Management of menorrhagia in primary care-impact on referral and hysterectomy: data from the Somerset Morbidity Project.

OBJECTIVE: To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates. DESIGN: Prospective observational study. SETTING: 11 general practices from the Somerset Morbidity Project. SUBJECTS: 885 women consulting their general practitioner with menorrhagia over four years. MAIN OUTCOME MEASURES: Proportions of these women investigated and treated with drugs in primary care, referred to a gynaecologist and undergoing operative procedures. The relation between investigation and prescribing in primary care and referral to and surgery in secondary care. RESULTS: Less than half of women had a vaginal examination (42%, 95% CI 39% to 45%), or a full blood count (39%, 95% CI 36% to 43%). Almost a quarter of women, 23% (95% CI 20% to 26%), received no drugs and 37% (95% CI 34% to 40%) received norethisterone. Over a third, 38% (95% CI 34% to 40%), of women were referred, and once referred 43% (95% CI 38% to 48%) of women were operated on. Women referred to a gynaecologist were significantly more likely to have received tranexamic acid and/or mefenamic acid in primary care (chi(2)=16.4, df=1, p<0.001). There were substantial between practice variations in management, for example in prescribing of tranexamic acid and/or mefenamic acid (range 16% to 72%) and referral to gynaecology (range 24% to 52%). There was a significant association between high referral and high operative rates (Spearman's correlation coefficient=0.86, p=0.001). CONCLUSIONS: Substantial differences in management exist between practices when investigating and prescribing for menorrhagia in primary care. Rates of prescribing of effective medical treatment remain low. The decision to refer a woman impacts markedly on her chances of subsequently being operated on. Effective management in primary care may not reduce referral or hysterectomy rates.

Collecting morbidity data in general practice: the Somerset morbidity project.

OBJECTIVE: To collect a valid, complete, continuous, and representative database of morbidity presenting to primary care and to use the data to help commission services on the basis of local need and effectiveness. SETTING: Computerised general practices in Somerset. METHODS: Participating general practices were selected to be representative of the district health authority population for general practice and population characteristics. All conditions presented at face to face consultations were assigned a Read code and episode type and the data were regularly validated. Data were sent by modem from the practices via a third party to the health authority each week. MAIN OUTCOME MEASURES: Proportion of consultations coded and accuracy of coding. RESULTS: 11 practices agreed to participate. Validations for completeness during April 1994 to March 1995 revealed that 96.4% of the records were coded; 94% of the 1090 records validated had appropriate episode types and 87% appropriate Read codes. The results have been used to help formulate the health authority's purchasing plans and have enabled a change in the local contracts for surgery for glue ear. CONCLUSIONS: The project has shown the feasibility of establishing a network of practices recording and reporting the morbidity seen in primary care. Early indications are that the data can be useful in evidence based purchasing.