Related Articles

Objective

Approximately 98% of Danish citizens are listed with a general practice which they consult for medical advice. Although 85% of the population contact their general practitioner (GP) every year, little is known about these contacts. The aim of the present paper is to gain updated knowledge about patients’ reasons for encounter and the GP activities and to make comparisons with a similar study from 1993.

Methods

All GPs in the Central Denmark Region were invited to register all contacts during one randomly chosen day within a year. The registration included questions about patients’ reasons for encounter, the types and contents of the contacts, referrals, and distribution between new episodes and follow-up contacts. Aggregated data were compared with the results from 1993.

Results

A total of 404 (46%) GPs participated. The number of contacts per 1000 inhabitants had risen by 19.7%. The reasons for encounter and final diagnoses resembled those in 1993. Musculoskeletal, psychological, and respiratory problems were the most common reasons for encounter, psychological problems being the only type to increase over the period. Interestingly, the proportion of diagnoses within the ICPC ‘A’ chapter rose from 13.5 to 19.7%. The referral rate rose by 2% (relative: 18.7%) from 10.7% to 12.7% and the share of follow-up contacts rose from 45.9% to 50.4% (relative: 8.7%).

Conclusion

Quite small changes were seen in the patterns of reasons for encounter and diagnoses from 1993 to 2009. However, an increase was found in contacts with general practice and referrals and in the proportion of follow-ups.

Background

In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity.

Aim

To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care.

Design of study

Retrospective cohort study.

Setting

Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database.

Method

Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models.

Results

Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity.

Conclusion

Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it.

Background

Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.

The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women.

Methods

Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007–2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days).

Results

Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were ‘pregnancy’ and ‘cystitis/urinary infection’, and ‘cystitis/urinary infection’ and ‘general disease not otherwise specified’ for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy.

Conclusions

GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.

OBJECTIVE--To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. DESIGN--A cross sectional evaluation of consultations. SETTING AND SUBJECTS--A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. MAIN OUTCOME MEASURES--The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. RESULTS--Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overall use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. CONCLUSION--The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.

Objective To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team.

Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.

Setting 34 general practices in a southern region of the Netherlands.

Participants 48 general practitioners.

Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.

Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.

Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.

Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.

Objective: Five years after its introduction, to evaluate the 1992 reform in the out of hours service in Denmark.

Design: Comparison of data before and after reform. Data were collected from published reports, Danish national health statistics, and the Danish trade union for general practitioners.

Setting: Denmark.

Main outcome measures: Number of out of hours services; workload of general practitioners; cost of the service; patient satisfaction.

Results: Five years after the reform, the percentage of telephone consultations had almost doubled, to 48%. Consultations in doctors’ surgeries were relatively unchanged, but home visits were much reduced, to 18%. The percentage of doctors who worked 5 hours or more out of hours per week dropped from about 70% to about 50%. Overall patient satisfaction in 1995 was high (72%).

Conclusion: The organisation of the out of hours service, with a fully trained general practitioner in a telephone triage function, is working satisfactorily. Many calls that previously would have required home visits are now dealt with by telephone or through consultations. The out of hours workload for general practitioners has decreased considerably.

Key messages The out of hours reform in Denmark has resulted in an organisation with a fully trained general practitioner performing the telephone triage function Hours on call for general practitioners have decreased considerably Home visits have largely been replaced by telephone consultations Patient satisfaction has declined slightly

Abstract

Objective. To estimate the frequency of psychological and social classification codes employed by general practitioners (GPs) and to explore the extent to which GPs ascribed health problems to biomedical, psychological, or social factors. Design. A cross-sectional survey based on questionnaire data from GPs. Setting. Danish primary care. Subjects. 387 GPs and their face-to-face contacts with 5543 patients. Main outcome measures. GPs registered consecutive patients on registration forms including reason for encounter, diagnostic classification of main problem, and a GP assessment of biomedical, psychological, and social factors’ influence on the contact. Results. The GP-stated reasons for encounter largely overlapped with their classification of the managed problem. Using the International Classification of Primary Care (ICPC-2-R), GPs classified 600 (11%) patients with psychological problems and 30 (0.5%) with social problems. Both codes for problems/complaints and specific disorders were used as the GP's diagnostic classification of the main problem. Two problems (depression and acute stress reaction/adjustment disorder) accounted for 51% of all psychological classifications made. GPs generally emphasized biomedical aspects of the contacts. Psychological aspects were given greater importance in follow-up consultations than in first-episode consultations, whereas social factors were rarely seen as essential to the consultation. Conclusion. Psychological problems are frequently seen and managed in primary care and most are classified within a few diagnostic categories. Social matters are rarely considered or classified.

Background

Multimorbidity has been defined as the co-existence of two or more chronic conditions. It has a profound impact on both the individuals affected and on their use of healthcare services. The limited research to date has focused on its epidemiology rather than the development of interventions to improve outcomes in multimorbidity patients, particularly for patients aged less than 65 years. Potential barriers to such research relate to methods of disease recording and coding and examination of the process of care. We aimed to assess the feasibility of identifying younger individuals with multimorbidity at general practice level and to explore the effect of multimorbidity on the type and volume of health care delivered. We also describe the barriers encountered in attempting to carry out this exploratory research.

Methods

Cross sectional survey of GP records in two large urban general practices in Dublin focusing on poorer individuals with at least three chronic conditions and aged between 45 and 64 years.

Results

92 patients with multimorbidity were identified. The median number of conditions was 4 per patient. Individuals received a mean number of 7.5 medications and attended a mean number of GP visits of 11.3 in the 12 months preceding the survey. Barriers to research into multimorbidity at practice level were identified including difficulties relating to GP clinical software; variation in disease coding; assessment of specialist sector activity through the GP-specialist communications and assessment of the full scale of primary care activity in relation to other disciplines and other types of GP contacts such as home visits and telephone contacts.

Conclusion

This study highlights the importance of multimorbidity in general practice and indicates that it is feasible to identify younger patients with multimorbidity through their GP records. This is a first step towards planning a clinical intervention to improve outcomes for such patients in primary care.

Objectives

To evaluate the impact of an intervention based in general practice on the incidence of repeat episodes of deliberate self harm.

Design

Cluster randomised controlled trial in which 98 general practices were assigned in equal numbers to an intervention or a control group. The intervention comprised a letter from the general practitioner inviting the patient to consult, and guidelines on assessment and management of deliberate self harm for the general practitioner to use in consultations. Control patients received usual general practitioner care.

Setting

General practices within Avon, Wiltshire, and Somerset Health Authorities, whose patients lived within the catchment area of four general hospitals in Bristol and Bath.

Participants

1932 patients registered with the study practices who had attended accident and emergency departments at one of the four hospitals after an episode of deliberate self harm.

Main outcome measures

Primary outcome was occurrence of a repeat episode of deliberate self harm in the 12 months after the index episode. Secondary outcomes were number of repeat episodes and time to first repeat.

Results

The incidence of repeat episodes of deliberate self harm was not significantly different for patients in the intervention group compared with the control group (odds ratio 1.2, 95% confidence interval 0.9 to 1.5). Similar findings were obtained for the number of repeat episodes and time to first repeat. Subgroup analyses indicated that there was no differential effect of the intervention according to patient's sex (P=0.51) or method used to cause deliberate self harm (P=0.64). The treatment seemed to be beneficial for people with a history of deliberate self harm, but it was associated with an adverse effect in people for whom the index episode was their first episode (interaction P=0.017).

Conclusions

An invitation to consult, sent by the general practitioner of patients who have deliberately harmed themselves, and the use of management guidelines during any subsequent consultation did not reduce the incidence of repeat self harm. A subgroup analysis that indicated that patients who had previously harmed themselves benefited from the intervention was inconsistent with previous evidence and should be treated with caution. More research is needed on how to manage patients who deliberately harm themselves, to reduce the incidence of repeat episodes.

What is already known on this topicAbout two thirds of patients consult their general practitioner in the three months after an episode of deliberate self harmThere have been no previous large scale randomised controlled trials of general practice based interventions aimed at reducing the incidence of repeat episodes of deliberate self harmWhat this study addsAn intervention comprising an invitation to consult from a patient's general practitioner and by the use of guidelines for the assessment and management of deliberate self harm in a subsequent consultation does not reduce the incidence of repeat episodes of deliberate self harm

Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls.

Design Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention.

Setting One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire.

Subjects All patients contacting the out of hours service or about whom contact was made during specified times over the trial year.

Intervention A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software.

Main outcome measures Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial.

Results 14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments.

Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.

Key messagesTelephone consultation is becoming an increasingly accepted approach to patient care and improves public access to medical information and adviceThis study found that nurse telephone consultation halved the number of cases dealt with by general practitioners and was at least as safe as existing out of hours servicesNurse telephone consultation not only replaced telephone advice given by a doctor but led to reductions in both home visits and surgery attendances out of hoursFurther testing is required of variants to the system used in this trial, including the selection and training of nurses and the decision support software usedThere are clear opportunities for and potential benefits from integrating existing out of hours services with NHS Direct

The purpose of this study is to assess patients consulting full-time traditional health practitioners (THPs) and the practice of THPs after they had been trained on Human Immunodeficiency Virus (HIV)/ Sexually Transmitted Infections (STI) prevention and care. The sample included 222 patients interviewed when exiting a THP's practice (n=17) in purposefully chosen two urban sites in KwaZulu-Natal. Results indicate that at post training evaluation the majority of the THPs were involved in HIV/STI management and most had low levels of HIV risk practices at the workplace. Major self-reported reasons for consulting the THP included a complex of supernatural or psychosocial problems, chronic conditions, acute conditions, generalized pain, HIV and other STIs. Overall, patients including HIV positive (n=18) patients had moderate knowledge of Antiretroviral Therapy (ART). A number of HIV positive patients were using traditional medicine and ART concurrently, dropped out of ART because of side effects and were using traditional medicine for HIV.

Background

The rapid increase in the prevalence of childhood obesity in recent years has led to inconclusive debate about the most effective way to manage the condition and the most appropriate care setting. Primary care has been suggested as a key site to identify and treat obesity in children.

Aim

To identify children from general practice databases with a body mass index (BMI) categorised as ‘obese’, and invite them for a primary care consultation and possible referral to a specialist secondary care clinic.

Design and setting

Targeted screening of GP practice databases for obese children in 12 general practices in Bristol, UK.

Method

Participating GP practices searched databases for children's BMIs which were then screened by the study team to identify obese children (≥98th centile). Practices invited families of obese children to consult their GP with the potential for referral to a specialist clinic. Follow-up data was recorded with respect to: consultations; consultations about child's weight; and referrals to specialist clinic; and other referrals.

Results

A total of 285 letters inviting families to consult their GP were sent; 134 patients consulted their GP in the follow-up period (minimum 3 months), and 42 of these consultations discussed the child's weight. Nineteen patients received a secondary care referral and six received an alternative weight-management referral.

Conclusion

The low take-up following the mail-out of an invitation to consult highlights the inherent difficulties of engaging families and their obese children in care pathways that facilitate long-term weight management.

A study was undertaken to investigate the management of ophthalmic conditions in general practice in order to identify areas requiring education and training input. Management of patients with eye disease presenting to 17 Nottingham general practitioners was examined over a 12-month period. Of all patients registered with the participating doctors, 4% presented with eye problems, accounting for 1.5% of all general practice consultations. Children under five years of age had the highest consultation rates, female patients having higher consultation rates than male patients in all age groups. Infective conjunctivitis was responsible for 41% of consultations about eye problems and allergic conjunctivitis for a further 13%; 70% of consultations resulted in a prescription. Corticosteroids were prescribed in 3% of consultations for eye problems; this was considered inappropriate by the study ophthalmologist in over a third of these cases. Patients were referred for further management following 16% of consultations. Thirty nine per cent of referrals to the hospital ophthalmic service were either to an eye casualty department or requested an urgent clinic appointment. While most eye problems are managed solely by general practitioners there is clearly a need for ophthalmic services that can rapidly provide a specialist opinion. However, most eye disease seen in general practice involves the external eye or anterior segment, and the diagnosis may be confidently made using basic ophthalmic history taking and examination skills with non-specialist equipment. The acquisition of these skills should be emphasized at undergraduate level and built upon in later years in postgraduate training.

Background

General practitioners often care for patients with several concurrent chronic medical conditions (multimorbidity). Recent data suggest that multimorbidity might be observed more often than isolated diseases in primary care. We explored the age- and gender-related prevalence of multimorbidity and compared these estimates to the prevalence estimates of other common specific diseases found in Swiss primary care.

Methods

We analyzed data from the Swiss FIRE (Family Medicine ICPC Research using Electronic Medical Record) project database, representing a total of 509,656 primary care encounters in 98,152 adult patients between January 1, 2009 and July 31, 2011. For each encounter, medical problems were encoded using the second version of the International Classification of primary Care (ICPC-2). We defined chronic health conditions using 147 pre-specified ICPC-2 codes and defined multimorbidity as 1) two or more chronic health conditions from different ICPC-2 rubrics, 2) two or more chronic health conditions from different ICPC-2 chapters, and 3) two or more medical specialties involved in patient care. We compared the prevalence estimates of multimorbidity defined by the three methodologies with the prevalence estimates of common diseases encountered in primary care.

Results

Overall, the prevalence estimates of multimorbidity were similar for the three different definitions (15% [95%CI 11-18%], 13% [95%CI 10-16%], and 14% [95%CI 11-17%], respectively), and were higher than the prevalence estimates of any specific chronic health condition (hypertension, uncomplicated 9% [95%CI 7-11%], back syndrome with and without radiating pain 6% [95%CI 5-7%], non-insulin dependent diabetes mellitus 3% [95%CI 3-4%]), and degenerative joint disease 3% [95%CI 2%-4%]). The prevalence estimates of multimorbidity rose more than 20-fold with age, from 2% (95%CI 1-2%) in those aged 20–29 years, to 38% (95%CI 31-44%) in those aged 80 or more years. The prevalence estimates of multimorbidity were similar for men and women (15% vs. 14%, p=0.288).

Conclusions

In primary care, prevalence estimates of multimorbidity are higher than those of isolated diseases. Among the elderly, more than one out of three patients suffer from multimorbidity. Management of multimorbidity is a principal concern in this vulnerable patient population.

Background

Multimorbidity is common in primary care populations. Within cardiovascular disease, important differences in disease prevalence and risk factor management by ethnicity are recognised.

Aim

To examine the population burden of cardiovascular multimorbidity and the management of modifiable risk factors by ethnicity.

Design and setting

Cross-sectional study of general practices (148/151) in the east London primary care trusts of Tower Hamlets, City and Hackney, and Newham, with a total population size of 843 720.

Method

Using MIQUEST, patient data were extracted from five cardiovascular registers. Logistic regression analysis was used to examine the risk of being multimorbid by ethnic group, and the control of risk factors by ethnicity and burden of cardiovascular multimorbidity.

Results

The crude prevalence of cardiovascular multimorbidity among patients with at least one cardiovascular condition was 34%. People of non-white ethnicity are more likely to be multimorbid than groups of white ethnicity, with adjusted odds ratios of 2.04 (95% confidence interval [CI] = 1.94 to 2.15) for South Asians and 1.23 (95% CI = 1.18 to 1.29) for groups of black ethnicity. Achievement of targets for blood pressure, cholesterol, and glycated haemoglobin (HbA1c) was higher for patients who were multimorbid than unimorbid. For cholesterol and blood pressure, South Asian patients achieved better control than those of white and black ethnicity. For HbA1c levels, patients of white ethnicity had an advantage over other groups as the morbidity burden increased.

Conclusion

The burden of multiple disease varies by ethnicity. Risk factor management improves with increasing levels of cardiovascular multimorbidity, but clinically important differences by ethnicity remain and contribute to health inequalities.

As part of a larger study 201 urban general practitioners from five health districts provided information on 6870 consultations with patients recorded as having psychosocial disorders, 5610 of which were concerned solely with psychosocial problems. The results showed a lower percentage of consultations for such conditions than other studies, although the age and sex distribution of the patients was similar. There was a wide variation in the proportion of such disorders in the case-mix of the 201 general practitioners, a higher proportion being associated with longer consultation times. The pattern of prescribing and referral is described and discussed. Referral to non-medical agencies played a small part in the overall care of patients with psychosocial disorders. Questions are raised as to the extent of team care in this wide cross-section of practices.

The practice of home visiting by the geriatrician in an inner city area is described. Visiting was of two kinds: domiciliary consultations made at the request of the general practitioner, and visits made with the consent of the general practitioner to see whether hospital admission was essential. Since 1962, 4,000 visits have been made, and in a sample of 100 visits made in 1977, 45 were domiciliary consultations and 55 followed requests for admission. Fifty-six patients were admitted at once and five following a subsequent outpatient appointment. The patients were referred by 51 general practitioners. At none of the consultations was the geriatrician accompanied by the general practitioner. Referral information given by the general practitioners was analysed. Information about acute physical disease and social conditions was commonly given but reference to psychological state, chronic disabilities, and drug therapy was much less common. Drugs were mentioned in only 27 referrals. More complete referrals would have been valuable to the geriatrician and to the general practitioner in deciding their courses of action. More accompanied visits and reference to a check-list consisting of acute physical disease, psychological state, social conditions, chronic disabilities, and drug therapy is suggested to improve communication and the quality of referrals.

A prospective, observational study of chronic disease surveillance consultations over a six-month period was performed in one semi-rural general practice in order to determine the content of the consultations, including incidental items not relevant to the chronic disease. At least one incidental item was recorded during 43% of consultations. There was substantial clinical content in these items: 23% of items required a prescription to be issued and 7% referral to a specialist. It is concluded that chronic disease surveillance consultations in general practice are frequently extended by patients who are anxious to discuss issues which may not be relevant to their chronic diseases. General practitioners must be sensitive to such patient expectations when they instigate chronic disease management clinics.

Objective

To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.

Design

Multicentre randomised controlled trial of patients requesting an appointment the same day.

Setting

20 general practices in England and Wales.

Participants

1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations).

Main outcome measures

Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs.

Results

Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).

Conclusions

The clinical care and health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners.

Background

GPs report that patients' psychosocial problems play a part in 20% of all consultations. GPs state that these consultations are more time-consuming and the perceived burden on the GP is higher.

Aim

To investigate whether GPs' workload in consultations is related to psychological or social problems of patients.

Design of study

A cross-sectional national survey in general practice, conducted in the Netherlands from 2000–2002.

Setting

One hundred and four general practices in the Netherlands.

Method

Videotaped consultations (n = 1392) of a representative sample of 142 GPs were used. Consultations were categorised in three groups: consultations with a diagnosis in the International Classification of Primary Care chapter P 'psychological' or Z 'social' (n = 138), a somatic diagnosis but with a psychological background according to the GP (n = 309), or a somatic diagnosis and background (n = 945). Workload measures were consultation length, number of diagnoses and GPs' assessment of sufficiency of patient time.

Results

Consultations in which patients' mental health problems play a part (as a diagnosis or in the background) take more time and involve more diagnoses, and the GP is more heavily burdened with feelings of insufficiency of patient time. In consultations with a somatic diagnosis but psychological background, GPs more often experienced a lack of time compared to consultations with a psychological or social diagnosis.

Conclusion

Consultations in which the GP notices psychosocial problems make heavier demands on the GP's workload than other consultations. Patients' somatic problems that have a psychological background induce the highest perceived burden on the GP.

Objective

To describe general practitioners’ (GPs’) evaluation of and management strategies in relation to patients who seek medical advice because of multiple chemical sensitivity (MCS).

Design

A nationwide cross-sectional postal questionnaire survey. The survey included a sample of 1000 Danish GPs randomly drawn from the membership list of GPs in the Danish Medical Association.

Setting

Denmark.

Results

Completed questionnaires were obtained from 691 GPs (69%). Within the last 12 months 62.4% (n = 431) of the GPs had been consulted by at least one patient with MCS. Of these, 55.2% of the GPs evaluated the patients’ complaints as chronic and 46.2% stated that they were rarely able to meet the patients’ expectations for healthcare. The majority, 73.5%, had referred patients to other medical specialties. The cause of MCS was perceived as multi-factorial by 64.3% of the GPs, as somatic/biologic by 27.6%, and as psychological by 7.2%. Partial or complete avoidance of chemical exposures was recommended by 86.3%. Clinical guidelines, diagnostic tools, or more insight in the pathophysiology were requested by 84.5% of the GPs.

Conclusion

Despite the lack of formal diagnostic labelling the patient with MCS is well known by GPs. The majority of the GPs believed that MCS primarily has a multi-factorial explanation. However, perceptions of the course of the condition and management strategies differed, and many GPs found it difficult to meet the patients’ expectations for healthcare. The majority of the GPs requested more knowledge and clinical guidelines for the management of this group of patients.

Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.

Design Systematic review.

Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011).

Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs.

Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out.

Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings.

Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.

OBJECTIVES--To evaluate integrated care for diabetes in clinical, psychosocial, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital diabetic clinic and three general practice groups in Grampian. PATIENTS--274 adult diabetic patients attending a hospital clinic and registered with one of three general practices. INTERVENTION--Random allocation to conventional hospital clinic care or integrated care. Integrated care patients seen in general practice every three or four months and in the hospital clinic annually. General practitioners were given written guidelines for integrated care. MAIN OUTCOME MEASURES--Metabolic control, psychosocial status, knowledge of diabetes, beliefs about control of diabetes, satisfaction with treatment, disruption of normal activities, numbers of consultations and admissions, frequency of metabolic monitoring, costs to patients and NHS. RESULTS--A higher proportion of patients defaulted from conventional care (14 (10%)) than from integrated care (4 (3%), 95% confidence interval of difference 2% to 13%). After two years no significant differences were found between the groups in metabolic control, psychosocial status, knowledge, beliefs about control, satisfaction with treatment, unscheduled admissions, or disruption of normal activities. Integrated care was as effective for insulin dependent as non-insulin dependent patients. Patients in integrated care had more visits and higher frequencies of examination. Costs to patients were lower in integrated care (mean 1.70 pounds) than in conventional care (8 pounds). 88% of patients who experienced integrated care wished to continue with it. CONCLUSIONS--This model of integrated care for diabetes was at least as effective as conventional hospital clinic care.

In order to obtain more information about the reasons why patients consult their general practitioner 1000 patients completed a questionnaire in the waiting rooms of eight general practices. After the consultation the patients received a second questionnaire. The aim of the study was to determine why people decide to consult their general practitioner about one complaint but not about a second complaint. Both questionnaires were based on the health belief model, augmented by three other factors: the perceptions patients have of their own abilities to cope with their condition (efficacy of self care), their knowledge about the complaint and their need for information. The results showed that two of the additional factors (efficacy of self care and need for information) as well as most of the factors of the health belief model (efficacy of general practitioner care, perceived severity of complaint and cues to consult) were important determinants of consulting the general practitioner. The results suggest that patients sometimes expect information from their general practitioner rather than medical treatment. Furthermore, as the perceived efficacy of general practitioner care is also an important determinant, unnecessary consultation or unnecessary delay in treatment could be prevented by offering patients information about the potential effectiveness of medical care or self care for specific conditions. Implications for general practitioners' daily practice and future research are discussed.

Walk-in open access in general practice may influence the general practitioner's (GP's) work, but very little research has been done on the consequences. In this study from Danish general practice, we compare the prevalence of burnout between GPs with a walk-in open access and those without. In a questionnaire study (2004), we approached all 458 active GPs in the county of Aarhus, Denmark, and 376 (82.8%) GPs returned the questionnaire. Walk-in open access was defined as at least 30 minutes every weekday where patients could attend practice without an appointment. Burnout was measured by the Maslach Burnout Inventory. Analyses using logistic regression were adjusted for gender, age, marital status, job satisfaction, minutes per consultation, practice organisation, working hours, number of listed patients per GP, number of contacts per GP, continuing medical education- (CME-) activities, and clusters of GPs. In all, 8% of GPs had open access and the prevalence of burnout was 24%. GPs with walk-in open access were more likely to suffer from burnout. Having open access was associated with a 3-fold increased likelihood of burnout (OR = 3.1 (95% CI: 1.1–8.8, P = 0.035)). Although the design cannot establish causality, it is recommended to closely monitor possible negative consequences of open access in general practice.