Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems.

Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than in NI (69.2% and 57.0% respectively) Less than 1 in 10 patients in ROI waited two or more working days to see a doctor of choice (8.1%) compared to almost half (45.0%) in NI. In NI overall satisfaction decreased as practice size increased; 82.8%, 80.4%, and 75.8%. In both systems, in large practices, accessibility is reduced when compared to smaller practices. The faster access to GP services in ROI may be due to the deterrent effect of the consultation charge freeing up services although, as it is the poorest and sickest who are deterred by the charge this improved accessibility may come at a significant cost in terms of equity. The underlying concern for policy makers centres around provision of equitable services.

Socio-economic gradients in self-reported health in Ireland and Northern Ireland.

BACKGROUND: Research and policy related to reducing health inequalities has progressed separately within Ireland and Northern Ireland. This paper describes the first exploration of the socio-economic influences on health on the island of Ireland since 1922. METHODS: Postal survey. RESULTS: The response rate was 52%; 11,870 respondents. Men reported more long-standing illness (LLTI) or poor general health (PGH); depression was more common amongst women. Socio-economic gradients in health were evident in both jurisdictions, with the effects of household income being particularly marked. Overall, morbidity levels were significantly better in Ireland than in Northern Ireland: adjusted odds ratio of 0.79 (95% CI 0.71 - 0.88) for LLTI; 0.64 (0.57 - 0.72) for PGH; 0.90 (0.82 - 0.99) for depression. CONCLUSIONS: There is evidence of strong and similar socio-economic gradients in health throughout the island of Ireland. This would suggest joint policy approaches or at least further comparative evaluation of the initiatives in each jurisdiction.

A randomized controlled trial using instant photography to diagnose and manage dermatology referrals.

BACKGROUND: Fifteen percent of GP consultations are for dermatological conditions; 4% of these are referred to a dermatologist. There are long waiting lists for dermatology appointments. This study examines the value of instant photography in managing dermatology referrals. OBJECTIVE: The purpose of our study was to compare outcomes of referral for dermatology appointments between patients whose referral letters do or do not include instant photograph(s). METHODS: Patients (136), referred to a dermatologist by GPs in two urban health centres, were randomly allocated to study and control groups. Instant photographs, taken by the GP, were included in the referral letters. Control group patients were given out-patient appointments in the usual way. The numbers of study group patients needing an appointment for diagnosis or management and with a changed diagnosis after face-to-face consultation were recorded. Waiting time from referral to appointment or management plan was recorded for both groups. RESULTS: For 63% of the study group (45/71), a diagnosis and a management plan were made without the patient requiring an appointment. This included 38% (27/71) who, after diagnosis and initial management, needed an appointment and 25% (18/71) who did not. The remainder of the study group (37%; 26/71) required a face-to-face consultation. The mean time for formulation of a management plan for patients without an appointment was 17 days (SD = 11); waiting times for appointments in study and control groups were similar (mean 55 days; SD = 40). CONCLUSIONS: Instant photography is helpful in managing dermatology referrals and offers the potential to reduce numbers requiring an out-patient appointment by 25%.

Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

OBJECTIVES: To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs). METHODS: Four GPs and two RNs were trained in the assessment of early inflammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical findings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA. RESULTS: Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was 0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Significant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions. CONCLUSION: Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.

Telerheumatology--diagnostic accuracy and acceptability to patient, specialist, and general practitioner.

This study examines the diagnostic accuracy and acceptability of telemedicine in the field of rheumatology. One hundred patients had a telephone and televisual consultation and the results were compared with a face-to-face consultation. While the telephone consultations were often unsatisfactory, the televisual consultations were highly accurate (97%) and acceptable to patients, general practitioners, and specialists.

Regional variations in sulfate and nitrate on annual, seasonal, and synoptic time scales.

Ambient data from Interagency Monitoring of Protected Visual Environments (IMPROVE) monitors are analyzed to evaluate the spatial structure of SO4 and NO3 aerosols in the mid-Atlantic region. Sub-weekly, seasonal, and annual data values are compared between the IMPROVE Washington, DC, site and three rural sites. Synoptic perturbations are compared between sites to quantify similarities in short-term temporal perturbations of SO4 and NO3. Based on these comparisons between the rural and urban IMPROVE monitors, the spatial structure of SO4 shows broad regional homogeneity that is recognizable from both the long-term average values and the short-term variations. NO3 data on a seasonal and annual basis show much larger spatial gradients between the urban Washington monitor and the three rural monitors than do SO4 data. Short-term NO3 perturbations at the three rural monitors also differ significantly from those at the Washington site. These dissimilarities in NO3 levels between the rural and urban IMPROVE monitors on both short-term and longer-term time scales indicate little homogeneity of NO3 aerosols in the mid-Atlantic region considered here. The volatility of NO3 aerosols and the removal rate of HNO3 via dry deposition could contribute to the spatial variability differences shown here between SO4 and NO3.

Reasons for patient removals: results of a survey of 1005 GPs in Northern Ireland.

There has been considerable debate on the issue of general practitioners (GPs) removing patients from their lists. The second report of the Health Service Ombudsman addressed this area in some detail and, among other observations, commented on the lack of information available on this subject. This is a report on a questionnaire survey of GPs, aimed at finding out their reasons for removing patients and their feelings about the changes that have been proposed regarding their automatic right to remove patients without giving them a reason.

Developing seasonal ammonia emission estimates with an inverse modeling technique.

Significant uncertainty exists in magnitude and variability of ammonia (NH3) emissions, which are needed for air quality modeling of aerosols and deposition of nitrogen compounds. Approximately 85% of NH3 emissions are estimated to come from agricultural nonpoint sources. We suspect a strong seasonal pattern in NH 3 emissions; however, current NH3 emission inventories lack intra-annual variability. Annually averaged NH 3 emissions could significantly affect model-predicted concentrations and wet and dry deposition of nitrogen-containing compounds. We apply a Kalman filter inverse modeling technique to deduce monthly NH3 emissions for the eastern U.S. Final products of this research will include monthly emissions estimates from each season. Results for January and June 1990 are currently available and are presented here. The U.S. Environmental Protection Agency (USEPA) Community Multiscale Air Quality (CMAQ) model and ammonium (NH4+) wet concentration data from the National Atmospheric Deposition Program (NADP) network are used. The inverse modeling technique estimates the emission adjustments that provide optimal modeled results with respect to wet NH4+ concentrations, observational data error, and emission uncertainty. Our results suggest that annual average NH 3 emissions estimates should be decreased by 64% for January 1990 and increased by 25% for June 1990. These results illustrate the strong differences that are anticipated for NH3 emissions.

Stress and morale in general practice: a comparison of two health care systems.

BACKGROUND: Poor morale and high levels of stress among general practitioners (GPs) are causing concern. Little research has previously been carried out to study possible differences in morale and stress between GPs working in two different but geographically similar health care systems. AIM: To compare perceived levels of stress and morale between GPs working in two different health care systems--one having a state monopoly (Northern Ireland) and the other having mixed private and state funding (Republic of Ireland)--and to look for factors that might help explain any differences in stress levels and morale between the two systems. METHOD: Anonymous and confidential questionnaires were sent to all 986 National Health Service (NHS) GPs in Northern Ireland (NI) and a random sample of 900 GPs in the Republic of Ireland (ROI). A common set of core questions on demographic details, partners and work patterns, perceived levels of stress and morale, safety, violence, and complaints were asked. RESULTS: Response rates were high in both areas: 91% in NI and 78% in the ROI. GPs in NI had significantly higher stress levels and significantly lower levels of morale than GPs in the ROI. The NI sample expect matters to get worse over the following year. Doctors in the ROI were more likely to be single handed and to work from two sites. Also, more GPs in ROI had fears for their safety and had been the subject of physical violence, but fewer had received complaints and medico-legal actions than in NI. CONCLUSIONS: A significant proportion of both groups of doctors report feeling highly stressed but GPs in NI appear more unhappy and have a poorer outlook for the future. It is suggested that the structure, management, and expectations of the NHS have taken a severe toll on its GPs, whereas a system in which doctors have less practice support but more control is good for morale.

Patient removals from general practitioner lists in Northern Ireland: 1987-1996.

BACKGROUND: Being struck off a general practitioner's list is a major event for patients and a subject for much media attention. However, it has not hitherto received much research attention. AIMS: To quantify the numbers of patients removed at doctors' request in Northern Ireland between 1987 and 1996. To describe the characteristics of those removed and to determine if the rate of removal has increased. METHODS: This is a descriptive epidemiological study involving a secondary data analysis of records held by the Central Services Agency. RESULTS: Six thousand five hundred and seventy-eight new patients were removed at general practitioner (GP) request between 1987 and 1996. This equated to 3920 removal decisions, a rate of 2.43 per 10,000 person-years. The very young and young adults had the highest rates of removal; most of the young being removed as part of a family. Ten point six per cent of removed patients had a repeat removal, and 16.3% of first removal decisions required an assignment to another practice. Family removals have decreased and individual removals have increased over the 10 years. Disadvantaged and densely populated areas with high population turnover were associated with higher rates of removal, though heterogeneity is evident between general practitioners serving similar areas. Compared to the period 1987 to 1991, removal rates for the years 1992 to 1993 were reduced by 20.0% (95% confidence interval (CI) for rate ratio (RR) 0.73-0.87), and those for the years 1994 to 1996 increased by 8% (95% CI = 1.01-1.16). The greatest increase was in the over-75 years age group (standardized RR = 1.60; 95% CI = 1.57-1.62). CONCLUSIONS: Removals are relatively rare events for both patients and practices, though they have been increasing in recent years. Further research is needed to understand the processes that culminate in a removal.

General practitioner records on computer--handle with care.

This 1 year prospective study involved nine general practitioners in an urban health centre who routinely record all patient contacts on computer. The study determines by comparison with a manual record how accurately doctors record laboratory investigations on computer and compares the effectiveness of three interventions in improving the completeness of computerized recording of presenting symptoms, problems/diagnoses and laboratory investigations. Recording was analysed for 1 month prior to and for two 1 month periods following each intervention. A control group was used. A total of 7983 patient contacts were analysed. Intervention led to an improvement in the recording of presenting symptoms and problems/diagnoses. Recording of investigations on the computer showed no improvement, remaining at one-third of the total in the treatment room book for both study and control doctors. The effectiveness of the different forms of intervention depended on both the aspect of the consultation considered and the familiarity of individual doctors with the method of data collection. Aspects considered less important required greater intervention to bring about a marked improvement, as did doctors relatively new to the practice. It may not be possible to get all aspects of the consultation recorded with the same degree of accuracy. This has implications for the accuracy of retrospective studies dependent on existing computerized data.

Diabetes care by general practitioners in Northern Ireland: present state and future trends.

A questionnaire returned by 250 (71.4%) of the 350 general practices in Northern Ireland indicated that although only 34 practices had special arrangements for seeing their diabetic patients, 178 practices stated that they would like to be more involved in the care of their non-insulin-dependent diabetes mellitus (NIDDM) patients. One hundred and eight practices felt the same way about their insulin-dependent diabetes mellitus (IDDM) patients. One hundred practices stated that the partners felt competent to manage their diabetic patients. The main area where general practitioners felt they needed to improve their knowledge was ophthalmology (56 practices). When asked which type of care scheme would appeal most to their practice, 135 practices stated that regular attendance with the general practitioner and annual hospital review would be the preferred arrangement. Overall there was a positive attitude towards increased general practitioner involvement in diabetes care.

A comparison of a ß2-adrenoceptor antagonist (ICI 118,551), diazepam and placebo in the treatment of acute anxiety.

The effect of ß( 2)-adrenoceptor antagonism in acute anxiety neurosis was investigated by comparing the effects of ICI 118,551, a specific ß(2)-adrenoceptor antagonist, diazepam and placebo in a double-blind, parallel group study. Sixty-three patients, who fulfilled criteria for Anxiety Disorder (DSM III) and were psychotropic drug- free (apart from six using hypnotics), were entered. Anxiety symptoms were rated using the Hamilton Anxiety Scale (HAS) and Spielberger State Anxiety Scale. Assessments were made at entry and following a 7-day single-blind placebo treatment phase, at the end of which only 51 wished to continue and had sufficient symptoms (HAS score >16 or reduction <25% on placebo) for entry to the next phase. Following a double- blind, random allocation they then received ICI 118,551 (50 mg), diazepam (2 mg) or placebo thrice daily for 4 weeks. Symptoms were assessed after 2 and 4 weeks in this active treatment phase (i.e. at weeks 3 and 5 of the study). Thirty-five patients completed the study. A statistically significant improvement in HAS score was seen for all patients but there were no significant differences between treatments. Treatments did not differ in their effects on blood pressure or heart rate. ß(2)-Adrenoceptor antagonism does not seem to have important effects on anxiety symptoms in anxiety neurosis.

Beta 2-adrenoceptor antagonism in anxiety.

The relative role of beta 1- and beta 2-adrenoceptor antagonism in the management of anxiety symptoms is not clear. We studied the effect of ICI 118,551, a selective beta 2-antagonist, in 51 patients presenting with acute anxiety symptoms and fulfilling DSM-III criteria for anxiety disorder. All patients received placebo during the first week of treatment followed by thrice daily diazepam (2 mg) or ICI 118,551 (50 mg) or placebo for 4 weeks with double-blind, random allocation. Hamilton anxiety scale scores improved on all treatments but there was no significant difference between treatments. Beta 2-adrenoceptor antagonism does not appear to be effective in acute anxiety neurosis. Some earlier literature suggests that beta 1-antagonism may be more important.

Patients on H2-receptor antagonists--are we investigating them?

A survey was made of patients receiving H2-receptor antagonists in a group practice serving 8600 patients. Two hundred and twelve patients (2%) who had received at least one prescription for H2 antagonists in a 12 month period were identified. When compared with the practice population, men and patients over 50 years old were more likely to be taking these drugs (P less than 0.01 and P less than 0.001, respectively). One hundred and fifty-seven patients (74%) were investigated before commencing therapy; 114 (73%) of these patients were investigated via the hospital outpatient department, despite the general practitioners having full open access to barium meals. Only 23 (15%) of the patients investigated were found to have no active pathology. Twenty-nine (14%) of the 212 study patients had received one or more gastrointestinal investigations in the 18 months subsequent to starting H2-antagonist therapy. Twenty-five of these patients had also received an investigation before starting therapy. One hundred and eleven patients (52%) had had their H2 antagonist therapy initiated by their general practitioner.

Repeat prescribing of non-steroidal anti-inflammatory drugs excluding aspirin: how careful are we?

About 5% of all National Health Service prescriptions in Britain and a quarter of reports of suspected adverse reactions are accounted for by non-steroidal anti-inflammatory drugs. Their prescription was investigated in two computerised group practices serving 11850 patients. Altogether 198 patients receiving repeat prescriptions of non-steroidal anti-inflammatory drugs were identified and relevant clinical details extracted from their notes. Of these patients, 119 were over 65 years old; 172 were receiving one of six different non-steroidal anti-inflammatory drugs; and 76 were taking drugs that can interact with non-steroidal anti-inflammatory drugs. Ninety one patients had one or more medical conditions that may be aggravated by non-steroidal anti-inflammatory drugs, and 36 had experienced side effects important enough for their treatment to be changed. A questionnaire to assess opinions and knowledge of non-steroidal anti-inflammatory drugs was given to 42 general practitioners and 26 rheumatologists. Although the two groups showed a comparable knowledge of the properties and costs of non-steroidal anti-inflammatory drugs, they differed significantly in their views on the circumstances under which these drugs should be used. Clear guidelines on the prescription of these drugs would indicate when careful monitoring is essential for patients to benefit from them safely.