General practitioners and hospitals. Continuity of care. Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost. Same information, different decisions: the influence of evidence on the management of hypertension in the elderly.
The study aimed to improve continuity of care for patients undergoing major gynaecological surgery, by increasing their general practitioners' contact with the hospital and providing a comprehensive discharge summary.
                Prospective randomised study of 200 patients admitted to a gynaecological oncology ward, and their GPs. Visits and telephone calls by GPs to hospital during their patients' admission were measured, with and without invitation and offer of payment for contact. A discharge summary was distributed. Postdischarge questionnaires surveyed patient satisfaction with care, confidence in future management by the GPs, and GP confidence in continuing patient care.
                Significant increases in contact rates by the GPs followed invitation. The discharge summary was not effectively distributed. No significant differences in patient satisfaction and confidence in future management by their GPs were found. General practitioners valued hospital contact most in meeting their patients' needs for information.
                Personal invitation increases GP contact with hospitals. While no statistically significant improvements in patient satisfaction or GP confidence were shown, the data suggested that GPs value contact to meet patient information needs. To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.
                A randomised controlled trial.
                A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.
                All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.
                Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.
                4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively.
                General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. Evidence-based medicine requires general practitioners (GPs) to act upon the results of clinical trials. Clinical trial evidence may be difficult to understand and apply in practice.
                To investigate whether GPs were unduly influenced in managing hypertension in the elderly by the ways in which benefits of trial results were presented, and to establish whether their current treatment of an elderly hypertensive patient was broadly in line with recent clinical trial evidence.
                Seventy-three GPs attending a refresher course were given a written questionnaire containing data from one clinical trial of treatment of hypertension in the elderly presented in four different ways (absolute risk reduction, relative risk reduction, difference in event-free patients, and number of patients who had to be treated in order to prevent one clinical event), as if from four different trials. The effect of each presentation on treatment preferences was assessed using Likert scales. The results were analysed to determine whether the method of presentation of results influenced decision making. A clinical scenario was presented to investigate their current treatment preferences in an elderly hypertensive.
                All GPs returned completed questionnaires. Relative risk reduction was the only presentation which was significantly different from the others, and was the most likely to influence prescribing. In free-text comments, 75% of GPs admitted having problems understanding statistics commonly found in medical journals. More than 90% conformed with recent clinical trial evidence for the management of hypertension.
                GPs were most influenced by relative risk reduction, and were unaware of how the presentation of research results could affect treatment decisions. Most GPs freely admitted to difficulty in comprehending medical statistics. Almost all of the GPs expressed treatment decisions which were broadly in line with clinical evidence.
Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.