such as a referral, prescription or laboratory tests. Using the International Classification of Primary Care (ICPC) even the most common diagnoses do not account for more than 3% of the consultations. The practice of the different doctors varies considerably as regards classifying consultations on a symptom level (ICPC 1-29) or a diagnosis level (ICPC 70-99). The results brought to light marked differences with regard to what general practitioners do, and what kind of problems their patients present. The patient populations differed to a lesser degree with respect to sex, age and social status. The findings provided an interesting and useful platform for group discussions among the participating doctors.
OBJECTIVE: To determine Australian general practitioners' (GPs') views about and recall of clinical practice guidelines. DESIGN: Self-administered questionnaire survey. SUBJECTS: Randomly selected Australian GPs. RESULTS: 286 of 373 GPs returned questionnaires (77% response rate). GPs' recall of each of nine guidelines ranged from 52% to 94%; 49% considered that their practice had changed as a result of a guideline. While 92% of respondents agreed that guidelines were "good educational tools", 85% indicated that guidelines were "developed by experts who don't understand general practice". Factors most frequently identified as important in deciding whether to follow the guideline recommendations were whether the guideline was based on evidence and credible endorsement. CONCLUSIONS: Australian GPs have positive views about the purpose of clinical practice guidelines and an evidence-based approach to guidelines development. However, respondents rating of the perceived impact of available guidelines in everyday practice was low. The dissemination of specific guidelines is patchy and there is little evidence of systematic implementation.
Thus far, the response to the nationwide screening programme for cervical cancer in The Netherlands, which was started in 1989, has been disappointing. One way to improve response is to involve general practitioners in the call system. A postal survey was conducted to review the implementation of the current screening programme in general practice and to examine the willingness of general practitioners to participate in a general practice-based call system. The response rate to the survey was 90%. The general practitioners were dissatisfied with follow-up, cost and time spent and compliance of women. Of all respondents 60% had already set up a call system within the practice or were willing to do so; another 31% were willing to participate in a regionally organized practice-based call system. On the basis of the results of this study a centralized general practice-based call system is recommended. The next step is to study the applicability of this system in a pilot programme.
INTRODUCTION: In Germany, there are hardly any reliable data on patient care in the primary care setting which warrant the development and implementation of clinical guidelines. In this paper, data generated by a prospective observational study of patients with urinary tract symptoms are compared to the recommendations of an evidence-based clinical guideline. PATIENTS AND METHODOLOGY: Over a period of 6 months all patients consulting one of 6 General Practitioners in southern Germany with symptoms of dysuria have been documented on a standardised patient record. Data were compared to the recommendations of the guideline "Dysuria" by the German Society of General Practice and Family Medicine (DEGAM) to assess the relevance and feasibility of the guideline. In a scenario, compliance with the guideline is extrapolated to the realm of primary care. RESULTS: Basic demographic and epidemiological data agree with basic assumptions of the guideline. As far as diagnostic and therapeutic strategies are concerned there are significant discrepancies between the recommendations and the realm of primary care. Microbiologic cultures are ordered far less then recommended, second line drugs are prescribed far more often then recommended, macroscopic urinoscopy is performed widely but not covered by the guideline at all. If GPs complied completely with the guideline, many more diagnostic procedures would be performed and a different palette of antimicrobial drugs would be prescribed. CONCLUSION AND OUTLOOK: The "Dysuria-Guideline" of DEGAM was developed for a prevalent and relevant topic in primary care in Germany. There are significant discrepancies between the recommendations and the realm of primary care. Post-hoc-analysis is an informative and feasible tool to identify potential obstacles against implementation of guidelines.
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German results from the European Project on Patient Evaluation of General Practice Care (EUROPEP). As part of the European collaborative study, "EUROPEP" 2224 patients in Germany (response rate 77.2%) filled in a questionnaire to evaluate their general practitioners (GP's) and the care they were delivering over the last 12 month. Overall satisfaction was high: 95.4% reported that they had no reasons to change to another GP. On a five-point scale ranging from 'excellent' to 'poor' the possibility to reach the practice on the phone was evaluated best (73.8% 'excellent') and waiting times were rated worst (31.0% 'excellent'). Also less often rated 'excellent' than other items were 'preparing the patient for what to expect from specialist or hospital care' (53.3%), 'the GP's knowledge on what s/he had done or told the patient during previous contacts' (54.3%) and 'helping the patient to deal with emotional problems related to her/his health status' (54.6%). Relevant differences between practices concerning evaluation of care and sociodemografic background of their patients were detected. Patient evaluation of care can contribute to make practices an their teams more responsive to patients needs.
OBJECTIVES: Chlamydia trachomatis is a common sexually transmitted infection with serious consequences if not treated. Chlamydia screening pilots in England have established feasibility in primary care but there are currently no examples of good practice in general practice. The objectives of the study were to understand issues of using general practice as a setting for chlamydia screening and to explore ways of implementing a successful screening strategy. METHODS: Based on findings of a literature review, a semi-structured schedule was constructed to interview a purposive sample of policymakers, consultants in sexual and reproductive health and primary care professionals. A thematic framework was used for qualitative analysis. RESULTS: Twenty-two themes were identified and were ranked in order of word count. The topic that generated most discussion was heterogeneity of knowledge, attitudes and skills in general practice. When broken down by professional group, this topic ranked the highest for practice nurses and consultants in sexual health; general practitioners (GPs) and the chlamydia screening coordinator spoke most about financial incentives while the public health consultant spoke most about access. CONCLUSIONS: Most believed screening can and should be done and general practice can offer better population coverage. It needs to have little impact on clinicians' workload, for example, by using urine tests and self-taken vaginal swabs. Financial recognition needs to reflect the administrative costs and the impact on reception staff, but this and the innovative tests might add to the cost of the screening programme. Incentives have to be handled sensitively to reduce inequity among GPs and other services offering screening.
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The aim of this study was to determine the frequency of audit and the proportion completed in a group of practices. Data obtained by interviewing a member of each practice and inspecting practice records were independently coded by researchers. Practices initiated an average of 3.5 (range 1-7) audits in 2 years, of which an average of 0.9 (range 0-3) were completed. Ten of 16 completed audits were externally funded or facilitated. Few audits are completed in general practice and practices require continuing support for audit.
Many reports have been recently published on the accuracy of mental distress detection by general practitioners. Recognition of 'caseness', irrespective of its accuracy, nevertheless determines the implementation of therapeutic interventions. This paper reports the results of a naturalistic study describing the consequences for the patients of being identified as 'cases' in the general practice (in terms of referral strategies at recruitment and outcome 3 months and 1 year later), in the context of care provision generated by the 1978 Italian psychiatric reform. Sixty-eight GPs recruited 878 'cases' according to implicit criteria. Overall 20% of the patients were referred the psychiatric setting; only half of these for psychiatric care. After 3 months and 1 year from recruitment respectively 12% and 23% of the subjects were no longer 'cases'. The factors contributing to predict the outcome at three months were age, symptom duration, comorbidity, presence of social context risk factors and prior psychiatric history (or presence of 'major' symptoms); after one year the predictors of caseness were caseness status at 3 months, and clinical severity, symptom duration and presence of somatization at recruitment. GPs remain the main care providers in the short- and long-term. The results of the study indicate the need for a reappraisal of the emphasis to be put on caseness recognition and on the development of standardized instruments for the identification of mental distress. Non-clinical variables concurring in the definition of caseness in general practice, and the factors influencing physicians' decision-making in the implementation of alternative intervention strategies should be further clarified by ad hoc studies.
The need for high-quality teaching practices and general practitioners (GPs) skilled in teaching is ever increasing. The authors determined the quality of teaching in the Göttingen general practice teaching network with regard to equipment, student participation and GPs' motivation for teaching. A questionnaire was mailed to all GPs in the Göttingen teaching network. The response rate was 81% (98/121). GPs considered taking histories (98%), decision-making (98%) and physical examination (94%) to be key elements of teaching in general practice. They felt that somatic topics like upper respiratory tract infections (98%) were easy to teach, while 51% acknowledged difficulties conveying psychosocial topics like caring for dying patients. In only half of the practices did students have the opportunity to take histories and perform physical exams by themselves. Participation in medical education was driven mainly by the satisfaction derived from teaching (66%) and the desire for academic affiliation (39%). GPs in the Göttingen network need support to teach their students more psychosocial-oriented topics and to allow them a more active role in consultations.