Postgraduate training for general practice in the United Kingdom.

Although the role of general practice is well established in the United Kingdom's National Health Service, formal postgraduate training for primary care practice is a recent development. Trainees may enter three-year programs of coordinated inpatient and outpatient training or may select a series of independent posts. Programs have been developed to train general practitioners as teachers, and innovative courses have been established. Nevertheless, there is a curious emphasis on inpatient experiences, especially since British general practitioners seldom treat patients in the hospital. In their outpatient experiences trainees are provided with little variety in their instructors, practice settings, and medical problems. The demands on this already strained system will soon be increased due to recent legislation requiring postgraduate training for all new general practitioners. With a better understanding of training for primary care in the National Health Service, those planning American primary care training may avoid the problems and incorporate the attributes of British training for general practice.     

The management of childhood urinary tract infections

Urinary tract infections can result in significant morbidity and represent one of the most common urological conditions that the pediatrician and family practitioner encounter in the pediatric patient population. The prevalence of UTI in girls may be as high as 8.1%. UTIs also represent the most commonly identified serious bacterial infection in infants presenting with a febrile illness. Of febrile infants aged 2-3 months, 3-10% have a documented UTI. While the majority of the UTIs are not associated with any significant underlying conditions, the mere presence of a UTI is worrisome to most parents. An appropriate evaluation will determine which of these patients need referral. A brief summary is therefore presented to assist the primary care physician in the evaluation and management of childhood UTIs.     

Management of urinary tract infections

Urinary tract infections (UTIs) are commonly encountered in medical practice and range from asymptomatic bacteruria to acute pyelonephritis. Enterobacteriaceae with E. coli being the most prevalent, are responsible for most commonly acquired uncomplicated UTIs and usually respond promptly to oral antibiotics. In contradistinction, more resistant pathogens cause nosocomially acquired infections which often require parenteral antibiotic therapy. Patients with acute bacterial prostatitis, usually caused by Enterobacteriaceae present with a tender prostate gland and respond promptly to antibiotic therapy. Chronic bacterial prostatitis on the other hand, is a subacute infection characterized by recurrent episodes of bacterial UTI where the patient presents with vague symptoms of pelvic pain and voiding problems. Treatment is protracted and may be frustrating. Nonbacterial prostatitis and chronic pelvic pain syndrome produce symptoms similar to those of chronic bacterial prostatitis. Treatment is not well defined due to their uncertain etiologies. Most episodes of catheter associated bacteruria are asymptomatic, where less than 5% will be complicated by bacteremia. The use of systemic antibiotics for treatment or prevention of bacteruria is not recommended, particularly in the geriatric age group, since it helps select for resistant organisms. Prevention thus remains the best option to control it. Few patients without catheters who have asymptomatic bacteruria develop serious complications and therefore routine antimicrobial therapy is not justified with only two exceptions : before urologic surgery and during pregnancy.     

Peripheral arterial disease detection, awareness, and treatment in primary care

CONTEXT: Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis that is common and is associated with an increased risk of death and ischemic events, yet may be underdiagnosed in primary care practice. OBJECTIVE: To assess the feasibility of detecting PAD in primary care clinics, patient and physician awareness of PAD, and intensity of risk factor treatment and use of antiplatelet therapies in primary care clinics. DESIGN AND SETTING: The PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program, a multicenter, cross-sectional study conducted at 27 sites in 25 cities and 350 primary care practices throughout the United States in June-October 1999. PATIENTS: A total of 6979 patients aged 70 years or older or aged 50 through 69 years with history of cigarette smoking or diabetes were evaluated by history and by measurement of the ankle-brachial index (ABI). PAD was considered present if the ABI was 0.90 or less, if it was documented in the medical record, or if there was a history of limb revascularization. Cardiovascular disease (CVD) was defined as a history of atherosclerotic coronary, cerebral, or abdominal aortic aneurysmal disease. MAIN OUTCOME MEASURES: Frequency of detection of PAD; physician and patient awareness of PAD diagnosis; treatment intensity in PAD patients compared with treatment of other forms of CVD and with patients without clinical evidence of atherosclerosis. RESULTS: PAD was detected in 1865 patients (29%); 825 of these (44%) had PAD only, without evidence of CVD. Overall, 13% had PAD only, 16% had PAD and CVD, 24% had CVD only, and 47% had neither PAD nor CVD (the reference group). There were 457 patients (55%) with newly diagnosed PAD only and 366 (35%) with PAD and CVD who were newly diagnosed during the survey. Eighty-three percent of patients with prior PAD were aware of their diagnosis, but only 49% of physicians were aware of this diagnosis. Among patients with PAD, classic claudication was distinctly uncommon (11%). Patients with PAD had similar atherosclerosis risk factor profiles compared with those who had CVD. Smoking behavior was more frequently treated in patients with new (53%) and prior PAD (51%) only than in those with CVD only (35%; P <.001). Hypertension was treated less frequently in new (84%) and prior PAD (88%) only vs CVD only (95%; P <.001) and hyperlipidemia was treated less frequently in new (44%) and prior PAD (56%) only vs CVD only (73%, P<.001). Antiplatelet medications were prescribed less often in patients with new (33%) and prior PAD (54%) only vs CVD only (71%, P<.001). Treatment intensity for diabetes and use of hormone replacement therapy in women were similar across all groups. CONCLUSIONS: Prevalence of PAD in primary care practices is high, yet physician awareness of the PAD diagnosis is relatively low. A simple ABI measurement identified a large number of patients with previously unrecognized PAD. Atherosclerosis risk factors were very prevalent in PAD patients, but these patients received less intensive treatment for lipid disorders and hypertension and were prescribed antiplatelet therapy less frequently than were patients with CVD. These results demonstrate that underdiagnosis of PAD in primary care practice may be a barrier to effective secondary prevention of the high ischemic cardiovascular risk associated with PAD.     

Community-oriented primary care in the United States. A status report

Community-oriented primary care (COPC) is a variation on the primary care model, which is characterized by the complementary use of epidemiologic and primary care skills to systematically address the health care needs of a defined population. A study by the Institute of Medicine developed an operational model of COPC and examined its feasibility under differing organizational and financial arrangements. Although COPC is usually associated with publicly funded programs for underserved populations, the study demonstrated its presence in the private sector as well. However, the financial structure of the practice remains a critical factor determining the particular expression of the model. The study points to the need for data describing the marginal cost and health impact of COPC, if this promising innovation is to become an important form of primary care practice.     

Immediate coronary care in general practice — a three-year review

The general practitioners in a rural practice in a three-year period were called to 101 patients (25% female) who suffered a myocardial infarction. The average response time was 15 minutes. Seventeen patients collapsed and died and the 84 who survived the initial period were given immediate coronary care and either cared for at home, admitted by cardiac ambulance to a coronary care unit, or admitted to a general medical ward with monitor facilities. The four-week mortality rates were 21.0%, 21.5% and 57.7% respectively. Thirty-six patients required treatment for arrhythmias in the initial care period, of whom nine required defibrillation. This survey supports the view that patients over the age of 60 years with uncomplicated myocardial infarction may be cared for successfully at home.     

Is prevention unbalancing general practice?

Australia has begun to encourage and financially reward general practitioners for implementing preventive activities. While an expanding preventive agenda for general practice remains attractive, there is a real potential for opportunity costs, especially in the absence of realistic practice-based support for preventive care. These costs may include a shift from the needs of individual patients to those of the community. It is crucial not to neglect the concept of relationship-centred primary care (which may actually enhance preventive activities), as well as enhancing the preventive environment of the practice, when considering strategies to improve preventive uptake.     

The economic impact and multiplier effect of a family practice clinic on an academic medical center

Academic medical centers are facing the need to expand their primary care referral base in an increasingly competitive medical environment. This study describes the medical care provided during a 1-year period to 6304 patients registered with a family practice clinic located in an academic medical center. The relative distribution of primary care, secondary referrals, inpatient admissions, and their associated costs are presented. The multiplier effect of the primary care clinic on the academic medical center was substantial. For every $1 billed for ambulatory primary care, there was $6.40 billed elsewhere in the system. Each full-time equivalent family physician generated a calculated sum of $784,752 in direct, billed charges for the hospital and $241,276 in professional fees for the other specialty consultants. The cost of supporting a primary care clinic is likely to be more than offset by the revenues generated from the use of hospital and referral services by patients who received care in the primary care setting.     

Do physician-payment mechanisms affect hospital utilization? A study of Health Service Organizations in Ontario.

OBJECTIVES: To determine whether payment of primary care physicians based on capitation, with an additional incentive payment for low hospital-utilization rates, resulted in lower hospital-utilization rates among patients of these physicians than among patients of physicians still paid on a fee-for-service basis. DESIGN: Retrospective cohort study. SETTING: Capitation-based and fee-for-service primary care practices in Ontario. SUBJECTS: Thirty-nine physicians whose method of payment was converted from fee-for-service to capitation during the period from June 1985 to January 1989 and 7 physicians who remained in fee-for-service practice, two of whom were matched with one physician in capitation-based practice on the basis of practice location, type of practice (academic v. community), hours of practice (part-time v. full-time), years since graduation, physician group size, practice size (number of patients), type of group (primary care v. multispecialty), sex, certification in family medicine, country of graduation (Canada v. other) and age. One physician in capitation-based practice was matched with only one physician in fee-for-service practice. OUTCOME MEASURES: Annual hospital-utilization rates (hospital separations or hospital days per 1000 patients in each practice) for the physicians paid on a capitation basis 3 years before, 1 year before and 3 years after they converted from fee-for-service payment and at corresponding periods for the matched physicians still paid on a fee-for-service basis. RESULTS: The mean annual rate of hospital days used, adjusted for the age and sex of patients as well as for their social-program-recipient status, fell from 1085 per 1000 patients (3 years before the conversion date) to 1030 (1 year before conversion) and to 954 (3 years after conversion) in capitation-based practices. For the matched physicians in fee-for-service practice, the rates during the corresponding periods were 1085, 1035 and 956 hospital days per 1000 patients. The pattern was similar for rates of hospital separations, adjusted for patient's age, sex and social-program-recipient status. There were no statistically significant differences between the rates of hospital utilization among patients of physicians in capitation-based practices and the rates among those of physicians in fee-for-service practices during each of the three periods, nor were there significant differences in the changes in rates. CONCLUSION: Capitation payment, with an additional incentive payment to encourage low hospital-utilization rates, did not reduce hospital use. Factors other than the method of physician payment appear to be responsible for the variations in hospital utilization among practices.     

Newly registered elderly patients: who are they and why such delay in the transfer of their medical records?

The time taken to transfer the records of elderly patients registering with a new general practice was investigated. Thirty five (5%) of a total of 671 patients aged 75 and over were entered as new patients on to the age-sex register of an urban group practice during one year. Twenty nine had moved into the area and six had changed their general practitioner for personal and other reasons. An average of 141 (range 71-296) days elapsed before dispatch of their medical records to the new practice. During this period an average of 3.5 (range 0-15) consultations with a general practitioner were recorded, indicating the need of such patients for medical care. The long delays were caused by the processing of medical records at the central register and the transfer of records between family practitioner committees and general practitioners. Delays were most apparent in the time taken for general practitioners to dispatch the necessary documents to the family practitioner committees, and these should be minimised. The use of a summary card written and updated by the general practitioner and retained by the patient would facilitate continuing care should patients change to a new practice. Meanwhile, assessment of elderly patients after registration with a new practice by a member of the primary health care team may identify problems before the records have been transferred and may help the resettlement of these high risk elderly patients.     

Acute Infections in Primary Care: Accuracy of Electronic Diagnoses and Electronic Antibiotic Prescribing

ObjectiveTo maximize effectiveness, clinical decision-support systems must have access to accurate diagnostic and prescribing information. We measured the accuracy of electronic claims diagnoses and electronic antibiotic prescribing for acute respiratory infections (ARIs) and urinary tract infections (UTIs) in primary care.DesignA retrospective, cross-sectional study of randomly selected visits to nine clinics in the Brigham and Women's Practice-Based Research Network between 2000 and 2003 with a principal claims diagnosis of an ARI or UTI (N = 827).MeasurementsWe compared electronic billing diagnoses and electronic antibiotic prescribing to the gold standard of blinded chart review.ResultsClaims-derived, electronic ARI diagnoses had a sensitivity of 98%, specificity of 96%, and positive predictive value of 96%. Claims-derived, electronic UTI diagnoses had a sensitivity of 100%, specificity of 87%, and positive predictive value of 85%. According to the visit note, physicians prescribed antibiotics in 45% of ARI visits and 73% of UTI visits. Electronic antibiotic prescribing had a sensitivity of 43%, specificity of 93%, positive predictive value of 90%, and simple agreement of 64%. The sensitivity of electronic antibiotic prescribing increased over time from 22% in 2000 to 58% in 2003 (p for trend < 0.0001).ConclusionClaims-derived, electronic diagnoses for ARIs and UTIs appear accurate. Although closing, a large gap persists between antibiotic prescribing documented in the visit note and the use of electronic antibiotic prescribing. Barriers to electronic antibiotic prescribing in primary care must be addressed to leverage the potential that computerized decision-support systems offer in reducing costs, improving quality, and improving patient safety.     

Vesicoureteric reflux and urinary tract infection in children

An association between vesicoureteric reflux (VUR) and renal damage was found in 1960. In 1973, the term reflux nephropathy (RN) was first used to describe the renal damage caused by VUR. Follow up studies show that about 10%-20% of children with RN develop hypertension or end stage renal disease. It is now evident that there is a sex difference in the development of RN. In most males with RN, the kidneys are congenitally abnormal. In females it is an acquired condition, the most severe damage being sustained by recurrent urinary tract infections (UTIs). The purpose of current UTI guidelines is to identify VUR or any other abnormality of the urinary tract. Since the advent of routine antenatal ultrasonography, there is no longer a need to identify an abnormality of the urinary tract after the first reported UTI. Routine investigations are not required. Recurrent UTIs and a family history of VUR need further evaluation. There is also an urgent need to establish the long term value of prophylactic antibiotics in children with VUR.     

Effects of a faculty prepaid group practice in a pediatric primary care clinic

Medical student and resident education at a hospital-operated pediatric primary care clinic (PPCC) was threatened by chronic financial deficits and by a state mandate that all patients receiving medical care through the state Aid to Families with Dependent Children program be enrolled in a health maintenance organization (HMO). To comply with the mandate, the PPCC was reorganized in 1984 as a faculty-operated prepaid group practice independent of the hospital. The new PPCC contracted with an HMO to provide care, with reimbursement based on capitation. The PPCC continues to serve the same patient population as before the reorganization, continues its teaching activities, and no longer has financial deficits. The experience at this clinic shows that converting to a faculty prepaid group practice can be cost-effective, promote efficiency, and improve faculty-hospital relations. Such a group practice is an appropriate organization for maintaining medical education programs while providing care in a capitation payment system.     

Practice nurses in Australia: current issues and future directions

Almost 60% of general practices now employ at least one practice nurse. Australian Government initiatives to support the expansion of practice nursing are not consistently based on strong evidence about effectiveness, outcomes or efficiencies. Reviews from other countries suggest that practice nurses can achieve good health outcomes, but there is little information about the Australian practice-nurse workforce, funding models to support their work, scope of their practice, or its outcomes. Australian practice nursing lacks a career structure and an education framework to advance nurses' skills and knowledge. To maximise the contribution of nurses in primary care, a more systematic approach is needed, with a stronger evidence base for policy to support effective outcomes.     

Primary and specialized care: implications for learning situations

Existing data suggest that there are differences between primary and specialized (consultant) care in clinical practice and in clinical decision-making. In addition, there are distinctions attributable to the nature of the two functions, the clinical settings, and the use of knowledge and technique. The most important difference, however, centers around the varying prevalence of disease between primary and specialized care and the practitioner's relative use of disease frequency in decision-making. Because of these differences, medical schools should develop primary care situations which are equally as valued as specialty care situations. Although the impact of substantial and attractive primary care curricula is unknown, their potential value in guiding appropriate students to enter primary or specialized care careers could be considerable.     

Ethics of evidence based medicine in the primary care setting

Evidence based medicine has had an increasing impact on primary care over the last few years. In the UK it has influenced the development of guidelines and quality standards for clinical practice and the allocation of resources for drug treatments and other interventions. It has informed the thinking around patient involvement in decision making with the concept of evidence based patient choice. There are, however, concerns among primary care clinicians that evidence based medicine is not always relevant to primary care and that undue emphasis placed on it can lead to conflict with a clinician's duty of care and respect for patient autonomy. In this paper we consider the impact of evidence based medicine on primary care, and the ethical implications of its increasing prominence for clinicians and managers in primary care.     

Effects of pruning of a decision-tree for the ear,nose, and throat realm in primary health care based on case-notes

In the primary health care center of Mjölby a sample of case notes in the ear-nose-and-throat realm (N=425) was computer processed using an inductive rule-based decision-tree generating program. As a result of incomplete information in the case-files, the decision trees were “noisy,” e.g., had branches and leaves without meaning. This led to a need for “pruning.” Various methods were tried. The effects of different methods of decision-tree generating and pruning are discussed. The choice of root argument and branching of the decision-trees suggested by the software was the most clinically applicable. The “statistic” approach to pruning gave the most compact and still most clinically relevant decision-tree. The pruned and edited decision trees are compared with a previously published preliminary essential data set for the ear-nose-and-throat realm in primary health care and then discussed as a possible decision support system for various primary health care groups in a practice setting.     

Inguinal Hernia: classification, diagnosis and treatment--classic, traumatic and Sportsman's hernia

Inguinal hernia repair is performed in more than 600,000 cases every year in the United States. However, the true prevalence may be even higher. Many groin hernias are not diagnosed, e.g., Sportmans' hernia, or are asymptomatic. The etiology of classic inguinal hernia, Sportsman's hernia or traumatic hernia may be different. The hernia repair is performed in agreement with a classification of the hernia, e.g., Nyhus classification. According to recent randomized controlled trials and meta-analyses open-mesh repair demonstrates several advantages in comparison to laparoscopic procedures. Laparoscopic procedures require more time and cost more, show a potential for serious complications and may be followed by an increased rate of recurrence. There may be a faster reconvalescence after laparoscopic procedures. However, there may be also a selection bias. Laparoscopic procedures are associated with specific complications, e.g., pneumomediastinum, pneumothorax, gas extravasation, trocar injuries, intraabdominal adhesions, bowel obstruction, which are rarely or never seen in open-mesh repair. In the United States we could observe an uncoupling of hernia repair from classification. In more than 90% of cases the treatment was open-mesh. In many hernia studies the hernias were classified as direct or indirect, primary or recurrent. The existing classifications are based on anatomical findings in relation to the development of the hernia: posterior floor integrity, enlarged interior ring and size of the hernia. However, the size of the hernia may not always be associated with the severity of the hernia and it may be difficult to estimate. The outcome of hernia repair may be influenced by other factors. There may be differences in the presentation of the hernia to the surgeon based on the damage done to the surrounding tissue in the inguinal canal, e.g., external ring, aponeurosis of the external oblique, inguinal ligament, which is most often accompanied by severe adhesions. Further factors influencing outcome of hernia repair may be patient-related factors, e.g., constipation, ASA classification, diabetes, smoking. A classification should be simple to use and easy to remember: (A) indirect hernia, (B) direct hernia, (C) scrotal or giant hernia, (D) femoral hernia. A and B can be classified as (0) uncomplicated, (1) posterior floor defect, (2) posterior floor defect plus defect in the anterior part of the inguinal canal. All four types (A-D) may be either primary or recurrent. In this classification combined femoral, indirect and/or direct hernias can be categorized by using the types A, B, C, or D as in a modular construction system. The category "other" is reserved for rare types of hernia, e.g., obturator hernia, Spieghelian hernia. Aggravating factors are included: Diabetes, obesity, age above 65, constipation, ASA III or more and cigarette smoking. This classification may be helpful to evaluate outcome of hernia repair with regard to patient related factors and the increased demands for the surgeon and the staff. In some health care systems the general belief is that all hernias are equal and be managed equally. However, groin hernias may be complex and need individual treatment.     

Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians' offices

CONTEXT: The US primary care safety net is composed of a loose network of community health centers, hospital outpatient departments, and physicians' offices. National data on how the mix of patients and services differ across sites are needed. OBJECTIVE: To develop and contrast national profiles of patient and service mix for primary care. DESIGN, SETTING, AND PATIENTS: Comparative analyses of 3 national surveys of primary care visits occurring in 1994: for data on physician's office visits, the National Ambulatory Medical Care Survey (NAMCS); for hospital outpatient department data, the National Hospital Ambulatory Medical Care Survey (NHAMCS); and for data on community health centers, the Bureau of Primary Health Care's 1994 Survey of Visits to Community Health Centers. A time trend analysis also was conducted using the 1998 NAMCS and NHAMCS. MAIN OUTCOME MEASURES: National estimates of primary care visit rates, types of patient presentation, patient case-mix, disposition of patients, and management interventions in 1994, and compared with 1998 data. RESULTS: The US population made 1.3 primary care visits per person in 1994, which accounted for 43.5% of all ambulatory visits to physicians' offices, community health centers, and hospital outpatient departments. Primary care visits per person were 20% lower for Hispanics and 33% lower for black, non-Hispanic persons compared with white, non-Hispanic persons. Visits to community health centers were more likely to be made by ethnic minorities, patients with Medicaid or no insurance, and rural dwellers than visits made to the other delivery sites. Visits at hospital outpatient departments were made by sicker populations and were characterized by less continuity than the other delivery sites. Controlling for patient mix, visits made to hospital outpatient departments were more commonly associated with imaging studies, minor surgery, and specialty referrals than those made to physicians' offices. In 1998, the US population made an estimated 3. 4 visits per person, 45.6% of which were primary care visits. National estimates of primary care visit rates and patient mix and practice pattern comparisons between hospital outpatient departments and physicians' offices were similar in 1998 and 1994. CONCLUSIONS: Expanding community health centers will likely improve access to primary care for vulnerable US populations. However, enhancing access to of physicians' offices is also needed to bolster the safety net. The greater service intensity and poorer continuity for primary care visits in hospital outpatient departments that we observed raises concern about the suitability of these clinics as primary care delivery sites. JAMA. 2000;284:2077-2083.