Referral to hospital in Nepal: 4 years' experience in one rural district

Formal referral systems have been proposed as a strategy to improve access to secondary care, yet their implementation can be problematic. This paper describes data from referrals in one rural district in Nepal over a four year period. Whilst the characteristics of those patients attending hospital after referral were similar to those described in other developing countries, the rate (1.0 per 1,000 population per year) is much lower, especially when compared to estimated need. Geographical and other barriers to access to secondary care in rural Nepal are discussed

Gatekeeping in Health Care

We study the competitive effects of restricting direct access to secondary care by gatekeeping, focusing on the informational role of general practitioners (GPs). In the secondary care market there are two hospitals choosing quality and specialisation. Patients, who are ex ante uninformed, can consult a GP to receive an (imperfect) diagnosis and obtain information about the secondary care market. We show that hospital competition is amplified by higher GP attendance but dampened by improved diagnosing accuracy. Therefore, compulsory gatekeeping may result in excessive quality competition and too much specialisation, unless the mismatch costs and the diagnosing accuracy are sufficiently high. Second-best price regulation makes direct regulation of GP consultation redundant, but will generally not implement first-best.gatekeeping, imperfect information, quality competition, product differentiation, price regulation

Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes

Objective To investigate the impact of factors outside the control of primary care on performance indicators proposed as measures of the quality of primary care. Design Multiple regression analysis relating admission rates standardised for age and sex for asthma, diabetes, and epilepsy to socioeconomic population characteristics and to the supply of secondary care resources. Setting 90 family health services authorities in England, 1989-90 to 1994-5. Results At health authority level socioeconomic characteristics, health status, and secondary care supply factors explained 45% of the variation in admission rates for asthma, 33% for diabetes, and 55% for epilepsy. When health authorities were ranked, only four of the 10 with the highest age-sex standardised admission rates for asthma in 1994-5 remained in the top 10 when allowance was made for socioeconomic characteristics, health status, and secondary care supply factors. There was also substantial year to year variation in the rates. Conclusion Health outcomes should relate to crude rates of adverse events in the population. These give the best indication of the size of a health problem. Performance indicators, however, should relate to those aspects of care which can be altered by the staff whose performance is being measured

Evaluation of the primary/secondary care interface in relation to a primary care rheumatology service

Objective The rheumatology department at The Royal Oldham Hospital developed a primary care service aimed at bridging the gap between primary and secondary care for patients with potential rheumatological conditions, and this was given the name rheumatology Tier 2. The objective of this study was to evaluate this primary care rheumatology service (Tier 2)in order to assess its validity, patient satisfaction and effectiveness. Design Ten patients participated in individual semi-structured interviews. Three GPs were interviewed individually, and two GPs formed a focus group. Thematic analysis was used to interpret the findings. Setting Patients were recruited from seven consecutive rheumatology Tier 2 clinics. GPs were recruited from Oldham Primary Care Trust (PCT) as this was the main source of patient referrals for the service. Results The key findings were in relation to the integration of primary healthcare and hospital services, i.e. the primary/secondary care interface. This highlighted the importance of early assessment, diagnosis and treatment of patients with suspected inflammatory arthritis. Conclusion Early diagnosis and treatment with disease-modifying anti-rheumatic drugs improves patients’ outcomes. The rheumatology Tier 2 service built on this evidence and provided a rapid assessment and referral to secondary care for those patients with suspected inflammatory arthritis

Gatekeeping in health care

We study the competitive effects of restricting direct access to secondary care by gatekeeping, focusing on the informational role of gatekeeping general practitioners (GPs). We consider a secondary care market with two hospitals choosing the quality and specialisation of their care. GPs perfectly observe the diagnosis of a patient and the exact characteristics of the secondary care market. Patients are either informed or uninformed when accessing the hospital market. We consider two distinct cases: first, we let the fraction of informed patients be exogenous, implying that the regulator can only influence patients' decision of consulting a GP by making this compulsory ('direct gatekeeping'). Second, we endogenise this fraction by assuming GP consultation to be costly for the patient. Then the reulator can influence the GP attendance rate through the regulated price ('indirect gatekeeping'). A main finding of the paper is that strict gatekeeping may not be socially desirable, even if it is costless.Gatekeeping; Imperfect information; Quality competition; Product differentiation; Price regulation

Patient and practitioner views of a new rheumatology (Tier 2) primary care service

The rheumatology Tier 2 service in Oldham was implemented to see patients in a primary care setting for their initial assessment. They were treated and discharged within the service, or referred on to secondary care in order to limit inappropriate attendance in secondary care and fast-track patients with inflammatory disease to the rheumatology consultant. The aim of this study was to evaluate patients’ and general practitioners’ (GPs’) views about the transfer of rheumatological services from secondary to primary care. Patients and GPs were from a single primary care trust in Oldham, north west England. A thematic analysis of interview data was taken, and findings showed high patient satisfaction with the service, favouring the primary care environment to a hospital setting. GPs reported on cost-effectiveness of the service and better management of the disease. The Tier 2 service has the potential to set a new direction for multiagency care within a primary care setting

High INR on warfarin

The bottom line Clarify the warfarin dose that the patient is taking, and check for co-existing problems (such as liver disease or cancer), dietary changes, and intake of alcohol and other drugs that may increase risk of bleeding or affect international normalised ratio control. Urgently refer all patients with suspected intracranial or gastrointestinal bleeding to secondary care

Commentary : controversies in NICE guidance on lipid modification for the prevention of cardiovascular disease

The new guidelines from the National Institute for Health and Clinical Excellence (NICE) on lipid modification for the prevention of cardiovascular disease will guide the way we assess cardiovascular risk and treat lipids, both in primary and in secondary care. What are the new aspects, and what is it that might spark controversy in this new publication

Assessment and Management of Suicide Risk in Primary Care

Abstract Background Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. Aim To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Method Data collection from clinical proformas, case records, and semi-structured face–to-face interviews with general practitioners. Results Primary and secondary care data was available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall kappa = 0.127; p = 0.10). Depression, care setting (post discharge), suicidal ideation at last contact and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices and 33% of staff received training in suicide risk assessments. Conclusion Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care

An evaluation of the Wallasey Heart Centre

This project report discusses an evaluation of Wallasey Heart Centre, an intermediate cardiovascular clinic designed to provide accessible high-quality patient care to an area with a high prevalence of of coronary heart disease and poor access to existing secondary care services. The service began in October 2000 with funding for three years. The views of local GPs, local cardiologists, and Wallasey Heart Centre staff and patients were sought