An analysis of an open access general practitioner bone densitometry service

Sim, Marc; Stone, Mike; Johansen, Antony; Ho, Pak‐Leung; Pettit, Rebecca; Evans, W. D.

doi:10.1111/j.1368-5031.2004.00151.x

Cited by 3 publications

(3 citation statements)

References 15 publications

(16 reference statements)

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“…In our clinic, 46% of referred patients fulfilled the World Health Organization definition of osteoporosis. This agrees closely with the 41% to 53%14 15 reported by clinics in the United Kingdom and United States, although slightly lower prevalences are reported by clinics who accept self referred patients 16. The most important limitation of our study was that we could not calculate the false negative rate.…”

Section: Discussionsupporting

confidence: 87%

Utility of testing for monoclonal bands in serum of patients with suspected osteoporosis: retrospective, cross sectional study

Abrahamsen

Andersen

Christensen

et al. 2005

BMJ

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Objective To determine whether measuring monoclonal bands (M component) in serum should be part of the investigation of patients referred to osteoporosis clinics. Design Retrospective, cross sectional, observational study. Setting Referral centre for osteoporosis in a university hospital, Denmark. Participants 799 people (685 women) aged 19 to 94 years newly referred with suspected osteoporosis. Main outcome measures Proportion of patients fulfilling the Nordic Myeloma Study Group definition for target condition and proportion of patients with other important haematological conditions. Results 4.9% (18 of 366) of patients with osteoporosis and 2.2% (9 of 408) of patients without osteoporosis had M component in serum ( 2 = 3.66, P = 0.04). Multiple myeloma was diagnosed in three patients with osteoporosis (absolute risk 0.8%, 95% confidence interval 0.11% to 1.7%). The relative risk of multiple myeloma in patients presenting with osteoporosis was 75 (10 to 160). As a diagnostic test for multiple myeloma in patients with osteoporosis, M component in serum had a specificity of 95.0% and a positive predictive value of 17.6%. 122 blood electrophoreses were carried out for each case of multiple myeloma diagnosed. All patients with multiple myeloma had a history of fragility fractures. If lymphoma was included as a target condition, the specificity increased to 95.3% and the positive predictive value increased to 23.5%. Monoclonal gammopathy of undetermined significance was diagnosed in 13 (3.6%) participants with osteoporosis and in eight (2.0%) participants with normal bone mineral density or osteopenia. Conclusions Patients presenting with osteoporosis should be tested for M component in serum, as 1 in 20 patients with newly diagnosed osteoporosis had multiple myeloma or monoclonal gammopathy of undetermined significance.

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Section: Discussionsupporting

confidence: 87%

Utility of testing for monoclonal bands in serum of patients with suspected osteoporosis: retrospective, cross sectional study

Abrahamsen

Andersen

Christensen

et al. 2005

BMJ

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“…Compared to outpatient clinics, waiting times are much improved, patient outcomes are comparable or better, and patient satisfaction is higher [34][35][36][37][38][39][40]. In turn, hospital outpatient referrals, and therefore waiting times for the relevant specialties are often reduced [31,36,41]. Cost efficiency varies, and in many studies was not commented on at all.…”

Section: Discussionmentioning

confidence: 99%

“…By facilitating GPs in investigating and treating their own patients in primary care, referral rates are reduced, and those referrals that are necessary are directed appropriately for therapeutic care rather than further investigations [12,31,32]. This has the knock-on effect of reducing outpatient waiting times.…”

Section: Discussionmentioning

confidence: 99%

Limited options: a report on GP access to services

et al. 2007

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Demand management for planned care: a realist synthesis

Pawson

Greenhalgh

Brennan

2016

Health Serv Deliv Res

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BackgroundThe task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution.MethodsThis report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become ‘whole-system’ models; over time policy-makers have advocated the need for concerted action on all of these fronts.FindingsThe remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes ‘work’ only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high ‘rule-out’ rates; and referral guidelines are more likely to work when implemented by staff with responsibility for their creation.ConclusionsThe report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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An analysis of an open access general practitioner bone densitometry service

Cited by 3 publications

References 15 publications

Utility of testing for monoclonal bands in serum of patients with suspected osteoporosis: retrospective, cross sectional study

Utility of testing for monoclonal bands in serum of patients with suspected osteoporosis: retrospective, cross sectional study

Limited options: a report on GP access to services

Demand management for planned care: a realist synthesis

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