Objective: To determine whether there is equivalence
in the competence of GPs and hospital doctors to
perform a range of elective minor surgical procedures,
in terms of the safety, quality and cost of care.
Design: A prospective randomised controlled
equivalence trial was undertaken in consenting patients
presenting at general practices and needing minor
surgery.
Setting: The study was conducted in the south of
England.
Participants: Consenting patients presenting at
general practices who needed minor surgery in
specified categories for whom the recruiting doctor felt
able to offer treatment or to be able to refer to a
colleague in primary care.
Interventions: On presentation to their GP, patients
were randomised to either treatment within primary
care or treatment at their local hospital. Evaluation was
by assessment of clinical quality and safety of outcome,
supplemented by examination of patient satisfaction
and cost-effectiveness.
Main outcome measures: Two independent observers
assessed surgical quality by blinded assessment of wound
appearance, between 6 and 8 weeks postsurgery, from
photographs of wounds. Other measures included
satisfaction with care, safety of surgery in terms of
recognition of and appropriate treatment of skin
malignancies, and resource use and implications.
Results: The 568 patients recruited (284 primary care,
284 hospital) were randomised by 82 GPs. In total, 637
skin procedures plus 17 ingrowing toenail procedures
were performed (313 primary care, 341 hospital) by 65
GPs and 60 hospital doctors. Surgical quality was
assessed for 273 (87%) primary care and 316 (93%)
hospital lesions. Mean visual analogue scale score in
hospital was significantly higher than that in primary
care [mean difference = 5.46 on 100-point scale; 95%
confidence interval (CI) 0.925 to 9.99], but the clinical
importance of the difference was uncertain. Hospital
doctors were better at achieving complete excision of
malignancies, with a difference that approached
statistical significance [7/16 GP (44%) versus 15/20
hospital (75%),
2
= 3.65, p = 0.056]. The proportion
of patients with post-operative complications was
similar in both groups. The mean cost for hospitalbased minor surgery was £1222.24 and for primary
care £449.74. Using postoperative complications as an
outcome, both effectiveness and costs of the
alternative interventions are uncertain. Using
completeness of excision of malignancy as an outcome,
hospital minor surgery becomes more cost-effective.
The 705 skin procedures undertaken in this trial
generated 491 lesions with a traceable histology report:
36 lesions (7%) from 33 individuals were malignant or
premalignant. Chance-corrected agreement (kappa)
between GP diagnosis of malignancy and histology was
0.45 (95% CI 0.36 to 0.54) for lesions and 0.41 (95%
CI 0.32 to 0.51) for individuals affected by malignancy.
Sensitivity of GPs for detection of malignant lesions was
66.7% (95% CI 50.3 to 79.8) for lesions and 63.6%
(95% CI 46.7 to 77.8) for individuals affected by
malignancy.
Conclusions: The quality of minor surgery carried out
in general practice is not as high as that carried out in
hospital, using surgical quality as the primary outcome,
although the difference is not large. Patients are more
satisfied if their procedure is performed in primary
care, largely because of convenience. However, there
are clear deficiencies in GPs’ ability to recognise
malignant lesions, and there may be differences in
completeness of excision when compared with hospital
doctors. The safety of patients is of paramount
importance and this study does not demonstrate that
minor surgery carried out in primary care is safe as it is
currently practised. There are several alternative
models of minor surgery provision worthy of
consideration, including ones based in primary care that
require all excised tissue to be sent for histological
examination, or that require further training of GPs to
undertake the necessary work. The results of this study
suggest that a hospital-based service is more costeffective. It must be concluded that it is unsafe to leave
minor surgery in the hands of doctors who have never
been trained to do it. Further work is required to
determine GPs’ management of a range of skin
conditions (including potentially life-threatening
malignancies), rather than just their recognition of them.
Further economic modelling work is required to look at
the potential costs of training sufficient numbers of GPs
and GPs with special interests to meet the demand for
minor surgery safely in primary care, and of the
alternative of transferring minor surgery large-scale to
the hospital sector. Different models of provision need
thorough testing before widespread introduction
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