The effects on prescribing patterns and costs of having a special interest in asthma.

To define the characteristics of general practices with a special clinical interest in asthma and to estimate the resulting extra prescribing costs, we sent a postal questionnaire to all English practices containing members of the General Practitioners in Asthma Group. Item and cost comparisons for 24 PACT (prescribing analysis and cost) aggregates were made between practices who had operated an agreed, written management plan for asthma before 1 April 1990 and all other practices in their respective Family Health Services Authorities. One hundred and sixty-three practices with GPIAG members responded (70%), of which 26 filled the management plan requirement. These 26 practices showed evidence of significantly better asthma care provision than the remainder of the sample. Their prescribing costs were significantly higher for respiratory drugs (median 37% higher) but lower in other drug categories. For respiratory drugs, costs were significantly higher for inhaled adrenoceptor stimulants, steroid inhalers, large spacers, and peak flow meters, but lower for cough medicines and systemic nasal decongestants: the number of items prescribed showed similar patterns. The prescribing costs of practices claiming a special interest in asthma are likely to show higher respiratory drug costs, but overall prescribing costs showed no increase in the practices studied.

General practitioner's knowledge of when to refer deaths to a coroner.

BACKGROUND: In 1992 about 179,000 deaths were reported to coroners in England and Wales and these represented 32% of the total number of registered deaths. Many of these cases were referred to coroners by general practitioners who certify the vast majority of deaths which occur outside hospitals. The safeguards to society which are provided by the coroner system in England and Wales are undermined if doctors fail to recognize those deaths which should be reported for further investigation. AIM: A study was undertaken to assess the ability of general practitioners to recognize deaths which require referral to a coroner. METHOD-A postal questionnaire consisting of 12 fictitious case histories was sent to all 323 general practitioners in Sheffield and the senior staff of the local coroner's office (two coroner's officers and two deputy coroners). Ten of the case histories contained a clear indication for referral to the coroner. RESULTS: A total fo 196 general practitioners (61%) and all the coroner's office staff returned the questionnaire. General practitioners correctly identified whether or not referral was indicated, with reasons, in a mean of 8.5 cases (range 4-12). Only six general practitioners (3%) were correct in all 12 cases. All of the coroner's staff were correct in all cases. CONCLUSION: General practitioners may be failing to bring certain categories of cases to the attention of coroners because of misconceptions of ignorance of their medico-legal responsibilities. General practitioner education in this area, and a closer working relationship between general practitioners and coroners may improve the situation.

The provision and use of medical services during the 1991 World Student Games in Sheffield.

This paper describes the provision and use of medical services organized by Sheffield during the World Student Games in 1991. A descriptive study of medical and physio-therapy records, together with minor incident logs and hospital referrals, was carried out. It was found that 571 medical records and 357 physiotherapy records were completed, of which 83 per cent were generated at the Games Village. The majority of patients were competitors, although team officials accounted for a disproportionate number. Most physiotherapy requests were for sports injuries, whereas this was not so for medical cases. Twenty-five per cent of medical records and 40 per cent of physiotherapy records were for recurrent conditions which had started before arrival. Athletics and football accounted for the greatest number of records per competitor. During the Games, 82 patients were referred to hospital, of whom only 12 were admitted. The largest group of hospital referrals was for dental treatment, and the next largest was for minor trauma. A total of 1089 minor incidents were recorded, mainly at the competition venues and in the Physiotherapy Room at the Games Village. In addition, the Red Cross and the St John Ambulance Association attended to 330 people during the Games. The smallest national teams tended to make most demands on services, probably because the larger teams were accompanied by their own medical and physiotherapy staff. It is concluded that the main demands for medical services at the World Student Games were for general practice and physiotherapy at the Games Village, and for first aid at competition venues.(ABSTRACT TRUNCATED AT 250 WORDS)

Practice organization before and after the new contract: a survey of general practices in Sheffield.

In order to assess the effects of the new contract on practice organization, all general practices in Sheffield were surveyed just before the new contract came into effect in April 1990, and again one year later. Of the 120 practices, 57% responded in 1990 and 61% in 1991, with 47% responding in both years. There were significant increases in the mean number of clinics and employed staff for the practices responding to both questionnaires and in the proportion of these practices which had a computer. These changes represent a response to the incentives and stated aims of the new contract.

How valid are responses to questions about behaviour in hypothetical illness situations?

Questions concerning the respondents' actions in response to hypothetical illnesses have been used in a number of studies of illness behaviour and health service utilization, but the answers obtained have never been validated by direct comparison with the respondents' behaviour during episodes of real illness. Five hundred and fifty-four questionnaires were returned by parents giving details of how they would respond to hypothetical episodes of cough, fever and sore throat in their children. During a two-month period of recording, the children suffered 78 episodes of one or other of these symptoms which led to a consultation. The aim of this study was to compare the parents' responses to the hypothetical situations in the questionnaire with what they said they had done before each of these consultations for real illness. The comparison concentrated on the intervals that parents waited before requesting consultations, and on their medication of their children. The parents' responses to the questionnaire were poor predictors of their reported behaviour during actual illness episodes.

Development and randomized controlled trial of a booklet of advice for parents.

A booklet was developed in the author's practice that provided advice for parents on the home management of cough, fever, sore throat, diarrhoea and vomiting in children, and included specific recommendations about when to seek medical help. The effect of distributing this booklet on the frequency of parent-initiated consultations was evaluated in a randomized, controlled trial. The overall effect of the booklet was a statistically non-significant reduction in consultations for the symptoms that it addressed ('booklet symptoms'). However, this finding masked a statistically significant reduction in daytime home visits for booklet symptoms (especially for cough, fever and sore throat) and a significant increase in out of hours consultations (for fever, diarrhoea and vomiting). Had all the households in the practice been sent a copy of the booklet then it was estimated that over the following year some 28% fewer home visits and some 173% more out of hours consultations would have been undertaken for booklet symptoms than if none of the households had been sent a copy.

The Medical Outcomes Study Instrument (MOSI)--use of a new health status measure in Britain.

The Medical Outcomes Study Instrument (MOSI), a 20 item functional health status measure was sent to all women aged 30-40 years (n = 486) in a General Practice (list size 6447). There was a 73% response rate to two mailings. Lower scores on all six dimensions of the MOSI were associated with the number of diagnoses and identified mental illness on the patient summaries, unemployment and with positive scores on the Nottingham Health Profile. In two categories, General Health Perceptions and Mental Health, the scores were lower for those on long-term medication. The paper suggests that the MOSI may be a candidate for Health Status measurement in research and audit in primary care, but further research is required.

Questionnaire to measure perceived symptoms and disability in asthma.

A questionnaire was designed for completion by parents of asthmatic children aged from 5-14 years that provides scales of good content validity and internal reliability for the measurement of perceived disability, perceived nocturnal symptoms, and perceived daytime symptoms. We hope that this questionnaire will be included in future clinical studies of these patients.

Survey of general practitioners' advice for travellers to Turkey.

Fifty general practitioners replied to a survey of the advice that they would offer to a tourist planning a package holiday in western Turkey. The range of prophylactic immunizations and other medication recommended by the respondents was wide, suggesting that some tourists travel without adequate protection, while some receive unnecessary injections. Most of the doctors would offer little other health advice to the traveller. General practitioners receive conflicting guidance on prophylactics for travellers, and it is suggested that the disagreements should be resolved. Wider availability of written advice for the traveller would also be valuable.

Audit of process and outcome in a mini-clinic for children with asthma.

A mini-clinic for the management of children with asthma was started in a general practice, and 31 children aged between five and 14 years were invited to attend. Thirty-one age and sex matched asthmatics were recruited for comparison from a neighbouring practice. There was evidence of only slight improvement in outcome among the children attending the mini-clinic, although they required considerably more respiratory consultations than the children in the comparison practice. These observations, and the methodology, are discussed.

Factors affecting estimates of the prevalence of asthma and wheezing in childhood.

Nine recent studies of the prevalence of asthma and wheezing in childhood are reviewed. Sample prevalences are found to range from 5 to 31% and possible reasons for this are considered; it is shown that the prevalence of asthma found is highly dependent on the criteria used for diagnosis. Some clinical and research implications are discussed.

Clinical efficiency in general practice.

A major problem in primary care is that of matching resources to demands and needs. An important limiting resource is the doctor's time, and one approach to improving care is to increase the efficiency with which he uses that time. In this paper, clinical efficiency is defined, and problems in its measurement are identified. Although it can rarely be measured directly, indirect criteria for identifying a change in efficiency are considered.

Variation in peak expiratory flow in children with asthma.

Twice daily peak expiratory flow measurements were obtained at home from 65 asthmatic children and 34 non-asthmatic controls, and a measure of the daily variation in peak expiratory flow was calculated for each child (mean daily variation). Children aged less than 7.5 years appeared unable to provide reproducable peak expiratory flows, but above that age the mean of the mean daily variations was significantly higher for the asthmatics than the controls. This was true even on days when the asthmatics exhibited no wheeze or took no medication. The significance of the findings is discussed, and it is suggested that calculation of the mean daily variation might assist in the assessment of children presenting with atypical respiratory symptoms.

Wide variations in the night visiting rate.

The night visit record of an out-of-hours rota service of a large health centre which includes 10 group practices was examined. The mean annual night visiting rate for the health centre was 35.2 per 1000 patients, ranging from 25.8 to 43.5 between individual practices. The organization of medical care at night was the same for all the practices, and no major demographic differences between practices were identified. It is argued that the doctor-patient relationship may have an influence on differences in night visiting rates.

Factors related to first dose hypotensive effect of captopril: prediction and treatment.

The blood pressure response to the first dose of captopril (6.25 mg, 12.5 mg, or 25 mg) was measured in 65 treated, severely hypertensive patients. Mean supine blood pressure was 187/108 mm Hg immediately before captopril was given. Twenty one patients experienced a fall in supine systolic pressure greater than 50 mm Hg, including five whose pressure fell more than 100 mm Hg and two whose pressure fell more than 150 mm Hg. Six patients developed symptoms of acute hypotension, including dizziness, stupor, dysphasia, and hemiparesis. Percentage reductions in blood pressure were greatest in those with secondary hypertension (p less than 0.05), high pretreatment blood pressure (p less than 0.05), and high concentrations of plasma renin and angiotensin II (p less than 0.01). No significant correlation was found between fall in blood pressure and serum sodium concentration, age, renal function, and the dose of captopril given. A severe first dose effect cannot be consistently predicted in individual patients who have received other antihypertensive drugs for severe hypertension. Such patients should have close medical supervision for at least three hours after the first dose of captopril.

The mechanical properties of human motor units with special reference to their fatiguability and recruitment threshold.

The recruitment thresholds, twitch tension, twitch contraction time and fatiguability of human motor units have been studied in the first dorsal interosseous of the hand. Units recruited at contraction strengths less than 50 g had relatively low twitch tensions (0.18-1.9 g), long contraction times (59-146 msec) and were non-fatiguable. Units recruited at higher contraction strengths (less than 200 g) had higher twitch tensions (15-26g), faster contraction times (33-57 msec) and were highly fatiguable. It is concluded that during graded voluntary muscle contractions motor units are recruited in order of increasing contraction strength and diminishing fatigue resistance.