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This week in BMJ Saturday 18 January 1997

Out of hours: GPs, deputising services, and GP cooperatives handle patients differently

Six papers this week look at the fast changing scene in providing out of hours primary care. Such care in Britain has traditionally been provided by general practitioners themselves or deputising services. In their randomised controlled trial of deputising doctors and practice doctors Cragg et al found that practice doctors gave more telephone advice and were more likely to visit patients quickly (p 187). They also prescribed fewer and cheaper drugs. No difference existed, however, in the number or duration of hospital admissions. In the same randomised comparison McKinley et al (p 190) found that the health status of patients was similar at 24-120 hours after the request for care and there was no difference in use of health services over the next two weeks. Patients were, however, less satisfied with the care provided by deputising doctors. To measure this the authors developed a questionnaire to elicit satisfaction (p 193) and urge that such validated scales should be used rather than ad hoc measures. General practice cooperatives, where practices band together to provide cover from within their own resources, have grown rapidly but with little evaluation. On p 182 Salisbury compares the activity of a cooperative and a deputising service in an overlapping area of London. Far more patients received telephone advice from the cooperative and fewer received prescriptions. The deputising service, however, visited more quickly. The authors want standard indicators to measure the performance of different services. Jessopp et al, in their short review of current developments in cooperatives (p 199), support that call. They found tat cooperatives are active in establishing quality standards but with little input from patients or health authorities. Finally, the South Wiltshire Out of Hours Project group piloted a nurse telephone triage service over six weeks (p 198) and found that nurses could deal with over a third of calls to two general practices.

Concussive convulsions after sports injury are not serious

On p 171 McCrory et al report on an investigation of the ictal phenomenology, aetiology, and outcome of convulsions occurring within seconds of impact in two violent collision sports-Australian rules football and elite rugby league. They analysed 22 cases, including four events documented on videotape. Videotaped convulsions began within 2 seconds of a facial blow and comprised a period of tonic stiffening followed by myoclonic jerks of all limbs lasting up to 150 seconds. Recovery of consciousness was rapid. No structural or permanent brain injury was present on clinical assessment, neuropsychological testing, or neuroimaging studies. All players returned to competition within two weeks. Epilepsy did not develop in any of the players, who were followed up for up to 13 years. The authors interpret these impact convulsions as a non-epileptic phenomenon, akin to convulsive syncope.

Less frequent follow up in breast cancer is not associated with deterioration in health

While the birth of a baby more than 12 weeks early poses many dilemmas, the threshold of viability has certainly been pushed back by the advent of respiratory support. Recent North American guidelines have suggested that survival occurs at 22 weeks, but Win Tin et al for the Northern Neonatal Network found no evidence for this in any white community (p 107) and identified only eight survivors among the 197 babies of 23 weeks' gestation who were alive at the start of labour in their own study (half of whom had severe disability at 2 years). A 6O% increase in survival in babies of under 28 weeks over the 12 years of the study had not been accompanied by any change in the proportion with disability, with 10% never likely to achieve mobility or communicate intelligibly. Recent developments have improved the outlook for the viable baby but have not changed the threshold of viability.

Less frequent follow up in breast cancer is not associated with deterioration in health

Women with breast cancer are usually followed up in specialist clinics after primary treatment On p 174 Gulliford et al report a randomised controlled trial of 196 women designed to evaluate the frequency of follow up of women with breast cancer Their findings gave no indication that less frequent follow up is associated with deterioration in quality of life related to health. This finding has implications for funding, and the authors recommend further research.

Vigabatrin may cause visual field constriction
On p 180 Eke et al describe three patients who suffered severe and persistent constriction of their visual fields while taking vigabatrin for their epilepsy. The three patients, aged 22 to 46, had all been taking vigabatrin for two to three years when they started to complain of reduced peripheral vision. Although vigabatrin was stopped, the visual fields failed to improve. World wide 28 cases of visual field defects have been reported to the manufacturer, out of 140,00 patients treated.