The role of the general practitioner in postnatal care: a survey from Australian general practice

BACKGROUND: Despite the practice of routine postnatal check-ups, many women experience problems in the months after childbirth. General practitioners (GPs) are involved in routine postnatal care, yet little research has been undertaken to explore this role. AIM: To report the views of Australian GPs as to what physical examination and discussion should take place at the routine six week postnatal check-up and to determine the influence of gender on the approach to the check-up. METHOD: Postal survey of 1104 Australian GPs, yielding an eligible sample of 1022. RESULTS: A total of 715/1022 (70%) usable surveys returned. Over 65% of GPs recommend routine examination of the abdomen, blood pressure, perineum, vagina, pelvic floor, and breasts at the six week check-up. Fewer than a half the sample believed that physical problems (urine and bowel symptoms, back problems), sexual issues, relationship and parenting issues should be routinely discussed. After controlling for age, practice location, obstetric practice, and qualifications, the sex of the GP remains an important factor influencing the GP's approach to postnatal care. Female GPs are three times more likely to believe that maternal feelings should be discussed routinely and about twice as likely to believe that infant sleeping/behaviour, maternal sleeping/diet/tiredness, coping with other children, relationship with partner, and household work should form part of the routine discussion with all recent mothers. CONCLUSIONS: Sex of practitioner and older age (60 years or more) are the two most important influences on a GP's approach to postnatal care. This study indicates a need for GPs to shift their focus from routine examination to indicated examination to allow more time to discuss common postnatal problems.     

Chronic debilitating fatigue in Irish general practice: a survey of general practitioners' experience

BACKGROUND: Doctors are called upon to treat chronic debilitating fatigue without the help of a protocol of care. AIMS: To estimate the incidence of chronic debilitating fatigue in Irish general practice, to obtain information on management strategy and outcome, to explore the attitudes of practitioners (GPs) towards the concept of a chronic fatigue syndrome (CFS), and to recruit practitioners to a prospective study of chronic fatigue in primary care. METHOD: A total of 200 names were selected from the database of the Irish College of General Practitioners (ICGP); 164 of these were eligible for the study. RESULTS: Altogether, 118 questionnaires were returned (72%). Ninety-two (78%) responders identified cases of chronic fatigue, giving an estimated 2.1 cases per practice and an incidence of 1 per 1000 population. All social classes were represented, with a male to female ratio of 1:2. Eleven disparate approaches to treatment were advocated. Many (38%) were dissatisfied with the quality of care delivered, and 45% seldom or hardly ever referred cases for specialist opinion. The majority (58%) accepted CFS as a distinct entity, 34% were undecided, and 8% rejected it. Forty-two (35%) GPs volunteered for a prospective study. CONCLUSION: Chronic fatigue is found in Irish general practice among patients of both sexes and all social classes. Doctors differ considerably in their management of patients and are dissatisfied with the quality of care they deliver. Many cases are not referred for specialist opinion. A prospective database is required to accurately assess the scale of this public health problem and to develop a protocol of care.     

Service-mix in general dental practice in Japan: a survey in a suburban area

The authors describe a supernumerary muscle in each orbit of an elderly male subject. There appear to be no previous reports of this muscle; most reports of anomalies of extraocular muscles describe hypoplasia or aplasia. Thirty-five formalin-fixed cadavers assigned to medical students for dissection were studied. The orbits were dissected by a superior approach which involved removal of the orbital plate of the frontal bone and the superior orbital margin. A supernumerary extraocular muscle was seen in each orbit of one cadaver, located between the superior oblique and levator palpebrae superioris muscles. It originated on the inferior surface of the lesser wing of sphenoid bone and was inserted into the skin of the medial one-third of the upper eyelid. It was innervated by a branch from the superior division of the oculomotor nerve. The insertion of the muscle into the upper eyelid produced a crease running obliquely upwards and medially, from the junction of the medial one-third and lateral two-thirds of the lid margin, towards the medial part of the superior orbital fold. The authors suggest the name levator palpebrae superioris accessorius for this muscle in view of its topography and action as tested in the cadaver. The significance of the findings is discussed and the literature on the development of the muscles supplied by the oculomotor nerve is reviewed.     

A survey of audit activity in general practice

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care.     

Children referred for specialist care: a nationwide study in Dutch general practice

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

Improving care of eczema in general practice

BACKGROUND AND OBJECTIVE: This study was designed to evaluate the relative cost effectiveness of the Holmium:YAG laser and the pulsed dye laser for the treatment of ureteral calculi. Cost containment is a priority for every health care facility. As a result, the staff of the Lutheran Medical Center (Wheat Ridge, CO) looked at alternative ways to provide quality laser treatment of ureteral stones. As part of our study, the laser committee offered the Holmium:YAG laser to urologists for ureteral lithotripsy. Previously, the pulsed dye laser was rented for ureteral calculi on a per case basis at $1,500. A hospital processing fee was added to this cost, resulting in a total charge of $1,638 to the patient. Our organization owns a Holmium:YAG laser and uses it primarily in orthopedics. STUDY DESIGN/MATERIALS AND METHODS: Two ureteral lithotripsy cases were performed and compared. One case used the Holmium:YAG for ureteral lithotripsy; the other procedure used the pulsed dye laser. A cost analysis was performed after the procedures. RESULTS: The data indicated a significant difference in cost between the two lasers. Approximately $1,000 was eliminated when using the Holmium:YAG laser. CONCLUSION: A cost savings of $15,000 per year would be realized if 15 cases were performed. The Holmium:YAG laser also can be used on cystine calculi, a procedure for which the pulsed dye laser is ineffective. The potential for ureteral injury exists. When using the Holmium:YAG laser, appropriate training is required. Due to this risk, not all urologists will use the Holmium:YAG laser. We also found a positive correlation between the proficiency of the urologists' laser skills and overall cost effectiveness.     

Obstetric practice amongst Queensland general practitioners: a survey of needs and attitudes

A survey of Queensland general practitioners was carried out to assess their needs and attitudes regarding obstetric practice. Less than half of the respondents now practise obstetrics, and many general practitioners felt a lack of support from specialist obstetricians, paediatricians, and anaesthetists. Many of the respondents expressed needs for further obstetric training, especially in labour ward management and neonatal care; however, few were able to attend extended courses.     

Sample survey methods as a quality assurance tool in a general practice immunisation audit

AIMS: In a multidoctor family practice there are often just too many sets of patients records to make it practical to repeat an audit by census of even an age band of the practice on a regular basis. This paper attempts to demonstrate how sample survey methodology can be incorporated into the quality assurance cycle. METHODS: A simple random sample (with replacement) of 120 from 580 children with permanent records who were aged between 6 weeks and 2 years old from an Auckland general practice was performed, with sample size selected to give a predetermined precision. The survey was then repeated after 4 weeks. RESULTS: Both surveys were able to be completed within the course of a normal working day. An unexpectedly low level of under 2 years olds that were recorded as not overdue for any immunisations was found (22.5%) with only a modest improvement after a standard telephone/letter catch up campaign. Seventy-two percent of the sample held a group one community services card. CONCLUSIONS: The advantages of properly conducted sample surveys in producing useful estimates of known precision without disrupting office routines excessively were demonstrated. Through some attention to methodology, the trauma of a practice census can be avoided.     

Increased general practice workload due to a primary care led National Health Service: the need for evidence to support rhetoric

Recent policy initiatives have focused on shifts in the balance of care from secondary care to primary care. A consequence of such shifts is increased workload in primary care. The aim of this paper is to appraise the literature critically to assess whether changes in the balance of care have led to additional work for general practices. In particular, the implications of this literature for the measurement of workload in general practice are highlighted. After an extensive, systematic literature search, only 12 studies that met the review criteria were identified. Although the studies pointed to negligible effects on the number of general practitioner (GP) visits, they failed to capture the many other attributes of a practice's work that are likely to be influenced by a shift in the balance of care. These include both qualitative (e.g. stress and mental effort) and quantitative (i.e. the use of resources in the practice, such as GPs, nurses and other staff's time and administration) measures of workload. The studies may therefore have under-estimated the effect on practice workload. To identify correctly the impact on workload of shifts in the balance of care, studies evaluating shifts need to improve their measurement of general practice workload. Furthermore, an extended definition of workload needs to be developed and tested, and workload monitored over time.     

Warfarin anticoagulation in primary care: a regional survey of present practice and clinicians' views

The demand for anticoagulation services is rising. Warfarin anticoagulation has been shown to reduce the risk of stroke in patients with non-valvular atrial fibrillation by 68%. This raises issues about how services are best organized to initiate and monitor anticoagulation in this potentially large group of patients. We report the results of a regional postal survey undertaken to describe the views of general practitioners and consultants regarding warfarin anticoagulation in light of this potentially high increase in demand.     

Training family practice residents in abortion and other reproductive health care: a nationwide survey

The majority of residents responding to a 1995 survey of program directors and chief residents at 244 family medicine residency programs in the United States reported they had no clinical experience in cervical cap fitting, diaphragm fitting or IUD insertion and removal. For all family planning methods except oral contraceptives, no more than 24% of residents had experience with 10 or more patients. Although 29% of programs included first-trimester abortion training as either optional or routine, only 15% of chief residents had clinical experience providing first-trimester abortions. Five percent of residents stated they certainly or probably would provide abortions, while 65% of residents stated they certainly would not provide abortions. A majority (65%) of residents agreed that first-trimester abortion training should be optional within family practice residency programs. Residents were more likely to agree with inclusion of optional abortion training and with the appropriateness of providing abortions in family practice if their program offered the training.     

Health authorities, GDPs and TECs: a partnership for general dental practice development

Major changes will occur in primary dental care over the next 5 to 10 years. These changes present a series of possible opportunities and threats to dental practices. This paper reports on how the health authority, the local training and enterprise council (TEC) and five general dental practices in North Cheshire worked collaboratively to support the development of the practices. Health authorities and dentists should be aware of the possibility of working with TECs to support general dental practice development.     

Bereavement follow-up: an opportunity to extend nursing care

Human herpesvirus-6 (HHV6) is a lymphotropic virus genetically related to human cytomegalovirus (CMV) and for which two variants, A and B, have been distinguished. Human CMV is usually cultivated with human fibroblasts (HF). The lack of cell lines useful for HHV6 isolation and propagation led us to investigate whether HHV6 variants A and B could infect HFs as CMV does. Isolates of HHV6 variants A and B were used to infect MRC-5 HFs. HHV6 infection was detected by means of immunoperoxidase assay using three specific monoclonal antibodies. HHV6-specific antigens were detected in 88 and 38% of cases after infection with variants A and B, respectively. The highest number of HHV6-antigen-positive cells was obtained at 4-5 days p.i. The titre of HHV6 stocks was determined in parallel by immunoperoxidase assay on HFs and by observation of cytopathic effect using serial dilutions on peripheral blood mononuclear cells (PBMC). The number of infectious particles inducing the appearance of antigen-positive HF cells was consistently lower than the titre of virus stocks, expressed as TCID50. The amount of HF-associated HHV6 DNA was measured using limiting dilution PCR assay; it was significantly increased during 4-day infection in the case of variant A but not variant B. The yield of virus from infected HFs was demonstrated only for variant A by the serial propagation of virus from HFs to PBMCs and by the increase in cell-free HHV6 DNA in HF culture supernatant. Our results show that HHV6 can reproducibly infect HFs, albeit at a low level, and that HFs are more permissive to variant A than to variant B, as reported previously for PBMCs and human T-cell lines.