[Analysis of a programme of direct referral between primary and specialist care in potential surgery patients]

Exérese de lipoma gigante na Clínica da Família: um relato de caso

A realização de procedimentos cirúrgicos na Unidade Básica de Saúde é preconizada e descrita na literatura. No entanto, tal prática vem sendo cada vez menos aplicada na atenção primária. Em um contexto de superlotações de hospitais terciários e consequente inoperação de cirurgias eletivas, é de extrema importância a realização desses procedimentos na Clínica da Família. Nesse trabalho, apresenta-se um caso de um paciente submetido à exérese de lipoma gigante incapacitante, na fossa poplítea esquerda, com 12 anos de evolução e com tentativa frustrada de resolução cirúrgica em um hospital terciário.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

Minor surgery activity in primary care

OBJECTIVE

The aim of this study was to describe the activity in our Outpatient Minor Surgery unit during its first five-year period.

DESIGN

Retrospective descriptive study.

METHODS

It was carried out in two centres of a Basic Health Area with a catchment area of 73,000 inhabitants.

PARTICIPANTS

Patients who underwent surgery from January 2002 to December 2007 were included in the research.

MAIN OUTCOME MEASURES

Information on the sociodemographic data of the patients, characteristics of the lesions, risk factors, treatment and its complications was gathered.

RESULTS

A total of 2317 surgical procedures was performed on 1520 patients. The mean was 46 years old and 52% were men. The concordance between clinical and anatomopathological diagnosis was 81%. There were complications in 5% of them. The main pathologies were: epidermoid cysts (22%), nevus (20%) and fibromas (18%). They were mainly located in the back (24%), superior extremities (14%) and head (11%). In 73% mepivicaine was used as anaesthetic. The most current techniques used were: incision (36%), curettage (33%) and fusiform excision (28%). Less than 1% had malignant lesions, 50% of which were not diagnosed clinically. The mean waiting time was 30 days. Ninety-two percent had the informed consent.

CONCLUSIONS

Minor surgery in primary care is feasible and has a good clinicopathological concordance and minimum complications, but some malignant lesions are overlooked in the diagnosis based exclusively on clinical criteria.

Can guidelines improve referral to elective surgical specialties for adults? A systematic review

Aim

To assess effectiveness of guidelines for referral for elective surgical assessment.

Method

Systematic review with descriptive synthesis.

Data sources

Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.

Selection of studies

Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults.

Outcome measures

Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs.

Results

24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change.

Conclusions

Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.

Limited options: a report on GP access to services

BACKGROUND

The Structure of Irish General Practice over 23 years was the third in a series of national studies that examined the development of general practice in 1982, 1992, and 2005.

AIMS

This study analysed specific data from the 2005 survey to determine the types of services offered by GPs, and to examine the changes in access to diagnostic/treatment services from 1982 to 2005.

METHODS

A questionnaire was sent to a stratified random sample of Irish GPs seeking information on their practice.

RESULTS

476 (87%) valid questionnaires were returned. The range of services offered by GPs had increased. Access to diagnostic/treatment services was limited, and varied considerably depending on the type of practice. Access to chest X-rays and skeletal X-rays had decreased.

CONCLUSIONS

Access to existing services must be increased, and significant resources must be put into the development of dedicated primary care services.

[Improving communication between levels of health care: direct referral of patients to a one-stop service for major outpatient surgery]

OBJECTIVE

To analyze the results obtained with a "one-stop" specialty service designed as part of a collaborative program involving primary and specialized care in order to improve communication between levels of care and reduce the delay in referral and surgical treatment for patients eligible for outpatient surgery.

DESIGN

Prospective, descriptive, longitudinal study.

SETTING

Major Outpatient Surgery Unit of the Hospital Clinico San Carlos and health centers serving Health Area 7 in Madrid, central Spain.

PARTICIPANTS

Patients more than 14 years of age with a surgical condition involving the abdominal wall, pilonidal sinus, soft-tissue tumor, or proctological disease.

INTERVENTION

Direct referral, with completed preoperative work-up, of patients from health centers to the Major Outpatient Surgery Unit of the Hospital Clinico San Carlos according to a protocol developed by consensus. The patient is seen on the same day for surgical work-up and anesthesia work-up, and is given preoperative information. Patients then make only one further visit to the hospital to undergo surgery.

MAIN MEASURES

Number of patients with each diagnosis referred, diagnostic concordance between the health center and hospital, delay from referral to surgical treatment, number of trips made for different appointments, and referral rate.

RESULTS

A total of 188 patients were referred. More than two thirds (68.7%) had an abdominal wall condition eligible for direct referral. Diagnostic concordance was 96%. The delay from referral until surgery was reduced by 60%, and the number of trips for appointments was reduced by 66.6%. The overall referral rate was 12.6%.

CONCLUSIONS

Because of its feasibility, acceptability, and cost-efficiency, the direct referral system has the potential to improve relations between primary and specialized care and enhance the quality of care by shortening the delay to treatment.

[Programme to introduce and develop minor out-patient surgery in primary care]

INTRODUCTION

Despite the priority placed on it, minor surgery is not performed enough in primary care (PC).

OBJECTIVE

To create and evaluate a programme to introduce and develop minor out-patient surgery in primary care in a way that matches our health areas needs.

DESIGN

Prospective, longitudinal and descriptive study.

SETTING

Health Area 19 (Valencian Health Service): Surgery Department of Elche Hospital and 3 health centres (HC) (Altabix, Crevillente and Santa Pola).

PARTICIPANTS

PC doctors and specialist surgeons. STAGES: a) Selection of HC. Working out protocol of kind of patient, pathology, paper-work and establishment of work circuits; b) surgical sessions at the HC, performed by two surgeons assisted by PC doctors (surgical leaders) and with surgical instruments from the hospital; c) surgery performed by PC doctors supervised by a surgeon, with instruments and the sterilisation circuit in the HC. The programme ends up with the PC doctors surgical autonomy and with use of the HCs own resources.

RESULTS

41 surgical sessions took place (14 in Altabix, 14 in Crevillente and 13 in Santa Pola). 335 patients were operated on in 398 surgical procedures (55.5% excisions, 34.9% electrocoagulation, 9.6% others). There were no immediate complications. The monthly evolution in the number of patients was constant, with a mean of 10.22 interventions per session. 36 doctors referred patients and 24 of them performed a surgical procedure.

CONCLUSIONS

A practical and safe programme to introduce and develop minor surgery in PC, to the satisfaction of doctors and patients.