Objectives To describe duration of symptoms and patterns of diagnosis and referral in women with chronic pelvic pain. Design Retrospective cohort analysis of the MediPlus UK Primary Care Database. Setting One hundred ...
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Objectives To describe duration of symptoms and patterns of diagnosis and referral in women with chronic pelvic pain. Design Retrospective cohort analysis of the MediPlus UK Primary Care Database. Setting One hundred and thirty-six general practices in the UK. Study group A cohort of 5051 incident cases of chronic pelvic pain. Methods The cohort was followed up from the start of their symptoms in 1992 until the end of the chronic pelvic pain episode or the end of 1995. Main outcome measures Duration of symptoms, frequency of diagnoses and referral rates. Results A third of women had symptoms persisting for more than two years. Duration of symptoms increased significantly with age (P < 0.001) from a median of 13.7 months in 13-20 year olds to 20.2 months in women over the age of 60. Irritable bowel syndrome and cystitis were the most common diagnoses at all ages. Twenty-eight percent of women never received a diagnosis during three to four years of follow up after first consultation, and 60% of women had no evidence of a specialist referral. Women aged 21-50 and women whose final diagnosis was endometriosis received the largest number of diagnoses and had the highest referral rates. Conclusions The numbers and types of diagnosis given to a woman with chronic pelvic pain and the likelihood of specialist referral depend on her age, as well as on the duration of symptoms. Women seen in secondary care for chronic pelvic pain are a highly selected group and are likely to represent only the tip of the iceberg.
Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in move symptomatic and impaired patients. As part of a randomized effectiveness study in primary cave patients with ...
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Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in move symptomatic and impaired patients. As part of a randomized effectiveness study in primary cave patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a signifi- cantly high frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with move prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However;the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care. (C) 2000 Elsevier Science Inc.
Study objective: Undiagnosed mental illness is highly prevalent and produces needless morbidity. Emergency department patients with vague or longstanding complaints are at risk far occult mental illness, but are seldo...
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Study objective: Undiagnosed mental illness is highly prevalent and produces needless morbidity. Emergency department patients with vague or longstanding complaints are at risk far occult mental illness, but are seldom diagnosed. We conducted this study to determine whether a previously validated, self-administered, computerized psychiatric interview (Primary Care Evaluation of Mental Disorders [PRIME-MD]) could increase the detection of occult psychiatric illness in the ED. Methods: This was a randomized, controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000. ED house staff and attending physicians participated. Patients were those with nonspecific complaints potentially associated with occult psychiatric illness (eg, long-standing headache, abdominal or back pain). Exclusion criteria were known psychiatric illness, complaint, or medication;and straightforward reason for the ED visit. Consenting subjects completed the PRIME-MD questionnaire in the waiting room, and were randomly assigned to either the "report" (report results given to physician) or "no-report" groups. PRIME-MD results were clipped to the front of the chart of report group patients. There was no other intervention. The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis, consultation, or referral from the emergency physician. Results: A total of 339 (5.1%) of all patients were approached;230 consented to participate in the study, and 218 completed the PRIME-MD session and were randomly assigned to study groups. Ninety-two patients in the report group and 98 cases in the no-report group were analyzed. Patients were omitted for the following reasons: left without being seen (8), mistakenly enrolled (10), or unretrievable medical records (10). Seventy nine (42%) patients received a psychiatric diagnosis from PRIME-MO and
Background: The need for colonoscopy in the care of patients with rectosigmoid adenoma 5 mm or less in diameter is still debatable. Methods: We estimated the prevalence of proximal adenomas among 3052 consecutive subj...
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Background: The need for colonoscopy in the care of patients with rectosigmoid adenoma 5 mm or less in diameter is still debatable. Methods: We estimated the prevalence of proximal adenomas among 3052 consecutive subjects undergoing total colonoscopy. Rectosigmoid adenoma was classified as diminutive (5 mm), small (6 to 10 mm), or large (greater than or equal to 11 mm). Advanced proximal adenoma was 10 mm in diameter or larger, or with a villous component, severe dysplasia, or infiltrating adenocarcinoma. Results: Proximal adenoma was found in 212 of 2483 patients (8.5%, 95% CI [7.5, 9.7]) without distal neoplastic polyps, 49 of 214 (22.9%, 95% CI [17.6, 29.2]) with diminutive, 44 of 174 (25.3%, 95% CI [19.1, 32.5] with small, and 70 of 181 (38.7%, 95% CI [31.6, 46.2]) with large distal adenoma. Advanced proximal adenoma was found in 49 (2.0%, 95% CI [1.5, 2.6]), 8 (3.7%, 95% CI [1.7, 7.5]), 17 (9.8%, 95% CI [6.0, 15.4]), and 29 patients (16.0%, 95% [11.2, 22.4]), respectively. In patients with distal adenoma risk for proximal lesions increased with increasing age, size, and number of distal adenomas (p = 0.01). Size of distal adenoma was the strongest predictor of the presence of proximal advanced adenoma (multivariate analyses). Conclusions: In a clinical setting, the decision to perform colonoscopy should take into account proximal lesions of clinical interest, life expectancy, costs, and risks associated with the procedure. When detection of advanced proximal adenoma is the goal, presence of distal diminutive adenoma alone might not be an indication for total colonoscopy.
Recent political and public interest has focused on the rapid evaluation of women with breast lumps. Additionally, audit of outcome seeks to improve the prognosis of those with malignancy by involvement of multidiscip...
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Recent political and public interest has focused on the rapid evaluation of women with breast lumps. Additionally, audit of outcome seeks to improve the prognosis of those with malignancy by involvement of multidisciplinary teams, leading to more effective local and systemic therapies. This ignores the raw material, namely those patients who consult their GPs with breast problems, since if selection for specialist referral is ineffective, one-stop clinics will . .
In this study we investigated patterns of referral and appropriateness of referrals to specialist oral and maxillofacial surgery services, using postal questionnaires and referral letters. The most common reasons for ...
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In this study we investigated patterns of referral and appropriateness of referrals to specialist oral and maxillofacial surgery services, using postal questionnaires and referral letters. The most common reasons for referral were the expected difficulty of the operation, the medical condition of the patient and the lack of facilities for general anaesthesia, Most referrals were made to the oral and maxillofacial surgery department of a general hospital but almost three-quarters of the respondents stated that they would refer patients to specialist surgical dentistry practices in the future. Few referrals to a university department of oral and maxillofacial surgery were considered to be inappropriate, nor were requests for a particular type of anaesthesia. Any future transfer from secondary to primary care for oral surgery may be hindered by the reduction in facilities for general anaesthesia in the primary care setting.
This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The me...
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This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1, One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular, The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients, Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 1986-88 to 9% in 1995-1997, A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions, Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97, Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.
Background. The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general pract...
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Background. The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care. Objectives. To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year;and to explore GPs' attitudes to the guidelines. Methods. Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines. Results. A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance. Conclusions. Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one y
Background Limited resources;managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with...
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Background Limited resources;managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with suspected heart disease. To study this strategy, we compared the management decisions of pediatricians with the recommendations of pediatric cardiologists who reviewed the records of the same patients. Methods Sixty-nine patients aged <23 years with suspected heart disease were referred by pediatricians (n = 40) on the inpatient service at Boston Medical Center, for either a cardiology consultation or echocardiography. Two pediatric cardiologists who were blinded to the management decisions and clinical outcomes later reviewed the patient records. Recommendations between the 2 pediatric cardiologist reviewers and the managing pediatricians were compared. Results Pediatricians scheduled significantly fewer cardiology follow-up visits, instituted cardiac medications significantly less often, arranged significantly fewer family meetings to review cardiac findings, and ordered significantly fewer additional cardiac procedures than the pediatric cardiologists. This result was consistent regardless of whether the pediatrician's management decisions were made on the basis of the echocardiogram results only or on the recommendations of a cardiology consultant. The 2 pediatric cardiologist reviewers agreed more often with each. other than either did with the managing pediatricians. Conclusions Pediatricians have different management styles than-pediatric cardiologists for patients with suspected cardiac disease. The effect of these differences on outcome is unknown, and further investigation is warranted.
Supply factors, depicted by input market conditions and government regulations, and demand factors, depicted by financing mechanisms and utilization patterns, are likely to determine the shape and character of private...
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Supply factors, depicted by input market conditions and government regulations, and demand factors, depicted by financing mechanisms and utilization patterns, are likely to determine the shape and character of private medical practice. The interaction of this complex set of factors will have considerable implications for the cost, access and quality of services offered by this sector. Understanding these characteristics from a provider perspective is imperative to influence the behaviour of providers in this sector. This paper describes some of the important characteristics of private medical practice using a case study of an urban district in India, Ahmedabad, and analyzes their implications. Using survey data of 130 private doctors in the allopathic system, the paper describes broad characteristics of private medical practice using parameters such as growth of private practice, patient load and referrals within the sector, payment methods and determinants, patient concerns, and risks associated with private practice. The paper presents views on the prevalence of various undesirable practices in the private medical sector. It also discusses the awareness of providers about selected important regulations. The findings suggest that growing capital intensity due to cost of location, medical equipment and technology, and financial sources of capital investments are some unfavourable environmental factors experienced by private providers. The findings also indicate a high prevalence of various undesirable practices and low awareness of the objectives of important legislation among practicing doctors. Lack of awareness of important and relevant legislation raises serious questions about the implementation of these laws. The paper identifies the strong need for instituting and implementing an effective continuing medical education programme for practicing doctors, and linking it with their registration and continuation of their license to practice. The paper also suggests
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