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PubMed1996

A study of general practitioners' reasons for changing their prescribing behaviour.

OBJECTIVES: To explore general practitioners' reasons for recent changes in their prescribing behaviour. DESIGN: Qualitative analysis of semistructured interviews. SETTING: General practice in south east London. SUBJECTS: A heterogeneous sample of 18 general practitioners. RESULTS: Interviewees were able to identify between two and five specific changes that had occurred in their prescribing in the preceding six months. The most frequently mentioned changes related to fluoxetine, angiotensin converting enzyme inhibitors, and the antibiotic treatment of Helicobacter pylori. Three models of change were identified: an accumulation model, in which the volume and authority of evidence were important; a challenge model, in which behaviour change followed a dramatic or conflictual clinical event; and a continuity model, in which change took place against a background of willingness to change, modulated by other factors such as cost pressures and the comprehensible therapeutic action of a drug. Behaviour change was reinforced and sustained by experiences with individual patients. CONCLUSIONS: Multiple factors are involved in general practitioners' decisions to change their prescribing habits. Three models of change can be identified which have important implications for the design and evaluation of interventions aimed at behaviour change.

Adult↗

PubMed1994

The recognition and management of melanoma and other skin lesions by general practitioners in New Zealand.

AIM: To assess current levels of knowledge and management practices with respect to melanoma and other skin cancers, in a representative sample of New Zealand general practitioners. METHODS: A self-administered questionnaire was sent to a random sample of 900 general practitioners. The questionnaire included 12 cases with coloured photographs of skin lesions and a brief presenting history. Responders were asked to assess probable diagnosis, need for biopsy and management of the lesion. Other attitudinal and relevant background information was also gathered. The questionnaire was sent to a comparison sample of 35 dermatologists. RESULTS: The overall response rate was 66% among the general practitioners and 68% among the dermatologists. The sample responding was representative of the larger population of doctors practising in New Zealand. Correct decisions whether or not to biopsy lesions (mean score of 10.1 out of 12) were significantly higher than the number of correct diagnoses (mean 8.4). Correct identification and recognition of the need to biopsy melanomas was high. Diagnostic skills and recognition of the need for biopsy were somewhat lower among general practitioners aged 50 years and over than among younger doctors. Doctors who had experience of a patient with melanoma had higher diagnostic skills and made more correct biopsy decisions. The general practitioners' scores for correct biopsy decisions were similar to those of the dermatologists sampled, although their diagnostic skills were somewhat lower, particularly with respect to nonmelanoma skin cancers. CONCLUSION: The findings indicate a high level of expertise in terms of diagnosis of skin lesions and identification of need to biopsy suspicious lesions among general practitioners in this country.

Clinical Competence↗

PubMed1988

Recent trends in the availability, distribution, utilisation and cost of general practitioner services.

GMS data for the 1983-4 and 1986-7 years were analysed to determine the availability, distribution and utilisation of general practitioners in New Zealand. In 1986-7 there were 1724 full time equivalents (FTE) general practitioners, one per 1923 population, an annual increase in availability of 2.8% over the three years studied. The rate of availability appears to be increasing rapidly and, from Medical Council data, was around 6% for the 1986-7 year. Wide variation exists in availability, the highest being in central Auckland with one general practitioner per 1351 population, the lowest being in Invercargill with one per 2500. Utilisation increased by just over 1% annually to 3.9 services per person. The median workload in 1986-7 was 7184 services per general practitioner equivalent to a GMS income of $31,454. Each general practitioner was associated with government expenditure of about $359,000 but received only about $33,670 of this, less than one seventh of that paid by government for pharmaceuticals. Radical changes are proposed to redress inefficiencies, inequities and the perverse incentives which continue to increase in this almost totally unmanaged but fundamentally important area of health care.

Costs and Cost Analysis↗

PubMed1980

Ambulatory medical care: a comparison of internists and family-general practitioners.

We analyzed data from the National Ambulatory Medical Care Survey to compare the style of practice of two primary-care providers, general internists and family-general practitioners. Whereas internists spent 18.4 minutes with the average patient, family-general practitioners spent 13.0 minutes. Whereas internists used laboratory tests in 73 per cent of visits and x-ray tests in 53 per cent, family-general practitioners used these studies in 34 and 19 per cent of visits. Internists provided instructions regarding health problems in 17.8 per cent of visits, and family-general practitioners in 12.4 per cent. The two provider groups did not differ in terms of therapy for emotional problems, both providing it in a relatively low proportion of visits (3 per cent). Whether by choice or necessity, family-general practitioners spent less time examining and instructing patients, and they ordered fewer laboratory and x-ray studies. The implications of these differences for the cost and quality of primary care need further study.

Ambulatory Care↗

PubMed1996

What is the quality of general practitioner records in Australia?

OBJECTIVE: To describe the quality of general practitioner (GP) medical records. SUBJECTS AND SETTING: One hundred and fifty fee-for-service GPs in suburban Brisbane. SETTING OF STANDARDS: Standards were set at meetings with general practitioner educators, and refined after circulating drafts to participants. Criteria were established in the 12 areas of: general ease-of-use (legibility; consciousness; and layout); whether certain patient data could be found (date of birth; past medical history; family history; allergies; alcohol and tobacco use; and immunisation status); and whether information about the most recent consultation could be found, (the reason for the consultation; its assessment; and management). MAIN OUTCOME MEASURES: Ten randomly selected medical records of consultations from each of the GPs scored blind by medical students. RESULTS: The mean weighted score was 11.4 out of a maximum possible of 18. Most records attained the standard with: consciousness (97%); recording date of birth (94%); and immunisation status (92%). Fewest attained the standard with family history (12%); adequate layout (17%); and recording alcohol and tobacco use (31%). Practice size and membership of the Royal Australian College of General Practitioners were not associated with significant differences in score, although sex, (being female) and date of graduation, (recent), were associated with significantly higher scores. CONCLUSION: There is considerable room for improvement in the quality of the clinical records of Australian GPs.

Analysis of Variance↗

PubMed1990

General practitioners and the provision of Papanicolaou smear-tests: current practice, knowledge and attitudes.

General practitioners are the main providers of Papanicolaou smear-tests yet, given the current suboptimal rates of cervical screening, it is clear that their full potential as screening providers is not being realized. To date, no information has been available concerning the possible barriers to the provision of Papanicolaou smear-tests by general practitioners. The present study assessed the views of a random sample of NSW general practitioners regarding the value of smear-tests, the most appropriate providers, the recommended screening protocol, and factors that were thought to influence both practitioners' provision and women's utilization of screening. The results indicate a number of changes to the current system which could counter screening barriers such as educational programmes for general practitioners, more female providers and the investigation of alternative services, consensus screening guide-lines, and screening registers and recall systems.

Adult↗

PubMed1997

A study of general practitioners' skin surgery in Canterbury.

AIMS: To evaluate skin surgery done by general practitioners in Christchurch. METHODS: Twenty-eight general practitioners performing regular skin surgery were studied. Their clinical accuracy and completeness of excision was analysed. Skin lesions referred for specialist treatment were also studied. RESULTS: Three hundred and three lesions were sent to the laboratory for analysis by participating practitioners. Sixty-one malignancies were present comprising 29 basal cell carcinomas, 28 squamous cell carcinomas, three malignant melanomas and one cutaneous lymphoma. Nineteen of the 61 malignant lesions were incompletely excised. Twenty eight further lesions were referred to specialists for treatment. CONCLUSIONS: General practitioners in Canterbury perform more skin surgery and remove more malignant lesions than their British counterparts. Although the adequacy of their skin surgery is better than other groups studied overseas there is considerable room for improvement.

Basal Cell Carcinoma↗

PubMed2003

[Management of cancer patients by general practitioners. Results of a survey among 422 physicians in Aquitaine].

OBJECTIVE: To have a better knowledge on the role of the general practitioner in the management of cancer patients, their opinion on communications with the specialists and their training in oncology. METHOD: In March 2000, a questionnaire was sent to a random sample of 730 general practitioners in the Aquitaine area. RESULTS: We obtained 440 answers (60%). The general practitioners declared taking care of a mean of 16 cancer patients among their clientele and seeing 5 new cases every year. Two thirds of them decided on the orientation of their patients, case by case. Nearly 70% of the practitioners reported difficulties, notably psychological, in the case of relapses or during the terminal phase. The majority (94%) considered the quality of the information provided by the specialists as correct or good. Globally, the practitioners would prefer to be more involved in the treatment of their cancer patients and 82% would accept to ensure the follow-up of the patients in remission. CONCLUSION: The expectations of the general practitioners defined in this study merit reflection for the development of treatment networks in order to improve their organisation and the collaboration between general practitioners and specialists.

Adult↗

PubMed1991

The clinical management of otorrhoea following grommet insertion: a survey of otolaryngologists and general practitioners.

A postal questionnaire of all Consultant Otolaryngologists in the British Isles, and of General Practitioners within the local family practitioner committee area, was designed to compare the current practice in the management of discharge from the ear following grommet insertion. 76% of the Otolaryngologists and 52% of the General Practitioners completed the questionnaire. Between the two groups, statistically significant differences were apparent in the management of this common complication of grommet surgery. A higher proportion of Consultants took a bacteriology swab of the ear as part of their treatment, which was significantly more frequently treated by antibiotic ear drops. Within the Consultant group, significant regional variations in choice of drugs and therefore the cost of treatment were apparent. The General Practitioners more commonly prescribed oral antibiotics. This common complication of grommet surgery is managed differently by General Practitioners and Otolaryngologists without a firm rational basis. Treatment based on current knowledge is discussed. Further evaluation of the efficacy of different treatment regimens by controlled prospective trials is required.

Cerebrospinal Fluid Otorrhea↗

PubMed2003

Perception of the risk of gastrointestinal adverse drug reactions with non-steroidal anti-inflammatory drugs (including coxibs): differences among general practitioners, gastroenterologists and rheumatologists.

OBJECTIVE: To compare the perception of risk of gastrointestinal adverse drug reactions (ADRs) with non-steroidal anti-inflammatory drugs (NSAIDs) (including coxibs) in general practitioners, gastroenterologists and rheumatologists. METHODS: Physicians (69 general practitioners, 45 gastroenterologists and 58 rheumatologists; 172 total) were interviewed using visual analogue scales in order to define a score of perceived risk (ranking from 0 to 10) of gastrointestinal ADRs associated with four classes of NSAIDs (indolics, oxicams, arylcarboxylic derivatives, coxibs). RESULTS: When the three groups of physicians were taken as a whole, indolic derivatives were ranked as the most dangerous NSAIDs [median score: 5.3 (25-75th percentiles: 3.5-7)] followed by oxicams [median score: 5.0 (25-75th percentiles: 3.1-6.2)], arylcarboxylic derivatives [median score 4.7 (25-75th percentiles: 3.0-6.5)] and coxibs [median score 1.9 (25-75th percentiles: 1.2-3.0)]. Among physicians, general practitioners gave the most important mean score [median score 4.8 (25-75th percentiles: 3.4-5.7)] for NSAIDs as a whole followed by gastroenterologists [median score 4.6 (25-75th percentiles: 3.6-5.6)] and rheumatologists [median score 3.6 (25-75th percentiles: 2.3-4.7)]. There was no significant difference among the three groups of physicians in the median score of perceived digestive risk associated with the use of indolic derivatives, whereas significant differences were found for arylcarboxylic derivatives, oxicams and coxibs, with higher median scores given by gastroenterologists followed by general practitioners and rheumatologists. CONCLUSION: This study shows differences in the perception of risks of gastrointestinal ADRs. Rheumatologists systematically considered NSAIDs as less harmful than general practitioners and gastroenterologists did. In contrast, the widely demonstrated difference in gastrointestinal risk among the different groups of NSAIDS (with, for example, a higher risk for oxicams) was not pointed out by the three studied groups of physicians. There are differences in the perception of gastrointestinal risks of NSAIDs (including coxibs) among physicians according to their medical education and medical specialisation.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1995

An experimental network of general practitioners for purposes of epidemiological surveillance in Italy.

A Computer Network of General Practitioners (GPs) has been established, connecting 150 general practitioners representing a statistically selected national sample, homogeneously distributed all over Italy. The purpose of the network is to increase the epidemiological surveillance on the health status of the Italian community, to collect useful data on the routine activity of the GPs, to promote computer use among them, and to organize some "ad hoc" investigations on specific subjects (case-control studies). To this purpose, a specific software was developed, both to meet the requirements of epidemiological research and to manage general practitioners' clinical files. A working prototype of a health card using micro-computer technology will also be experimented with a subset of the GPs.

Computer Communication Networks↗

PubMed1995

Reasons for poor detection of frequent falls in elderly people by general practitioners.

Frequent falls in old people are an important marker for other serious diseases, but are poorly detected by general practitioners. This paper examined the reason for this in 603 people aged 65 and over taken from a random sample of the population of those living at home in Cardiff in South Wales. The people were questioned about whether they suffered from falls, whether they had sought advice, and whether the treatment they obtained was effective. Most people said that they would report frequent falls to their general practitioner. However, people who actually suffered the problem were unlikely to report it. Those who did were subsequently less likely to earmark their general practitioner as useful for treating the problem than those who had not attended. The poor detection of frequent falls by general practitioners appears to be a combination of two things. Firstly, there is a reluctance on the part of elderly people to report the problem, and secondly the relative inability of general practitioners to manage the problem successfully.

Accidental Falls↗

PubMed2000

Social and gender variation in the prevalence, presentation and general practitioner provisional diagnosis of chest pain.

OBJECTIVES: To describe the prevalence of Rose angina and non-exertional chest pain in men and women in socioeconomically contrasting areas; to describe the proportions of men and women who present with the symptom of chest pain and who receive a provisional general practitioner diagnosis of coronary heart disease; to assess the effects of gender and deprivation. DESIGN: Two random general population samples in socially contrasting areas were surveyed using the Rose angina questionnaire: the case notes of people identified with chest pain were reviewed. SETTING: Glasgow conurbation. PARTICIPANTS: 1107 men and women, aged 45-64, with chest pain. OUTCOME MEASURES: Prevalence of Rose angina and non-exertional chest pain; the proportions who had presented with chest pain and received a general practitioner's provisional diagnosis of coronary heart disease. RESULTS: There was no difference between social groups in the prevalence of all chest pain but a greater proportion of those in deprived groups had Rose angina and a greater proportion of these had the more severe grade. The proportion of people who had presented with chest pain was higher among socioeconomically deprived groups but there was no difference in the proportions receiving a general practitioner provisional diagnosis of coronary heart disease. Men were more likely to present with chest pain than women and were more likely to receive a provisional general practitioner diagnosis of coronary heart disease. CONCLUSIONS: No evidence was found of social differences in patient presentation or general practitioner diagnosis that might explain reported variations in uptake of cardiology services. In contrast, gender variation may originate in part from differences in patient presentation and general practitioner diagnosis. Further investigation of socioeconomic variations in uptake of cardiology services should focus later in the care pathway, on general practitioner referral patterns and clinical decisions taken in secondary care.

Age Distribution↗

PubMed1992

South Australian hypertension survey. General practitioner knowledge and reported management practices--a cause for concern?

OBJECTIVE: To survey South Australian general practitioners to investigate their knowledge and reported management of patients with hypertension. DESIGN, SETTING AND PARTICIPANTS: Of 156 randomly selected SA general practitioners 132 responded to a questionnaire survey. RESULTS: This survey showed substantial differences between general practitioners in their knowledge about hypertension and in their reported practices for diagnostic levels, investigations to be undertaken once diagnosis had been made, levels at which pharmaceutical treatment should be initiated, at which level treatment was regarded as having attained satisfactory control, and length of time for routine review. There was also a demand for materials to be provided to assist in the management of this important condition. CONCLUSIONS: There is a perceived need for better and more appropriate educational materials and a need for a different approach to try and reduce the reported variability in management of patients with hypertension by general practitioners.

Aged↗

PubMed1995

Assessment of the practicality and safety of thrombolysis with anistreplase given by general practitioners.

BACKGROUND: Recent guidelines recommend that patients with obvious acute myocardial infarction receive thrombolysis, unless contraindicated, within 60-90 minutes of summoning assistance. If this target is to be achieved, an increasing number of general practitioners are likely to be involved in the administration of thrombolytic agents. AIM: This study aimed to assess the practicality and safety of thrombolysis with anistreplase when given by general practitioners. METHOD: An observational study was conducted in 805 general practices throughout the United Kingdom. Between March 1991 and September 1992, a total of 3383 patients with a clinical diagnosis of myocardial infarction were recruited--888 by 344 general practitioners who wished to include anistreplase in their management of myocardial infarction ('user' group) and 2495 by 776 general practitioners who did not wish to use anistreplase but who were willing to provide information about their cases ('comparison' group). RESULTS: More than half the patients were seen within two hours of onset of symptoms. A high frequency of contra-indications to thrombolysis, diagnostic uncertainty, and other, mainly practical, reasons limited the number of occasions on which anistreplase was administered. Thus, only 310 patients were given anistreplase in the community. The general practitioners in the study used anistreplase safely. Their diagnostic accuracy was high (of the 310 patients given anistreplase 69% had a definite, possible or probably myocardial infarction, 4% a definite non-cardiac diagnosis), the number of patients given anistreplase in spite of a documented contraindication was small (seven patients), and the doctors appeared to be aware of potential bleeding problems associated with thrombolysis. In all cases, the complications of acute myocardial infarction appeared to be managed appropriately. CONCLUSION: General practitioners can use anistreplase both appropriately and safely in the early management of acute myocardial infarction. Recognized contraindications to thrombolysis and practicalities of diagnosis and drug administration may, however, limit the number of occasions on which anistreplase is used.

Adult↗

PubMed1988

Diagnosis of occupational dermatitis by general practitioners and employment medical advisors: a pilot study.

This pilot study examined how closely general practitioners and employment medical advisors agreed when jointly investigating occupational dermatitis. The criterion for admitting a patient to the study was dermatitis on one or both hands. This presented most commonly among men aged 41-60 years and women aged 21-40 years. There was some reluctance among general practitioners to take part in the study, probably owing to the medico-legal problems associated with this condition. General practitioners and employment medical advisors were equally likely to attribute a case of dermatitis to occupational factors if the patient was employed in industry; but if the patient was in nonindustrial employment, general practitioners were more likely to consider the possibility of an occupational origin than employment medical advisors. These differences suggest that before initiating a wider study more information is required concerning the trigger mechanisms for dermatitis on the hands in order to reduce the diagnostic variability.

Adult↗

PubMedDate not supplied

[Acute sinusitus in adults. Management by general practitioners].

OBJECTIVE: Acute sinusitis is a common condition encountered in general practice and raises the question of appropriate management. Sufficient data are still lacking in the literature to provide a fully satisfactory response. METHODS: We conducted a survey among 193 physicians representative of the general practitioners in France to collect 755 cases of acute sinusitis treated in the outpatient setting from January 6 through March 15, 1999. We recorded clinical features and therapeutic management. RESULTS: Pain was the predominant clinical sign (97% of the patients). Facial pain with a highly suggestive localization and aggravated by pressure and headache were the most frequent. Most of the patients also had a nasal symptom (77%) and an infectious context (90%). Three circumstances had been pre-defined by the experts: unique acute sinusitis, acute episode of chronic sinusitis, and recurrent acute sinusitis. In 67% of the cases of unique acute sinusitis, the diagnosis of the general practitioner was confirmed a posterori by the experts. Few complementary tests were ordered (in 17% of the patients) mainly in fragile patients and mainly limited to a radiography of the sinus (81% of the complementary tests ordered). An oral antibiotic was almost always prescribed (96% of the patients) although antibiotics comprised only 29% of all prescriptions. General corticosteroid therapy (41%), local treatment (73%) and anti-cough or expectoration medications (52%) were also prescribed. Despite the painful nature of sinusitis, analgesics were only prescribed for 36% of the patients. CONCLUSION: This observational survey enabled us to describe the diagnostic and therapeutic strategy used by French general practitioners for acute sinusitis in adults. There was general agreement on the strategy that was well adapted to the patient profiles. An evaluation of the different classes of drugs prescribed, and their efficacy in the outpatient setting, that remains to be determined, was not however attempted.

Acute Disease↗

PubMed1992

General practitioners' confidence in diagnosing and managing eye conditions: a survey in south Devon.

In order to open dialogue aimed at increasing eye care in general practice and reduce waiting times for ophthalmic outpatient appointments general practitioners in the Torbay health district were asked about their levels of confidence in ophthalmology as a subject, and in the diagnosis and management of specific eye conditions. They were also asked about ophthalmic equipment available to them, their management policies for 34 specific eye conditions, and their perceived need for further training in this subject. A total of 75% of the general practitioners responded to the questionnaire. Despite more than half of the general practitioners indicating that they did not feel confident with ophthalmology generally, most expressed confidence in diagnosing and managing common eye conditions. Basic equipment for examining the eye was available to most doctors. Referral policies varied considerably, and these have resource implications. Seventy eight per cent of respondents were prepared to take on more eye care in general practice, and over 80% of general practitioners requested informal teaching sessions in ophthalmology. Support must be forthcoming if general practitioners are to provide eye care in general practice.

Clinical Competence↗