How should GPs be paid? We need evidence that can underpin fundamental change.

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Aid to diagnosis of melanoma in primary medical care

To evaluate an intervention designed to reduce the number of benign melanocytic lesions excised from the skin.A randomised controlled field trial based in the medical practices of two cities. Examination of histopathological reports of 5823 melanocytic skin lesions excised over the intervention period and in the preceding six months.Medical practitioners were offered an algorithm and use of an instant developing camera.Over 50 medical practitioners, mostly in general practice, in each of two cities in tropical Queensland, Australia.Percentages of benign (neither malignant nor potentially malignant) melanocytic lesions excised during the two year intervention period.There were no significant differences in the percentages of benign lesions reported in the intervention and control cities before the intervention started (93.6% and 94.0%, respectively), but there was a significant difference afterwards (88.8% and 93.8%, P < 0.001). There was no difference in the percentage of invasive melanomas excised per month in the intervention city (3.4%) compared with control city (3.4%).Clinical diagnostic accuracy may be enhanced by offering to clinicians managing suspicious melanocytic skin lesions a simple algorithm and a camera with which to record the appearance of lesions objectively

Can GPs co-operate after hours in a competitive urban environment?

Before designing an intervention aimed at improving the quality of after-hour general practice services to the residents of a relatively isolated outer suburb of Brisbane, a survey of 247 residents was conducted to assess the provisions of after-hours care. The results of the survey were presented to the suburb's general practitioners (GPs). Meetings with the GPs led to attempts at improved communication, using patient-held Health Summary Cards and doctor-to-doctor clinical feedback forms. Forty-four per cent of the 27 GPs participated in the co-operative scheme. One year later the community was resurveyed to assess the impact of the changes in medical services. There was a small but insignificant increase in satisfaction with the provision of after-hours care from 45% to 48%

The skin cancer workload in Australian general practice.

Skin cancer is common in Australia. It is managed in large portion within general practice, and early excision usually affords cure, therefore, it may form a much greater workload for general practitioners (GPs) than incidence figures would imply. The aim of this study was to describe the skin cancer workload in Australian general practice.Analysis of data recorded by 495 randomly selected GPs relating to 113,468 consultations (98,796 weighted for State size), which were collected as part of a national descriptive study. Medicare and census data were used to calculate rates at which GPs were consulted for different conditions.Skin tumours accounted for 2,083 (1.5%) of all 145,799 problems managed in 98,796 encounters. Annual rates at which GPs were consulted were: 13/1,000 people for 'malignant' tumours of the skin; 23/1,000 for 'naevus/mole; and 13/1,000 for 'other benign' lesions. The rates of diagnoses of 'malignant skin neoplasms' increased with age to a maximum among women and men aged 65 years or more of > 80/1,000 and > 100/1,000, respectively. For 'naevus/mole' the rates of maximum diagnoses were 40/1,000 for women and 351/1,000 for men aged 15-24 years. There was no sex difference for the maximal rate (15/1,000) among the 45-64 age groups for 'other benign skin lesions'. The main form of management was procedural for malignant skin lesions (90% of consultations) and naevi/moles (50%). Referral to specialist services was most common during consultations for malignant disease (22% of consultations), in comparison to naevi/moles (15%) and other benign skin neoplasms (9%). Procedures (cryotherapy, diathermy and excision) and referrals were more common for malignant lesions and naevi/moles.There were important differences in age distribution for rates of management of benign and malignant skin tumours and naevi. Skin tumours usually were managed in conjunction with other problems. Most were managed procedurally. Only a minority were referred. Skin cancer represents a greater workload for Australian GPs than suggested by previous incidence reports

Notifying women of the results of their cervical smear tests by mail: Does it result in a decreased loss to follow-up of abnormal smears?

We undertook a prospective randomised intervention study of the proportions of women with abnormal cytology results who were lost to follow-up in 42 general practices in urban and rural Queensland over 26 weeks. Practices in the intervention group were provided with a redesigned cervical smear request form that allowed patients to provide an address for direct notification from the laboratory by mail. Satisfaction questionnaires sent to the general practitioners in the intervention group showed that most made at least some use of direct notification, and most felt it was worthwhile. For women with an initial result of cervical intraepithelial neoplasia (CIN), there was a loss to follow-up of 23 per cent (95 per cent confidence interval (CI) 11 to 39) among the control group compared to none in the intervention group (upper CI 7 per cent), a highly significant difference (P < 0.001). Mailing cervical screening results to women may reduce the loss to follow-up of those with CIN findings

Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis

Objective: To determine the effect of antibiotic treatment for acute otitis media in children. Design: Systematic search of the medical literature to identify studies that used antibiotics in randomised controlled trials to treat acute otitis media. Studies were examined blind, and the results of those of satisfactory quality of methodology were pooled. Subjects: Six studies of children aged 7 months to 15 years. Main outcome measures: Pain, deafness, and other symptoms related to acute otitis media or antibiotic treatment. Results: 60% of placebo treated children were pain free within 24 hours of presentation, and antibiotics did not influence this. However, at 2-7 days after presentation, by which time only 14% of children in control groups still had pain, early use of antibiotics reduced the risk of pain by 41% (95% confidence interval 14% to 60%). Antibiotics reduced contralateral acute otitis media by 43% (9% to 64%). They seemed to have no influence on subsequent attacks of otitis media or deafness at one month, although there was a trend for improvement of deafness at three months. Antibiotics were associated with a near doubling of the risk of vomiting, diarrhoea, or rashes (odds ratio 1.97 (1.19 to 3.25)). Conclusions: Early use of antibiotics provides only modest benefit for acute otitis media: To prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early. There is wide variation in the use of antibiotics for early treatment of acute otitis media in children, and we examined the literature by meta-analysis to establish what benefits or harm antibiotics provide Antibiotics did not influence resolution of pain within 24 hours of presentation, though at 2-7 days after presentation, by which time only 14% of children in control groups still had pain, early use of antibiotics reduced the risk of pain by about 40% Antibiotics also reduced contralateral acute otitis media but seemed to have little influence on subsequent attacks of otitis media or deafness Antibiotics were associated with a near doubling of the risk of vomiting, diarrhoea, or rashes Early use of antibiotics provides only modest benefit for acute otitis media: To prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early

Antibiotics for sore throat.

Sore throat is a very common reason for people to attend for medical care. Sore throat is a disease that remits spontaneously, that is, 'cure' is not dependant on treatment. Nonetheless primary care doctors commonly prescribe antibiotics for sore throat and other upper respiratory tract infections.To assess the benefits of antibiotics in the management of sore throat.Systematic search of the literature from 1945 to 1999, using electronic searches of MEDLINE (using the keywords, "pharyngitis", "sore throat" and "tonsillitis") after 1966, the Cochrane Library, the Cochrane collection of hand-searched trials, and the reference sections of the articles identified. Abstracts of identified articles were used to determine which studies were trials.Trials of antibiotic against control with either measures of the typical symptoms (throat soreness, headache or fever), or complications (suppurative and non-suppurative) of sore throat.RevMan 4.0.3A total number of 10,484 cases of sore throat have been studied. 1. Non-suppurative complications There was a trend for protection against acute glomerulonephritis by antibiotics, but insufficient cases were recorded to be sure of this effect. Several studies found benefit from antibiotics for acute rheumatic fever, which reduced this complication to less than one third (OR = 0.30; 95% CI = 0.20-0.45). 2. Suppurative complications Antibiotics reduced the incidence of acute otitis media to about one quarter of that in the placebo group (OR = 0.22; 95% CI = 0.11-0.43) and reduced the incidence of acute sinusitis to about one half of that in the placebo group (OR = 0.46; 95% CI = 0.10-2.05). The incidence of quinsy was also reduced in relation to placebo group (OR = 0.18; 95% CI = 0.08-0.43). 3. Symptoms Symptoms of headache, throat soreness and fever were reduced by antibiotics to about one half. The greatest time for this to be evident was at about three and a half days (when the symptoms of about 50% of untreated patients had settled). About 90% of treated and untreated patients were symptom-free by one week. 4. Subgroup analyses of symptom reduction Subgroup analysis by age; blind vs unblinded; us of antipyretics; or results of swabs for Streptococcus yielded no significant differences.Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics who will derive no benefit. Antibiotics shorten the duration of symptoms, but by a mean of only about half of one day at day 3 (the time of maximal effect), and by about eight hours overall