The demand for surgery: an analysis of referrals from Australian general practitioners (original) (raw)
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BMC health services research, 2004
The interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties. A three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plu...
IOSR Journals , 2019
This hospital based study was conducted to determine the profile of patients coming to the general surgery outpatient department (OPD) of a tertiary care hospital. Demographic details, morbidity profile, investigations done, treatment rendered and the clinical outcomes of patients were evaluated. The difference in the rate of employment between male and female patients was statistically highly significant (X2=45.04, p<0.01). Abdominal pain was the main presenting symptom with 13 (11.82%) of the patients presenting with burning epigastric pain, 11 (10%) with hypochondriac pain while 5 (4.55%) presenting with right iliac fossa pain. An ultrasound of the abdomen and pelvis was the most common investigation ordered ie, for 36 (32.72%) patients. Gastritis was the commonest diagnosis ie, in 14 (12.72%) patients followed by hernia in 13 (11.71%) patients and cholelithiasis in 11 (10%) patients. 22 (20%) patients had diabetes followed by 9 (8.18%) who had hypertension. 46 (41.82%) patients developed complications after treatment which included surgical site infections, urinary tract infections and paralytic ileus. 22 (20%) patients had diabetes followed by 9 (8.18%) who had hypertension while 8 (7.27%) had both diabetes and hypertension. The difference in the rates of complications amongst those who have co-morbidities and amongst those who do not is statistically significant (X2=7.87, p=0.005).
New Zealand general practitioners' non-urgent referrals to surgeons: who and why?
The New Zealand medical journal, 2008
To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment. During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral. 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in ...
Health service reconfigurations may result in increasing numbers of minor surgical procedures migrating from secondary care in hospitals to primary care in the community. Procedures may be performed by General Practitioners with a specialist interest in Surgery, or secondary care Surgeons who are sub-contracted to perform procedures in the community. Surgical training in such procedures, which are currently hospital based, may therefore be adversely affected unless surgical training also takes advantage of these opportunities. There is potential for surgical trainees to benefit from training in the community setting. ASiT supports the development of formal surgical training in the community setting for junior surgical trainees, providing high standards of patient care and training provision are ensured. Anticipated problems relating to the migration of surgical services to the community relate to the availability and quality assurance of training opportunities in primary care, its funding, including exposure to issues of indemnity cover for trainees, and also the release of surgical trainees from hospital duties in order to attend these training opportunities. These consensus recommendations set out a framework through which both patient care and training remain at the forefront of these continued service reconfigurations.
BMJ Open, 2015
Objectives: Increasing numbers of minor surgical procedures are being performed in the community. In the UK, general practitioners (family medicine physicians) with a specialist interest (GPwSI) in surgery frequently undertake them. This shift has caused decreases in available cases for junior surgeons to gain and consolidate operative skills. This study evaluated GPwSI's case-load, procedural training and perceptions of offering formalised operative training experience to surgical trainees.
Identification and characterisation of the high-risk surgical population in the United Kingdom
Critical Care, 2006
Introduction Little is known about mortality rates following general surgical procedures in the United Kingdom. Deaths are most common in the 'high-risk' surgical population consisting mainly of older patients, with coexisting medical disease, who undergo major surgery. Only limited data are presently available to describe this population. The aim of the present study was to estimate the size of the high-risk general surgical population and to describe the outcome and intensive care unit (ICU) resource use. Methods Data on inpatient general surgical procedures and ICU admissions in 94 National Health Service hospitals between January 1999 and October 2004 were extracted from the Intensive Care National Audit & Research Centre database and the CHKS database. High-risk surgical procedures were defined prospectively as those for which the mortality rate was 5% or greater. Results There were 4,117,727 surgical procedures; 2,893,432 were elective (12,704 deaths; 0.44%) and 1,224,295 were emergencies (65,674 deaths; 5.4%). A high-risk population of 513,924 patients was identified (63,340 deaths; 12.3%), which accounted for 83.8% of deaths but for only 12.5% of procedures. This population had a prolonged hospital stay (median, 16 days; interquartile range, 9-29 days). There were 59,424 ICU admissions (11,398 deaths; 19%). Among admissions directly to the ICU following surgery, there were 31,633 elective admissions with 3,199 deaths (10.1%) and 24,764 emergency admissions with 7,084 deaths (28.6%). The ICU stays were short (median, 1.6 days; interquartile range, 0.8-3.7 days) but hospital admissions for those admitted to the ICU were prolonged (median, 16 days; interquartile range, 10-30 days). Among the ICU population, 40.8% of deaths occurred after the initial discharge from the ICU. The highest mortality rate (39%) occurred in the population admitted to the ICU following initial postoperative care on a standard ward. Conclusion A large high-risk surgical population accounts for 12.5% of surgical procedures but for more than 80% of deaths. Despite high mortality rates, fewer than 15% of these patients are admitted to the ICU.
Can guidelines improve referral to elective surgical specialties for adults? A systematic review
Quality and Safety in Health Care, 2010
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 prereferral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.
Health services research in surgery—definitions, approaches and methods
Langenbeck's Archives of Surgery, 2008
Background and aims Health services research (HSR) investigates the translation of clinical studies into the practice of health care in relation to quality and efficiency from the individual and socioeconomic perspective. Given the fact that HSR has become increasingly popular during the last decade, this article aims at providing an overview of the significance and benefit of HSR in general and especially in the field of surgery. Results The first part of the overview provides various definitions that apply to the field, gives a brief historical overview of the development in Germany in contrast to the USA and Great Britain, and describes relevant theoretical frameworks and methods. In the second part it deals with gaps in patient care, patient-related outcomes, registry research, the integration of clinical and ambulatory surgery, and research on implementation of guidelines into practice. Conclusions This overview shows that HSR is by now regarded as an essential field, at least in developed countries, and that we are just at the beginning to understand why demonstrated effective strategies in the clinical context do not or rarely translate into routine patient's care.
Specialization and the Current Practices of General Surgeons
Journal of the American College of Surgeons, 2014
Background-The impact of specialization on the practice of general surgery has not been characterized. Our goal was to assess general surgeons' operative practices to inform surgical education and workforce planning. Study Design-We examined the practices of general surgeons identified in the 2008 State Inpatient and Ambulatory Surgery Databases of the Healthcare Cost and Utilization Project (HCUP) for three US states. Operations were identified using ICD-9 and CPT codes linked to encrypted physician identifiers. For each surgeon, total operative volume and the percentage of practice comprised of their most common operation were calculated. Correlation was measured between general surgeons' case volume and the number of other specialists in a health service area. Results-There were 1,075 general surgeons who performed 240,510 operations in 2008. The mean operative volume for each surgeon was 224 annual procedures. General surgeons performed an average of 23 different types of operations. For the majority of general surgeons, their most common procedure comprised no more than 30% of total practice. The most common operations, ranked by the frequency that they appeared as general surgeons' top procedure, included: cholecystectomy, colonoscopy, endoscopy, and skin excision. The proportion of general surgery practice comprised of endoscopic procedures inversely correlated with the number of gastroenterologists in the health service area (Rho =-0.50, p = 0.005). Conclusions-Despite trends toward specialization, the current practices of general surgeons remain heterogeneous. This indicates a continued demand for broad-based surgical education to allow future surgeons to tailor their practices to their environment.
Background: Up to 30-40% of emergency patients undergo surgery, which poses an increased risk of serious complications and death. The Royal College of Surgeons of England recently discussed the concerning variation in patient mortality after emergency surgery (e.g. 3.6% to 41.7%), and discussed poor support for trainees in some hospitals as a contributing factor. Newly qualified doctors are frequently responsible for evaluating patients when they arrive at emergency but non-rapid decision-making and referral to surgery can put patients at risk. Method: The naturalistic experiment design triangulated good versus poor working conditions for new doctors (e.g. staffing levels and training support derived from a random sample of hospitals’ quality data) against two independent variables from a national in-patient survey. These were emergency/nonemergency context and presence/absence of surgical procedures. The dependent variable was the rating of overall experience on a scale of 0-10 by a random sample of 1808 adult patients who spent at least one night in hospital. Results: A 2x2x2 univariate analysis of variance found a significant main effect of new doctors' working conditions, p = .012, a significant simple interaction of new doctors' working conditions and emergency context, p = .045, and a significant three-way interaction of new doctors' working conditions, emergency context and surgery, p = .03. Hospitals where new doctors have good working conditions have patients who report significantly better emergency surgical care. Conclusion: A pressing solution is inductions that improve new doctors’ diagnostic skills, to aid rapid decision-making about emergency patients who need referral to surgery.