The impact of specialists on prescribing by general practitioners.

OBJECTIVE: To investigate the direct impact of specialists on prescribing by general practitioners. DESIGN: Cross-sectional, prescription-based study. SUBJECTS AND SETTING: 88 GPs in the Hunter Urban Division of General Practice, Hunter Valley, NSW. MAIN OUTCOME MEASURE: Proportions of specialist-initiated prescriptions for eight commonly prescribed drug classes. RESULTS: The proportion of specialist-initiated prescriptions was greatest for proton pump inhibitors (85%), and lowest for diuretics (8%), newer antidepressants (10%) and H2-receptor antagonists (13%). Specialists initiated 29% of prescriptions for beta-blockers, 26% for calcium-channel blockers, 20% for statins and 19% for angiotensin-converting enzyme inhibitors or angiotensin II antagonists. Specialists were more likely to have been involved in starting therapy with metoprolol than other beta-blockers (51% v 23%) and diltiazem than other calcium-channel blockers (48% v 19%), and this was related to indication for treatment. In contrast, prescriptions for the more recently introduced drugs (angiotensin II antagonists and atorvastatin) were not more likely to have been specialist-initiated than prescriptions for established angiotensin-converting enzyme inhibitors and statins. CONCLUSIONS: The direct impact of specialists on prescribing in the Hunter Urban Division of General Practice is substantial and varies with the drug class. This highlights the need to engage both GPs and specialists in efforts to improve prescribing practices.

The divisional alternative.

GPs working together in groups, with a corporate body providing the organisational framework, is an inevitable outcome of healthcare system changes. Divisions of General Practice--regional corporations owned and operated solely by local GPs--should be seen as the logical alternative to the non-regional, for-profit, often publicly listed corporations. The divisional model combines economies of scale and organisation with clinical and practice autonomy and a regional focus, as well as an emphasis on patient values, quality of care, and equity of access. The Hunter Urban Division of General Practice is exploring the possibility of a Division-based general practice cooperative.

Prescribing patterns in general practice. A comparison of two data sources.

OBJECTIVE: To compare data captured by an electronic general practice prescribing package with prescribing data from the Health Insurance Commission (HIC). METHODS: Twenty GPs from the Hunter Urban Division of General Practice (HUDGP) used the electronic prescribing package. Data for June-July 1996 were analysed. Prescribing data for all GPs (n = 369) in the HUDGP were extracted from HIC files to provide the comparison. RESULTS: Each data source had limitations, and provided different, but complementary information. HIC data allowed calculation of prescribing rates (prescriptions per 100 Medicare services), but had incomplete capture of information on some classes of drugs, and no information on the patients receiving the drugs or the indications for the use of the drugs. The HUDGP database could only provide information on choice of agent when the decision to prescribe something had been made. However, it provided the context information (patient characteristics, indication for use, other medications) that could permit some assessment of the appropriateness of therapy. CONCLUSIONS: HIC data may be useful for an overall assessment of divisional activities. However, for a full assessment of the quality of prescribing at the level of individual GPs, additional patient related information is required. This requires much wider use of electronic prescribing packages that can capture the clinical details needed to review the appropriateness of treatment decisions.

Severe exacerbation of chronic obstructive airways disease: health resource use in general practice and hospital.

The objective of this study is to examine the treatment of exacerbations of chronic obstructive airways disease (COAD) in the hospital and in the community setting using a retrospective study of patients admitted to a major teaching hospital combined with a general practice chart audit. The admission records for 248 admissions from 128 patients were reviewed. Most patients (70%) had visited their GP within 2 weeks of admission, antibiotics were prescribed for 30% of the exacerbations while 51% were treated with ingested corticosteroids. During hospitalization, features of infection were present in 64% (n = 159) of exacerbations and 79% (n = 196) received antibiotics. Patients were also treated with nebulized bronchodilators, oxygen and corticosteroids (82%). The median length of stay was 10 days (range 0-55). There was a high readmission rate (70%) at 1 year for exacerbation of COAD during the study period. Exacerbations of COAD frequently demonstrated the clinical features of infection. Treatment in general practice was less intensive than in hospital, and there is a need to reconcile these differences with studies of early therapy with antibiotics and corticosteroids. Although corticosteroids were used less often in general practice, the literature in this area is not conclusive and the evidence supporting guideline recommendations is not explicit. There are opportunities to examine the role of early therapy and early discharge programmes to minimize the cost burden from exacerbations of COAD.

General practitioner perceptions of surgical waiting times.

This study explored general practitioners' (GP) perceptions of waiting times and the importance of these perceptions in choosing a surgeon. A randomly selected sample of GPs in the Hunter Area of New South Wales, Australia, provided information prospectively on patients referred to a surgeon. The results indicated that GPs feel a lack of private health insurance makes only a small difference in waiting time to see a surgeon but a large difference in the waiting time for an operation. Additionally, GPs consider that sizeable numbers of patients will wait longer than they consider reasonable for surgical consultations and procedures. However, perceptions of waiting times do not appear to have a major influence on the choice of surgeon.

Divisions of general practice: a status review.

This paper looks at the emergence of divisions of general practice in Australia. Divisions are local groups of general practitioners working to integrate general practice into the wider health system and to explore opportunities for improving service delivery, teaching and research. There are now 116 divisions of general practice, covering over 95 per cent of the Australian population. Projects and infrastructure funding was approximately $35 million in 1994-95. Divisions have enabled general practitioners to retain their autonomy while responding to a government health reform process which depends on their participation. They are a uniquely Australian solution to the problems confronting general practice in the 1990s, bridging the gap that previously existed between individual general practitioners and the health system as a whole. The Divisions and Projects program is being evaluated using a variety of methods which allow feedback into the program in a timely way. The program thus remains sensitive to new strategies and directions, either from the general practitioners themselves or from other stakeholders.