Greg Rubin

Is the two week rule for cancer referrals working?: Not too well

Mortality rates in the United Kingdom for several cancers compare unfavourably with those in other countries,1 and this may be explained at least partly by British patients having more advanced disease at the time of treatment than their European counterparts. Morbidity and mortality can be reduced through primary and secondary prevention, including screening; by early detection; and by prompt and effective treatment. Last year, in the context of the NHSs disgracefully long waiting lists, the government pledged that patients with suspected cancer would be seen by a specialist within two weeks of referral by their general practitioner. The aim was to reduce delays between presentation, diagnosis, and treatment. The two week rule has now been implemented across a range of specialties, supported by widely distributed information about risk factors and criteria for rapid referral for suspected cancer. How is it working?nnLocal rapid access referral mechanisms have been established, including specially designed forms and direct electronic access to outpatient appointments for patients meeting prespecified criteria. In addition, the government established the cancer services collaborative programme, creating nine cancer networks covering about 15 million people, aimed at optimising systems of care and improving …

Gastrointestinal and Cardiovascular Risks of Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed but can have serious gastrointestinal (GI) and cardiovascular side effects, which have led to the withdrawal of some of these drugs and continuing uncertainty about the best approach to patients requiring NSAID therapy, particularly in those with GI or cardiovascular risk factors. To define the risks to the GI and cardiovascular systems associated with NSAID therapy, we have undertaken a series of systematic reviews of original articles published between January 1995 and December 2006. In this article we describe the mechanisms and patterns of GI and cardiovascular side effects in NSAID-taking patients and identify a range of drug and patient factors that contribute to an increased risk of adverse events. We conclude that NSAID therapy should not be started unless it is essential, and that Helicobacter pylori eradication should be considered in patients at increased GI risk. We discuss the use of gastroprotective agents and provide practical advice to help physicians assess and balance both cardiovascular and GI risks and benefits in their prescribing decisions.

Patient experience of infertility management in primary care: an in-depth interview study

BACKGROUNDnGPs do not have a full range of diagnostic resources to help manage infertile couples. Little is known about the patient experience of infertility management in primary care.nnnOBJECTIVEnTo explore the patient experience of infertility management from a primary care perspective.nnnMETHODSnThis was a nested qualitative study with infertile couples in North-East England. In-depth interviews of infertile couples identified in the course of an observational study describing the incidence, prevalence, referral patterns and pregnancy outcomes for infertile couples. A grounded approach was used, with the interviews and analysis proceeding together using the method of constant comparison. Emergent themes and their links gave an overall explanation to the interview data.nnnRESULTSnWe interviewed 22 patients in 13 interviews. Factors that influenced a couples experience of infertility management were personal and professional relationships, patient autonomy in decision making and access to services.nnnCONCLUSIONSnThis study provides insights into the experiences of infertile couples seeking assisted reproduction from their GP. A good experience was linked to a strong personal relationship, a patient-centred professional relationship fostering informed decision making by the couple, GPs using diagnostic resources, interpreting restrictive clinical and social criteria and referring appropriately.

Management of dyspepsia across the primary-secondary healthcare interface.

Primary care remains at the frontline of care for most patients and the need to contain healthcare costs has led to a re-evaluation of the divide between primary and secondary care. Dyspepsia has a community prevalence of 25–50%, and forms 5% of the primary care physician’s workload, 10% of whom are referred to a specialist. Problems presenting in primary care tend to be undifferentiated; those who do not have alarm symptoms and are under the age of 55 years are unlikely to have serious pathology. Management is largely symptom driven, on an empirical basis rather than on a diagnostic model as in secondary care where investigation rates are higher. The predictive value of symptoms for a specific diagnosis is small; primary care physicians include gastro-oesophageal reflux disease as part of the dyspepsia complex and the overall expenditure on acid suppression therapy is relatively large. The availability of open-access investigations such as endoscopy has influenced specialist referral rates and the ability to diagnose and treat patients with Helicobacter pylori-related problems has opened further opportunities. However, variations in the availability of the recommended diagnostic tests and the implications to primary care clinical practice of some of the new management recommendations (Maastricht II) in some national settings illustrate the divide with secondary care. The gap between primary and secondary care is narrowing in gastroenterology and the two groups need to continue collaboration to attain effective and cost-effective management for their patients.

Gastro-oesophageal reflux disease redefined: Implications for primary care

Gastro-oesophageal reflux disease (GORD) is one of the commonest digestive disorders encountered by general practitioners. The condition affects around 10 to 20% of the population of western societies, and incidence and prevalence rates appear to be rising in the eastern world (1). The disorder has significant implications for quality of life and the cost of medical treatment (2), and is also regarded as a risk factor for Barrett’s oesophagus and oesophageal adenocarcinoma. One of the difficulties of getting to grips with GORD has been the lack of a consistent definition of the condition. Different words are used in different countries to describe what are regarded as the cardinal symptoms of GORD*heartburn and regurgitation*and it appears that different GORD symptoms may be regarded as more or less troublesome in different cultures and countries (2 4). In addition, there is evidence that general practitioners’ approach to the management of GORD is variable and often inconsistent with the current evidence base, particularly with regard to the use of investigations and different treatment modalities. For these reasons, a group of primaryand secondary-care clinicians with a particular interest in GORD became involved in a project which eventually generated the ‘‘Montreal definition’’ of GORD, the summary paper of which has recently been published in the American Journal of Gastroenterology (5). The conclusions of the Montreal working group were based on a series of carefully conducted systematic reviews in which the strength of evidence was assessed using the GRADE system (6). These informed a Delphi process (7), which was used to identify globally acceptable definitions of GORD and its associated symptoms that would be useful in clinical practice, in research, and in pharmaceutical regulation. A number of important messages for primary care have emerged, which are summarized in the box. The first of these is that the diagnosis of GORD can generally be made on the basis of clinical symptoms, and treatment can be started without the need for endoscopy. Conversely, it is important for clinicians to recognize the existence of ‘‘nonerosive reflux disease’’, in which patients have typical symptoms but no abnormal findings at endoscopy. The relationship between endoscopy and clinical symptoms is poor, and clinicians are advised to assess response to therapy in terms of symptom response, rather than conducting serial endoscopies. GORD is a common cause of non-cardiac chest pain, and ‘‘GORD chest pain syndrome’’ is now recognized as an integral feature of the condition, in which pain which is often indistinguishable from ischaemic heart pain is caused by acid reflux and/or oesophageal motor abnormalities. The Montreal definition also emphasizes the links between oesophageal damage and subsequent metaplastic and malignant change in the oesophageal mucosa, whilst recognizing that the incidences of Barrett’s oesophagus and adenocarcinoma in the GORD population are relatively low, although they appear to be rising (8).

Are primary care research networks up to the challenge

How swiftly things change! It does not seem so long ago that primary care research networks (PCRNs) were espoused within the NHS Research and Development (R&D) programme, with the Mant Report (NHS Executive, 1997) recommending network arrangements for all localities and co-ordination at a national level. The initial remit was to facilitate research and to promote the acceptance of a culture of research in primary care. These now sound rather old-fashioned sentiments. Increasing ‘research capacity’ has been the more recent adage, and we know well how great a need there is for this in primary care, but is there a possibility that a still newer priority is approaching? Networks are currently under intense pressure to deliver. The current climate suggests that PCRNs have to be seen to be part of the national and regional R&D initiatives, including the carrying through of new policies and priorities, rather than acting as independent initiatives. Funding changes have sharpened the view that PCRNs have to respond and conform to the strategic intentions of the Department of Health in order to survive (Department of Health, 2000a). The shift of balance from Regional R&D funding towards Culyer, and now the Support for Science and the Priorities and Needs Funding streams, potentially leaves PCRNs somewhere between the cracks, in danger of being squeezed or, in some cases, squeezed out altogether. The priorities of networkers themselves may in future need to run parallel or be subservient to the changing administrative and management requirements within the new NHS research ethic. Add to this the shifting ground in relation to national R&D requirements, especially research governance, and network leaders can’t be blamed for asking themselves what they are supposed to be doing, for whom, or whether it is worth it. Nowhere is this more apparent than in the challenges faced by primary care in responding to the