General practitioners and hospitals. Continuity of care. Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost. Same information, different decisions: the influence of evidence on the management of hypertension in the elderly. Randomized controlled trial of general practitioner versus usual medical care in a suburban accident and emergency department using an informal triage system. Improving the use of early follow-up care after emergency department visits. A randomized trial. An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Can small group education and peer review improve care for patients with asthma/chronic obstructive pulmonary disease? Humanistic outcomes in the hypertension and COPD arms of a multicenter outcomes study. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial.
The study aimed to improve continuity of care for patients undergoing major gynaecological surgery, by increasing their general practitioners' contact with the hospital and providing a comprehensive discharge summary.
                Prospective randomised study of 200 patients admitted to a gynaecological oncology ward, and their GPs. Visits and telephone calls by GPs to hospital during their patients' admission were measured, with and without invitation and offer of payment for contact. A discharge summary was distributed. Postdischarge questionnaires surveyed patient satisfaction with care, confidence in future management by the GPs, and GP confidence in continuing patient care.
                Significant increases in contact rates by the GPs followed invitation. The discharge summary was not effectively distributed. No significant differences in patient satisfaction and confidence in future management by their GPs were found. General practitioners valued hospital contact most in meeting their patients' needs for information.
                Personal invitation increases GP contact with hospitals. While no statistically significant improvements in patient satisfaction or GP confidence were shown, the data suggested that GPs value contact to meet patient information needs. To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.
                A randomised controlled trial.
                A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.
                All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.
                Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.
                4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively.
                General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. Evidence-based medicine requires general practitioners (GPs) to act upon the results of clinical trials. Clinical trial evidence may be difficult to understand and apply in practice.
                To investigate whether GPs were unduly influenced in managing hypertension in the elderly by the ways in which benefits of trial results were presented, and to establish whether their current treatment of an elderly hypertensive patient was broadly in line with recent clinical trial evidence.
                Seventy-three GPs attending a refresher course were given a written questionnaire containing data from one clinical trial of treatment of hypertension in the elderly presented in four different ways (absolute risk reduction, relative risk reduction, difference in event-free patients, and number of patients who had to be treated in order to prevent one clinical event), as if from four different trials. The effect of each presentation on treatment preferences was assessed using Likert scales. The results were analysed to determine whether the method of presentation of results influenced decision making. A clinical scenario was presented to investigate their current treatment preferences in an elderly hypertensive.
                All GPs returned completed questionnaires. Relative risk reduction was the only presentation which was significantly different from the others, and was the most likely to influence prescribing. In free-text comments, 75% of GPs admitted having problems understanding statistics commonly found in medical journals. More than 90% conformed with recent clinical trial evidence for the management of hypertension.
                GPs were most influenced by relative risk reduction, and were unaware of how the presentation of research results could affect treatment decisions. Most GPs freely admitted to difficulty in comprehending medical statistics. Almost all of the GPs expressed treatment decisions which were broadly in line with clinical evidence. We determined if care provided by general practitioners (GPs) to non-emergency patients, in a suburban accident and emergency (A&E) department using an informal triage system, differs significantly from care provided by usual A&E staff. One thousand eight hundred and seventy-eight patients participated. By comparison with usual A&E staff, GPs prescribed significantly more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the first study to report that sessional GPs working in an A&E department utilize similar or more resources than usual A&E staff. It emphasizes the need for the continued audit of initiatives that have been introduced into new settings. To test the hypothesis that the appropriateness of parents' use of early follow-up care after emergency department (ED) visits can be improved by postvisit support from a nurse practitioner.
                Randomized controlled trial, single blinded.
                Urban university hospital ED linked to hospital's primary care center.
                Parents of 190 children younger than 8 years who sought care in the ED for acute illnesses and who were treated as outpatients with primary care center follow-up at the discretion of ED clinicians.
                Parents in the experimental group were called by a nurse practitioner who offered both individualized guidance regarding follow-up and access to a nurse practitioner for further help as needed. The control group received "usual" follow-up advice during ED visits.
                In the week after the ED visits, parents in the experimental group, compared with parents in the control group, were more compliant with instructions regarding follow-up (79% vs 61%), less apt to miss appointments (15% vs 31%), and less apt to "shop" elsewhere for care (2% vs 9%). Appropriateness of follow-up was assessed in "blinded" fashion using preestablished guidelines. Inappropriate use of follow-up care was significantly reduced among experimental group subjects (10% vs 20%).
                The nurse practitioner's intervention improved parents' use of follow-up care in our sample. Overall care for episodic ED users might be improved by similar interventions. Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes.
                A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both.
                Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001).
                Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings. To study the effectiveness of an intensive small group education and peer review programme aimed at implementing national guidelines on asthma/chronic obstructive pulmonary disease (COPD) on care provision by general practitioners (GPs) and on patient outcomes.
                A randomised experimental study with pre-measurement and post-measurement (after one year) in an experimental group and a control group in Dutch general practice.
                Two groups of GPs were formed and randomised. The education and peer review group (17 GPs with 210 patients) had an intervention consisting of an interactive group education and peer review programme (four sessions each lasting two hours). The control group consisted of 17 GPs with 223 patients (no intervention).
                Knowledge, skills, opinion about asthma and COPD care, presence of equipment in practice; actual performance about peakflow measurement, non-pharmacological and pharmacological treatment; asthma symptoms (Dutch Medical Research Council), smoking habits, exacerbation ratio, and disease specific quality of life (QOL-RIQ). Data were collected by a written questionnaire for GPs, by self recording of consultations by GPs, and by a written self administered questionnaire for adult patients with asthma/COPD.
                Data from 34 GP questionnaires, 433 patient questionnaires, and recordings from 934 consultations/visits and 350 repeat prescriptions were available. Compared with the control group there were only significant changes for self estimated skills (+16%, 95% confidence interval 4% to 26%) and presence of peakflow meters in practice (+18%, p < 0.05). No significant changes were found for provided care and patient outcomes compared with the control group. In the subgroup of more severe patients, the group of older patients, and in the group of patients not using anti-inflammatory medication at baseline, no significant changes compared with the control group were seen in patient outcomes.
                Except for two aspects, intensive small group education and peer review in asthma and COPD care do not seem to be effective in changing relevant aspects of the provided care by GPs in accordance with guidelines, nor in changing patients' health status. To evaluate the effects of pharmaceutical care on selected humanistic outcomes in patients with hypertension or chronic obstructive pulmonary disease (COPD).
                Clinic patients with hypertension or COPD were randomly assigned to a treatment group (pharmaceutical care) or a control group (traditional pharmacy care) over a six-month period. Clinical pharmacists and pharmacy residents conducted the protocols. There were 133 evaluable patients (63 treatment, 70 control) in the hypertension study arm and 98 evaluable patients (43 treatment, 55 control) in the COPD study arm. The Pharmaceutical Care Questionnaire evaluated patient satisfaction with care. Tests specific to the disease states assessed disease and disease management knowledge. Quality of life (QOL) was evaluated using the Health Status Questionnaire 2.0 (HSQ 2.0) in the COPD arm; in the hypertension arm, the Hypertension/Lipid TyPE Specification Form 5.1 was used.
                Ambulatory care centers of 10 Department of Veterans Affairs (DVA) medical centers and 1 university medical center.
                Patient-centered pharmaceutical care model (employing standardized care) implemented by clinical pharmacy residents.
                Satisfaction with pharmaceutical care, disease and disease management knowledge, and QOL.
                Statistically significant differences in most satisfaction items were found, with treatment patients expressing greater satisfaction. Treatment groups in both arms strongly agreed that pharmacists helped them with confidence in use of their medication and understanding of their illness, gave complete explanations about their medications, made them feel that their care was a priority, and followed up on their questions and concerns. In the hypertension arm, treatment patients demonstrated significant increases in knowledge scores. Trends in QOL were positive for both hypertension groups, with a significant decrease found in number of treatment patients reporting problems with sexual function. In the COPD arm, improvement trends were significantly stronger for treatment patients.
                Although patients were not dissatisfied with traditional pharmacy care, they were more satisfied overall with the pharmaceutical care model. Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.
                Inner-city academic general internal medicine practice.
                Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.
                During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.
                Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.
Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.