Schizophrenia in general practice: a national survey of general practitioners in Ireland

BACKGROUND

Chronic schizophrenia is challenging to manage in primary care.

AIMS

We sought to establish the views of General Practitioners about managing patients with chronic schizophrenia in primary care.

METHODS

A cross-sectional, postal survey questionnaire of a randomly selected sample of 20% of GPs was carried out.

RESULTS

Most GPs (97.2%) have at least one person with schizophrenia attending their practice. A substantial number of GPs (22.2%) treat cases of schizophrenia without specialist input following an initial referral to psychiatric services. Almost all (88.7%) advised patients who had experienced multiple relapses to remain on medication indefinitely. One third of GPs reported that they always experience difficulties managing patients with schizophrenia in their practice. Non-adherence with prescribed medication and loss to follow-up were the commonest impediments to treatment encountered.

CONCLUSION

GPs require appropriate back up from specialist services to enable their management of chronic schizophrenia.

Undergraduate medical students' experience in general practice

BACKGROUND

Increasingly, undergraduate medical education is becoming community-based. Logbooks are a useful tool in documenting the range of clinical exposure and learning opportunities available to students during clinical training, particularly where the role of new clinical settings for training medical students is being explored.

AIMS

To describe the clinical experience of medical students during an undergraduate programme in general practice at an Irish University.

METHODS

Medical students in the fifth year of medical school were asked to record data from 20 consecutive consultations during a clinical attachment in general practice.

RESULTS

A total of 186 students (82% of total) recorded data on 3,710 consultations. The patient population encountered was similar in demography and morbidity profile to other general practice populations, with hypertension, preventive immunisation and cough the most frequently encountered diagnostic labels. Respiratory illness and circulatory illness were the most frequently encountered primary and secondary presentations, respectively. An active role was adopted by students in almost half of all consultations.

CONCLUSIONS

This paper provides evidence that general practice in Ireland is a setting in which medical students can both encounter a wide range of clinical problems and engage in active learning processes.

Experience of hepatitis C among current or former heroin users attending general practice

The majority of injecting drug users in Ireland are infected with hepatitis C (HCV) and many attend general practice for methadone maintenance treatment. To describe awareness and experience of HCV infection, related investigations and treatment, a semi-qualitative interview study of current or former heroin users attending a general practice was carried out. Twenty-five patients (69% of total) were interviewed, of whom 23 were on methadone maintenance therapy at the time of the interview and 22 were HCV positive. While awareness of harm reduction measures and health implications of the infection was good, continued high-risk activity was common. Negative experiences at diagnosis, of subsequent investigations and treatments received were common. Only one person had been treated for HCV. We conclude there are a number of barriers to effective HCV management among heroin users and further research is needed to improve our understanding of this issue.

High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial

OBJECTIVE

To compare two dosing regimens for caffeine citrate in the periextubation period for neonates born at less than 30 weeks gestation in terms of successful extubation and adverse effects.

DESIGN

A multicentre, randomised, double blind, clinical trial.

SETTING

Four tertiary neonatal units within Australia.

PATIENTS

Infants born less than 30 weeks gestation ventilated for more than 48 hours.

INTERVENTIONS

Two dosing regimens of caffeine citrate (20 v 5 mg/kg/day) for periextubation management. Treatment started 24 hours before a planned extubation or within six hours of an unplanned extubation.

MAIN OUTCOME MEASURE

Failure to extubate within 48 hours of caffeine loading or reintubation and ventilation or doxapram within seven days of caffeine loading.

RESULTS

A total of 234 neonates were enrolled. A significant reduction in failure to extubate was shown for the 20 mg/kg/day dosing group (15.0% v 29.8%; relative risk 0.51; 95% confidence interval (CI) 0.31 to 0.85; number needed to treat 7 (95% CI 4 to 24)). A significant difference in duration of mechanical ventilation was shown for infants of less than 28 weeks gestation receiving the high dose of caffeine (mean (SD) days 14.4 (11.1) v 22.1 (17.1); p = 0.01). No difference in adverse effects was detected in terms of mortality, major neonatal morbidity, death, or severe disability or general quotient at 12 months.

CONCLUSIONS

This trial shows short term benefits for a 20 mg/kg/day dosing regimen of caffeine citrate for neonates born at less than 30 weeks gestation in the periextubation period, without evidence of harm in the first year of life.

The North Dublin randomized controlled trial of structured diabetes shared care

BACKGROUND

A new diabetes shared care service was introduced in North Dublin. It was designed as a randomized controlled trial with a complex intervention comprising education of participating practitioners, the introduction of a community-based diabetes nurse specialist, local agreement on clinical protocols and structured communication across the primary-secondary care interface.

OBJECTIVES

Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care.

METHODS

A Cluster randomized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practices in North Dublin. Biophysical outcomes (HbA1c, blood pressure, body mass index), psychosocial measures (smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores) and process outcomes were collected.

RESULTS

There were significant improvements in diabetes care delivery and in psychosocial outcomes, but no significant improvements in biomedical outcomes. Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual reviews and fewer patients defaulting from care. There were also significant improvements in information exchange between primary and secondary care.

CONCLUSION

Structured diabetes shared care, in a mixed health care system, can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients, with improved information exchange across the primary-secondary care interface.

A qualitative investigation of the views and health beliefs of patients with Type 2 diabetes following the introduction of a diabetes shared care service

AIMS

A qualitative research approach was adopted in order to explore the views and health beliefs of patients with Type 2 diabetes who had experienced a new structured diabetes shared care service.

METHODS

Patients from 15 general practices were randomly selected and invited to attend three focus groups. Two independent researchers adopted the "Framework" technique to analyse the transcribed data and identify key themes expressed by patients.

RESULTS

Themes relating to diabetes included frustration, victimization and powerlessness in relation to living with diabetes, controlling blood sugar, medication and economic barriers to care. Differences in emphases between patients and healthcare providers emerged. Patients were generally positive about shared care and largely identified it with the nurses involved.

CONCLUSION

This research highlights the importance of an in-depth exploration of patients' views during changes in diabetes care delivery to identify service delivery failures and gaps in patient knowledge such as lack of awareness of the extent of macrovascular risk.

Hepatitis C infection among drug users attending general practice

BACKGROUND

The prevalence of hepatitis C (HCV) infection among injection drug users is high and addiction-related care is increasingly being provided by GPs in Ireland.

AIMS

To determine the prevalence and associated factors of HCV infection among injecting drug users attending general practice.

METHODS

The records of 571 patients attending 42 general practices in the Eastern Regional Health Authority (ERHA) area for methadone maintenance treatment were reviewed.

RESULTS

The HCV status was recorded in 380 cases (67%). Of these, 193 had a test performed by their GP, 74 had been tested by another service and 113 had no evidence of being tested, but HCV status was recorded based on information provided by the patient himself. A total of 276 cases were identified as being HCV positive (prevalence 73%), with no difference in prevalence between the three sources of information (p = 0.12). A history of injecting drug use was the major determinant of testing for HCV.

CONCLUSIONS

While a large proportion of drug users attending GPs for methadone maintenance treatment are known to be HCV positive, a considerable number have not been tested. Barriers to testing need to be explored to facilitate comprehensive screening.

Patients presenting with acute myocardial infarction to a district general hospital: baseline results and effect of audit

The Cardiovascular Health Strategy recommended that patients presenting with acute myocardial infarction receive thrombolysis within ninety minutes of alerting medical or ambulance services. The aim of this prospective study was to describe the management of patients with acute myocardial infarction (AMI) presenting to a district general hospital in Donegal. All patients with a confirmed diagnosis of acute myocardial infarction, excluding those from the Donegal Area Rapid Treatment Study (DARTS) practices, admitted to Letterkenny General Hospital (LGH) from 31.08.99 to 31.08.01 were included in the study. 349 patients were included in the study; average age of 68 ranging from 30 to 96 years and 69% were male. Of the 349 patients, 101 (29%) were located more than 30 miles from LGH at the time of onset of symptoms. The median time taken from the onset of symptoms to calling for help was 119 minutes. The median time from hospital arrival to patients being admitted to CCU was 90 minutes. Thrombolytic therapy was administered in 31% of patients; for these patients the median call to needle time was 200 minutes. Call to needle times differed significantly between rural (median 227.5 minutes n = 64) and urban patients (median 175 minutes n = 37, p < 0.05, Mann-Whitney). Hospital delay times decreased throughout the study period (p > 0.05, Mann-Whitney). The study extends the findings from previous research by investigating the individual time delay components from onset of symptoms to treatment in AMI patients. Delay times exceed the recommended call to needle and door to needle times suggesting the need for interventions to reduce these times.

"What makes a good doctor?" A cross sectional survey of public opinion

Our understanding of the characteristics that 'make' a good doctor is continually changing. The aim of this study, therefore, was to determine the characteristics that the general public consider important in doctors who would 'treat them or a member of their family.' A cross sectional survey of 599 members of the general public was carried out. Interviewees were asked to identify three qualities, attributes or characteristics and a randomly selected 20% sample was then asked to rate the importance of previously determined characteristics in response to the same question. When presented with an open-ended question, interpersonal characteristics (eg 'someone who is friendly' and 'someone who listens') were identified as most important. When presented with a 'checklist,' however, cognitive characteristics (eg 'somebody who is intelligent and bright' and 'somebody who is knowledgeable about medical matters') were identified as most important. Both interpersonal and cognitive characteristics therefore are important qualities for doctors to possess.

"Why are we working so hard?" A cross-sectional survey of factors influencing GP workload in the Eastern Regional Health Authority area

There is increasing evidence to suggest that the subjective workload of GPs in Ireland is too heavy. The aims of this study, therefore, were to identify the social and demographic issues that GPs perceive as being implicated in determining their workload. A self-administered questionnaire, inviting GPs to score a series of factors according to the degree to which it increased their workload, was sent to one-quarter of GPs practising in the Eastern Regional Health Authority (ERHA) area. The response rate was 71%. Seventy-nine (60%) felt their workload was 'too heavy,' while 109 (85%) felt they could improve the quality of care they provide, if their workload was reduced. Access to OPD services (mean score = 7.31), access to other hospital services (mean score = 7.16), and the number of elderly patients (mean score = 6.28) were considered to be the most important factors in determining workload. This paper describes the factors that impact on self-perceived workload for GPs, factors which need to be considered when planning and funding future developments in primary care.

Prevalence of fatigue in general practice

BACKGROUND

Fatigue is an important symptom in general practice due to its association with physical, psychological and social problems.

AIM

To determine the prevalence of fatigue as an unsolicited symptom during general practice consultations.

METHODS

A random sample of GPs practising in Ireland was invited to provide data on consultations held over one day. Data were recorded on the presence of fatigue as a main or supporting symptom, social and demographic characteristics.

RESULTS

Data were recorded by 89 GPs on 1,428 consultations. The prevalence of fatigue was 25%. It was the main reason for attending the doctor in 6.5% and a secondary reason in 19%. Sixty-two per cent of patients were female and 48% were eligible for free GP services. The mean age was 47.1 years. The presence of fatigue was associated with: attending a female GP, being female, attending a GP who had been qualified for fewer years and attending the GP frequently.

CONCLUSION

The prevalence of fatigue reported in this study is over three times higher than that reported in earlier work. Doctor characteristics appear to be as important as patient characteristics in determining fatigue.

The North Dublin Diabetes Shared Care (DiSC) Project: a profile of current diabetes care in Ireland

The DiSC Project aims to assess the feasibility, effectiveness and costs of diabetes shared care in Ireland. Baseline results provide a profile of diabetes care in Ireland. Thirty general practices are participating in this randomised controlled trial. Outcomes include biophysical and psychosocial measures. The majority of patients agreed to participate in diabetes shared care. Data was collected from 183 patients with type 2 diabetes. The mean age of the patients is 65 years, 56% are male and 63% are GMS eligible. The mean HBA1c was 6.8% though 21% of patients had a HBA1c>8%. The majority of patients had a blood pressure, total cholesterol and body mass index above recommended guidelines. Only half the patients are attending a dietician or a chiropodist. The majority of patients have good glycaemic control but poor blood pressure and cholesterol control. The full trial results will determine if a shared care approach can improve clinical and psychosocial outcomes for patients.

Deaths in general practice: an Irish national profile

BACKGROUND

There is little information on general practitioner (GP) involvement in terminal care. Aim This study explores general practice experience of the care of dying patients.

METHODS

One hundred and forty-two GPs offered to participate in a study of consecutive deaths during three months, to a maximum of five cases per practice. Data were collected on patient characteristics, cause and place of death, terminal care and GP notification of deaths.

RESULTS

One hundred and three GPs (73%) completed data collection. Participating GPs were younger and more likely to be in group practice. There were 297 deaths reported: 34% of practices had five deaths or more but 20% had no death. Seventy-five per cent of patients had one GP consultation in the final three months, 60% had at least one hospital admission and 38.8% of deaths occurred at home. Mean home visit, surgery consultation and phone consultation rates were 5.4, 1.8 and 3.6 respectively. In 88% of cases, the GP was informed of the death within one week.

CONCLUSIONS

GPs are notified rapidly of deaths in all groups and causes. In the majority, the GP has had recent clinical contact and has often been heavily involved in care. Most deaths and care occur outside the cancer-related sphere.

Patients' views on out-of-hours care in general practice in Dublin

BACKGROUND

Little is known regarding patients' views and levels of satisfaction with out-of-hours care in Irish general practice despite significant recent changes in service delivery.

AIMS

This study aimed to record patients' experience of out-of-hours care on a specific occasion and elicit their satisfaction with out-of-hours care in general.

METHODS

Patients requesting out-of-hours care in three south inner city Dublin practices in June and July 2000 were identified and sent an anonymous postal questionnaire.

RESULTS

Two hundred and forty patients were identified and 58% responded to the questionnaire. The approximate call rate was 195 calls per 1,000 patients per year. Sixty-one per cent of patients used the co-operative service, 28% received a house call and 3% received telephone advice only; 86% are currently satisfied with out-of-hours care.

CONCLUSIONS

The majority of patients are satisfied with the current out-of-hours service. Telephone consultation rates are significantly lower than other countries. These findings need to be considered before the widespread introduction of systems involving increased telephone consultations.

Cervical smears: comparison of knowledge and practice of a general practice sample with a high-risk group

Successful cervical screening programmes depend on the participation of an informed target population. A national cervical screening programme is shortly to be introduced in the Republic of Ireland. We compare the knowledge, attitudes and practice of 395 Irish urban women with 323 high-risk women, genitourinary medicine (GUM) clinic attenders. There was little difference in knowledge between the 2 groups. Fifty-five per cent of the general practice (GP) sample and 45% of the GUM sample correctly identified the purpose of a smear. Eighty-three per cent of both groups had had at least one smear but only 59% of the high-risk group had had a smear before attending the GUM clinic. Both groups expressed a preference for a female provider. Socio-economic grouping is the strongest predictor of knowledge and uptake of cervical smears and high-risk women were less likely to have opportunistic cervical smears. Information programmes to encourage participation in screening programmes must build on pre-existing knowledge and focus on the relevance and acceptability of the test.

A national census of ambulance response times to emergency calls in Ireland

BACKGROUND

Equity of access to appropriate pre-hospital emergency care is a core principle underlying an effective ambulance service. Care must be provided within a timeframe in which it is likely to be effective. A national census of response times to emergency and urgent calls in statutory ambulance services in Ireland was undertaken to assess current service provision.

METHODS

A prospective census of response times to all emergency and urgent calls was carried out in the nine ambulance services in the country over a period of one week. The times for call receipt, activation, arrival at and departure from scene and arrival at hospital were analysed. Crew type, location of call and distance from ambulance base were detailed. The type of incident leading to the call was recorded but no further clinical information was gathered. Results-2426 emergency calls were received by the services during the week. Fourteen per cent took five minutes or longer to activate (range 5-33%). Thirty eight per cent of emergencies received a response within nine minutes (range 10-47%). Only 4.5% of emergency calls originating greater than five miles from an ambulance station were responded to within nine minutes (range 0-10%). Median patient care times for "on call" crews were three times longer than "on duty" crews.

CONCLUSION

Without prioritized use of available resources, inappropriately delayed responses to critical incidents will continue. Recommendations are made to improve the effectiveness of emergency medical service utilisation.

Drug users attending general practice in Eastern Regional Health Authority (ERHA) area

Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care for this group has increased over the last four years. A Central Methadone Treatment List (CMTL) registers all clients currently on treatment. To obtain a social, demographic and drug using profile of opiate users attending general practitioners (GPs) for methadone maintenance. A cross sectional survey of opiate users attending general practice for methadone maintenance in the Dublin area in early 1999. Data was collected on 571 clients (62% of total number attending general practice), of whom 97% had used heroin in the past and 12% had never injected. Although clients had been receiving methadone maintenance in general practice for a mean of 14 months, 16% were still using heroin, of whom 31% were still injecting. The mean age of first drug use was 15.5 years and of first injecting was 19.4 years. Younger clients are starting both to use drugs and inject drugs at an earlier age. Record keeping was good, with most items of information present in over 70% of the charts surveyed. A total of 17% of clients recorded on the CMTL could not be traced to the GP recorded as providing care. Despite treatment with methadone maintenance, there is a high level of continued risk activity in this group. Furthermore, a trend towards earlier initiation to drug use is apparent. The CMTL registration process requires further exploration.

A & E services in Ireland: the potential role of general practice in accident and emergency services

BACKGROUND

In 1996, Irish accident and emergency (A&E) departments had approximately 1.2 million visits. General practitioners (GPs) have been shown to work efficiently in A&E.

AIM

This study aimed to describe the current A&E structures in Ireland and the potential contribution of general practice.

METHOD

Questionnaires were sent to all 43 Irish A&E departments seeking information on staffing levels, training posts and interest in the role of GPs within the department.

RESULTS

Thirty-four (79%) hospitals responded, representing at least 71% of all A&E visits. Eleven (32%) had A&E consultants. In 16 (47%) hospitals the A&E department was supervised by other consultants; in 14 supervision was for five hours per week or less. Seven hospitals had no consultant supervision. Twenty-six (76%) had NCHDs assigned to the department. Only 11% of NCHDs were in training in A&E medicine. Six departments employed GPs but 28 said they would like to do so. Most wished GPs to see non-urgent cases but one-third wished them to see all cases. Current staffing levels had little relationship with departmental workload.

CONCLUSIONS

The limited consultant supervision and small numbers of NCHDs in training for A&E medicine raise concerns about staffing. Most hospitals want GPs to work in their A&E departments. This has implications for training and for the interface between general practice and the A & E department.

Experience of heroin overdose among drug users attending general practice

BACKGROUND

Heroin overdose is responsible for significant mortality. It has not previously been highlighted as an important prevention or care issue for general practitioners (GPs) involved in the management of drug misuse.

AIMS

To examine the prevalence and experience of heroin overdose in a population of drug users attending a general practice.

METHOD

A questionnaire-based interview of drug users attending a general practice in Dublin, Ireland.

RESULTS

Twenty-four (73% of estimated total) drug users were interviewed. Although 17 (71%) were on recognised methadone treatment programmes, 10 (42%) were still injecting heroin. A total of 23 (96%) had witnessed an overdose, with 10 (42%) having been victims of overdose themselves. Twenty-two (92%) knew a victim of fatal overdose, with four (17%) having been present at a fatal overdose. The interviews revealed high levels of activity associated with overdose and poor use of preventive measures.

CONCLUSION

The issue of prevention and management of overdose should become a priority for GPs caring for opiate-dependent patients.

Experiences of and attitudes to contraceptive services among a sample of attenders at general practices in Dublin

The aim of this pilot project, using quantitative and qualitative methods, was to gain insights into contraceptive service utilisation by studying the experiences and attitudes of a sample of women using general practice for contraception services in Dublin.

Methadone maintenance in general practice: impact on staff attitudes

BACKGROUND

The evaluation of a structured protocol for the discharge of stabilised patients on methadone maintenance to general practice provided an opportunity to evaluate the impact on the attitudes of general practitioners (GPs) and practice staff.

AIM

To assess attitudes, expectations and experience among GPs and practice staff before the introduction of structured methadone maintenance and six months after its introduction.

METHODS

A postal questionnaire was sent to 31 GPs and 23 receptionists in 23 Dublin general practices before the patient's first visit and six months later at the end of the study period. Outcome measures were staff attitudes, incidence of disruption, perceived difficulties in providing care and in prescribing methadone, and stress levels.

RESULTS

There was a generally positive attitude to provision of methadone in general practice for stabilised patients, although it was not anticipated to be problem free. Following six months involvement attitudes were similar; stress levels were unchanged, but fewer GPs anticipated problems in delivering the service. All continued to participate in the scheme.

CONCLUSION

GPs and receptionists in this sample had mixed views about methadone maintenance which were unchanged by six months experience of the service. The study illustrates important issues in the recruitment and support of general practice in meeting this need.