The reliability of diagnosis using store-and-forward teledermatology.

We compared diagnoses made by a teledermatologist from digital photographs and patient histories sent from general practitioners using a store-and-forward technique and those made by another dermatologist in a face-to-face consultation with the same patients. A total of 117 patients (mean age 47 years) were referred by 18 general practitioners for diagnosis of a skin condition. Between one and seven digital images were transmitted per case. In 31% of the cases, three images were transmitted. There was full concordance between store-and-forward and face-to-face diagnoses in 57 of 106 cases (54%); in 10 cases (9%) there was overlap between the differential diagnoses provided by the teledermatologist and the face-to-face consultant. Diagnostic categories with relatively high concordances were eczema and follicular eruptions. General practitioners need to be trained in the making of digital images and in giving a good patient history.

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.

Patients at the outpatient rheumatology clinic: do they really need to be there?

BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.

[The value of joint general practitioner and rheumatologist consultations in primary care patients]. / De waarde van een gezamenlijk consult van huisartsen en reumatologen bij patiënten in de eerste lijn.

OBJECTIVE: To compare the effects of regular referral by general practitioners to the Rheumatology outpatients' clinic with that of joint consultations by general practitioners (GPs) and rheumatologists, and to compare the subsequent treatment policy followed. DESIGN: Randomised. METHOD: In 1999 and 2000 all rheumatological patients who, according to the 17 participating GPs in the Maastricht region had an indication for referral, were referred to the outpatients' clinic or seen during a joint consultation where three GPs and one rheumatologist decided on a treatment policy in the presence of the patient. Agreement about diagnosis and diagnostic and therapeutic approaches between the rheumatologists and GPs was determined using questionnaires. The patient's state of health was assessed using the 'EuroQol health-related quality of life questionnaire' (EuroQol) and their satisfaction was determined by means of questionnaires. RESULTS: One hundred and sixty-six patients were included: 45 (27%) men and 121 (73%) women, with an average age of 53.7 years (SD: 14). The rheumatologists and the GPs differed in opinion on the diagnosis in 64% of the patients. Agreement on diagnosis resulted in greater agreement on the treatment policy than when there were discrepancies about the diagnosis. The rheumatologist used additional diagnostic tools and follow-up consultations at the outpatient clinic (78% and 65%) more frequently than during the joint consultation (44% and 15%). Patient satisfaction and general state of health were comparable in both groups.

Joint consultation of general practitioner and rheumatologist: does it matter?

OBJECTIVE: To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. METHODS: All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. RESULTS: During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001). CONCLUSIONS: Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.