Referrals and relationships: in-practice referrals meetings in a general practice

BACKGROUND

GP referrals to secondary care are an important factor in the cost of running the NHS. The known variation in referral rates between doctors has the potential to cause tension within primary care which will be exacerbated by the latest reorganization of primary care and the trend towards capitation-based budgets. The importance of postgraduate learning for GPs has been recognized; continuing professional development is moving towards self-directed practice-based learning programmes. Educational interventions have been shown to alter doctors' prescribing behaviour. This, together with the pressure on accounting for referral activity, makes the prospect of improving, and possibly reducing, referral activity through educational interventions very attractive.

OBJECTIVES

This study complemented a randomized controlled trial (RCT) which investigated whether an intervention of the type which had reduced prescribing costs would have a similar effect on referral activity.

METHODS

The context of the study, description of the characteristics of the practice and the issues seen as important by the doctors and practice manager were identified through preliminary semi-structured interviews. The practice then held a series of educational in-practice meetings to discuss referrals and issues arising from referrals. The audio- and videotaped transcripts were interpreted using content and group dynamic analysis. Participants commented upon our preliminary findings. In addition, we used dimensional analysis to induce a preliminary theory describing the effect of the intervention on this general practice which enabled us to review the findings of the parallel RCT. The educational value of the meetings and the learning needs of the participants were also assessed.

RESULTS

Our complementary study showed no alteration of practice referral rates following the educational intervention. The qualitative study, unencumbered by the assumptions inherent in the development of the hypothesis tested in the RCT, highlighted the complexity of decision making in general practice and the likely impact of historical background and a variety of internal and external pressures on this self-directive educational intervention. The practice members described the individual and group learning needs identified as a result of the meetings.

CONCLUSION

The findings of this study raise important questions for developing practice-based learning. The outcomes of self-directive interventions in practices will be influenced by internal and external events both past and present. Such outcomes may be qualitative and difficult to measure. They are likely to differ from outcomes seen when interventions are applied to groups of doctors who are not all members of the same practice.

Referrals. Risky business

There are wide variations in referral rates between GPs. The reasons for this are not well understood. Reduction in referrals will require protocols and the involvement of patients.

Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records

OBJECTIVES

To identify patients with ischaemic heart disease by using a practice computer and to estimate the work required to do so.

DESIGN

Cross sectional study. Data from the notes and from the computer records of 1680 patients were used to build a database. This was used to compare different methods of identifying patients with ischaemic heart disease.

SETTING

11 general practices in the Battersea primary care group in south London.

SUBJECTS

1 in 40 random sample of patients aged 45 or older.

MAIN OUTCOME MEASURES

Numbers of patients identified with ischaemic heart disease.

RESULTS

The combination of the Read code for ischaemic heart disease (G3) and a prescription for a nitrate had a 73% sensitivity and a yield (100/positive predictive value) of one case of ischaemic heart disease for every 1.2 sets of notes reviewed. By searching the records of patients also receiving aspirin, atenolol, digoxin, or a statin, the sensitivity was increased to 96% but the yield fell to one in three.

CONCLUSION

Although commonly used to identify cases, a computer search for G3 code or nitrate missed almost 30% of patients with ischaemic heart disease. A substantially higher percentage of patients can be identified by adding other drugs to the search strategy.

Towards a conceptual framework for evaluating primary care research networks

We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.

Effective drift velocities and effective diffusivities of swimming microorganisms in external flows

In this note we calculate the effective drift velocities and the effective diffusivities of swimming microorganisms in an external flow field. It is shown that if the ambient velocity field is incompressible then the effects of reorientation of the cells can under certain circumstances enhance the effective drift velocity along the preferred direction.

Exactly solvable sandpile with fractal avalanching

A simple one-dimensional sandpile model is constructed which possesses exact analytical solvability while displaying both scale-free behavior and fractal properties. The sandpile grows by avalanching on all scales, yet its shape and energy content are described by a simple, continuous (but nowhere differentiable) analytical formula. The avalanche energy distribution and the avalanche time series are both power laws with index -1 ("1/f spectra").