Referrals for coronary angiography in a high risk population.
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OBJECTIVES: To examine variations in referral for coronary angiography within Northern Ireland and relate these to local death rates from coronary artery disease (ICD rubrics 410-414). DESIGN: A descriptive retrospective analysis of aggregate hospital activity data for 1979-88 and corresponding mortality rates in the local population. SETTING: Two regional referral hospitals and 26 local district council areas. PATIENTS: 5173 patients aged 35-74 years with an underlying diagnosis of ischaemic heart disease, whose records contained complete information on their age, sex, and home address. MAIN MEASURES: Age-standardised angiography rates and corresponding standardised death rates derived from the registrar general's reports. RESULTS: Among the 26 constituent district council areas there was significant heterogeneity in the angiography rates, ranging from 62 to 335/100,000 in men and from 7 to 62/100,000 in women (likelihood ratio statistic 856 and 359 respectively). There was no significant association between these angiography rates and the local death rates from ischaemic heart disease. CONCLUSION: The results suggest a non-uniform threshold for referral for angiography. IMPLICATIONS: Clinicians need to examine the appropriate indications for referral for invasive investigation. (+info)
Referral of patients to an anticoagulant clinic: implications for better management.
(18/5680)
The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit. (+info)
Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia.
(19/5680)
OBJECTIVE: To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN: Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING: Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS: 179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES: Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS: Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION: Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care. (+info)
Is choice of general practitioner important for patients having coronary artery investigations?
(20/5680)
OBJECTIVE: To determine whether particular sociodemographic characteristics of patients with stable angina affected their general practitioners' (GPs') decisions to refer them for revascularisation assessment. DESIGN: Postal questionnaire survey. SETTING: Collaborative survey by the departments of public health medicine in each of the four health boards in Northern Ireland, serving a total population of 1.5 million. SUBJECTS: All (962) GPs. MAIN MEASURES: The relation between GPs' referral decisions and patients' age, sex, employment status, home circumstances, smoking habits, and obesity. RESULTS: 541 GPs replied (response rate 56%). Most were "neutral" towards a patient's sex (428, 79%), weight (331, 61%), smoking habit (302, 56%), employment status (431, 80%), and home circumstances (408, 75%) in making decisions about referral. In assigning priority for surgery most were neutral towards the patient's sex (459, 85%), employment status (378, 70%), and home circumstances (295, 55%). However, most GPs (518, 95%) said that younger patients were more likely to be referred, and a significant minority were less likely to refer patients who smoked (202, 37%) and obese patients (175, 32%) and more likely to refer employed patients (97, 18%) and those with dependents (117, 22%) (compared with patients with otherwise comparable clinical characteristics); these views paralleled the priority which GPs assigned these groups. The stated likelihood of referral of young patients was independent of the GPs' belief in ability to benefit from revascularisation, but propensity to refer and perception of benefit were significantly associated for all other patient characteristics. CONCLUSION: GPs' weighting of certain characteristics in reaching decisions about referral for angiography is not uniform and may contribute to unequal access to revascularisation services for certain patient groups. (+info)
The role of private medical practitioners and their interactions with public health services in Asian countries.
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This paper aims to review the role of private practitioners and their interactions with public health services in developing countries, focusing largely on the Asian region. Evidence on the distribution of health facilities, manpower, health expenditures and utilization rates shows that private practitioners are significant health care providers in many Asian countries. Limited information has been published on interactions between public and private providers despite their co-existence. Issues related to enforcement of regulations, human resources, patient referrals and disease notifications, are examined. (+info)
User fees and patient behaviour: evidence from Niamey National Hospital.
(22/5680)
Evidence is presented on the effects of price changes on the delay before seeking care and on referral status in a sample of hospital patients in Niger. Price changes are measured as differences across patients at one hospital in whether or not they pay for care, rather than as differences in prices across several hospitals. User fees are charged, but the fee system allows exemptions for some payor categories such as government employees, students, and indigent patients. Evidence is also presented on the effect of income on the delay before seeking care and referral status. The analysis demonstrates a technical point on whether household consumption or current income is a more appropriate measure of income. The analysis shows that user fees affect patient behaviour, but the effects are not the same for outpatients and inpatients. Outpatients who pay for care wait longer before seeking care, but inpatients do not. Inpatients who pay for care are more likely to be referred, but outpatients are not. Patients with more income wait less time to seek care and are less likely to be referred than other patients. Further, household consumption explains patient behaviour better than current income. (+info)
Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority.
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OBJECTIVES: To develop, from simple clinical factors, criteria to identify appropriate patients for referral to a surgeon for consideration for arthroplasty, and to rank them in the queue once surgery is agreed. DESIGN: Delphi process, with a panel including orthopaedic surgeons, rheumatologists, general practitioners, epidemiologists, and physiotherapists, who rated 120 case scenarios for appropriateness and 42 for waiting list priority. Scenarios incorporated combinations of relevant clinical factors. It was assumed that queues should be organised not simply by chronology but by clinical and social impact of delayed surgery. The panel focused on information obtained from clinical histories, to ensure the utility of the guidelines in practice. Relevant high quality research evidence was limited. SETTING: Ontario, Canada. MAIN MEASURES: Appropriateness ratings on a 7-point scale, and urgency rankings on a 4-point scale keyed to specific waiting times. RESULTS: Despite incomplete evidence panellists agreed on ratings in 92.5% of appropriateness and 73.8% of urgency scenarios versus 15% and 18% agreement expected by chance, respectively. Statistically validated algorithms in decision tree form, which should permit rapid estimation of urgency or appropriateness in practice, were compiled by recursive partitioning. Rating patterns and algorithms were also used to make brief written guidelines on how clinical factors affect appropriateness and urgency of surgery. A summary score was provided for each case scenario; scenarios could then be matched to chart audit results, with scoring for quality management. CONCLUSIONS: These algorithms and criteria can be used by managers or practitioners to assess appropriateness of referral for hip or knee replacement and relative rankings of patients in the queue for surgery. (+info)
Assessing general practitioners' care of adult patients with learning disability: case-control study.
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OBJECTIVE: To compare general practitioners' care of adult patients with learning disability with that of control patients in the same practice. DESIGN: Case-control study of patients and controls by a structured interview study of general practitioners. SETTING: Avon. PATIENTS: 78 adult patients with learning disability and 78 age and sex matched controls--cared for by 62 general practitioners. MAIN MEASURES: Number and content of consultations and opinions of the general practitioners. RESULTS: There were more consultations for diseases of the central nervous system and of the skin among the patients than the controls (15 v 3 for central nervous system disease and 15 v 4 skin disease). There were also significantly fewer recordings of blood pressure and cervical cytology tests (34 v 51 for blood pressure and 2 v 18 for cytology). Although more patients were taking drugs affecting the central nervous system (33 v 6), more controls were taking drugs for musculoskeletal complaints (17 v 7). CONCLUSION: Although adult patients with learning disability consult with their general practitioners at equivalent rates to other patients, they get less preventive care and consult for different types of problems than do other patients. The reasons for these differences in preventive care are not clear. Carers and general practitioners should be informed of these differences to ensure that appropriate care is given. (+info)