Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 1991 Jun 22;302(6791):1509–1513. doi: 10.1136/bmj.302.6791.1509

Twenty five years of case finding and audit in a socially deprived community.

J T Hart 1, C Thomas 1, B Gibbons 1, C Edwards 1, M Hart 1, J Jones 1, M Jones 1, P Walton 1
PMCID: PMC1670219  PMID: 1855023

Abstract

OBJECTIVE--To evaluate audit and case finding (whole population care) in a community over 25 years. DESIGN--Contemporary screening for and audits of care of chronic disease and risk factors; retrospective review of computerised practice records; and comparisons of mortality and social indices with neighbouring communities. SETTING--One general practice in Glyncorrwg, West Glamorgan. SUBJECTS--1800 people registered with the practice in 1987 and 558 people who died from 1964 to 1987, whose records had been retained. MAIN OUTCOME MEASURES--Detection of high blood pressure, smoking, airways obstruction, obesity, diabetes, and alcohol problems in adults aged 20-79; prevalence of smoking in this population and in hypertensive and diabetic groups; age standardised mortality ratios in relation to indices of social deprivation. RESULTS--In the population aged 20-79 (1207 patients) 249 (21%) had peak expiratory flow rate less than 50% of expected value or which improved by 15% or more with an inhaled beta agonist, 207 (17%) had body mass index at or over 30 kg/m2, 118 (10%) had untreated mean arterial pressures greater than 159/104 mm Hg (three readings), 80 (7%) (65 (16%) men, 15 (4%) women) had recognised alcohol problems, and 35 (3%) had diabetes. The proportion of men aged 20-64 who said they smoked fell from 61% (290/476) in 1968-70 to 36% (162/456) in 1985 whereas that of women who smoked was unchanged (43%, 187/436 v 42%, 190/448 respectively). In 116 screened hypertensive patients group mean blood pressure fell from 186/110 mm Hg before treatment to 146/84 mm Hg at 1987 audit, as did the proportion of smokers (56% v 20%), but body mass index and total cholesterol concentration showed no significant change. In 34 diabetic patients mean blood pressure and the proportion of smokers fell (171/93 mm Hg v 155/81 mm Hg; 44% v 12%). The age standardised mortality ratio in 1981-6 was lower than in a neighbouring village without a developed case finding programme (actual to expected deaths less than 65 = 21 to 22 in Glyncorrwg, 48 to 30 in control village). CONCLUSIONS--Whole population care through organised case finding and audit is feasible but only with a labour intensive approach combining accessibility, flexibility, and continuity, as well as a planned and structured approach, which requires substantial expansion of staff numbers and assiduous recording. It may reduce risks for at least some high risk groups. Despite their shortcomings the available data are consistent with the hypothesis that whole population care helps reduce mortality. Incentives in the new contract, which encourage the uncritical development of structured process, may diminish health outputs.

Full text

PDF
1509

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Amiel S., Health I., Bennett J., Kelley D., Dickinson C., Miller R. Health promotion in general practice. BMJ. 1991 Mar 2;302(6775):527–527. doi: 10.1136/bmj.302.6775.527. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Ballard D. J., Strogatz D. S., Wagner E. H., Siscovick D. S., James S. A., Kleinbaum D. G., Cutchin L. M., Ibrahim M. A. Hypertension control in a rural southern community: medical care process and dropping out. Am J Prev Med. 1988 May-Jun;4(3):133–139. [PubMed] [Google Scholar]
  3. Catford J. C., Ford S. On the state of the public ill health: premature mortality in the United Kingdom and Europe. Br Med J (Clin Res Ed) 1984 Dec 15;289(6459):1668–1670. doi: 10.1136/bmj.289.6459.1668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Coope J. A screening clinic for hypertension in general practice. J R Coll Gen Pract. 1974 Mar;24(140):161–166. [PMC free article] [PubMed] [Google Scholar]
  5. Day J. L., Humphreys H., Alban-Davies H. Problems of comprehensive shared diabetes care. Br Med J (Clin Res Ed) 1987 Jun 20;294(6587):1590–1592. doi: 10.1136/bmj.294.6587.1590. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. HAMILTON M., THOMPSON E. M., WISNIEWSKI T. K. THE ROLE OF BLOOD-PRESSURE CONTROL IN PREVENTING COMPLICATIONS OF HYPERTENSION. Lancet. 1964 Feb 1;1(7327):235–238. doi: 10.1016/s0140-6736(64)92344-x. [DOI] [PubMed] [Google Scholar]
  7. Hart J. T. General-practice workload, needs, and resources in the National Health Service. J R Coll Gen Pract. 1976 Dec;26(173):885–892. [PMC free article] [PubMed] [Google Scholar]
  8. Hart J. T., Humphreys C. Be your own coroner: an audit of 500 consecutive deaths in a general practice. Br Med J (Clin Res Ed) 1987 Apr 4;294(6576):871–874. doi: 10.1136/bmj.294.6576.871. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Hart J. T. James Mackenzie lecture 1989. Reactive and proactive care: a crisis. Br J Gen Pract. 1990 Jan;40(330):4–9. [PMC free article] [PubMed] [Google Scholar]
  10. Hart J. T. Measurement of omission. Br Med J (Clin Res Ed) 1982 Jun 5;284(6330):1686–1689. doi: 10.1136/bmj.284.6330.1686. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Hart J. T. Semicontinuous screening of a whole community for hypertension. Lancet. 1970 Aug 1;2(7666):223–226. doi: 10.1016/s0140-6736(70)92582-1. [DOI] [PubMed] [Google Scholar]
  12. Hart J. T. The inverse care law. Lancet. 1971 Feb 27;1(7696):405–412. doi: 10.1016/s0140-6736(71)92410-x. [DOI] [PubMed] [Google Scholar]
  13. Hart J. T. The marriage of primary care and epidemiology: the Milroy lecture, 1974. J R Coll Physicians Lond. 1974 Jul;8(4):299–314. [PMC free article] [PubMed] [Google Scholar]
  14. Hayes T. M., Harries J. Randomised controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics. Br Med J (Clin Res Ed) 1984 Sep 22;289(6447):728–730. doi: 10.1136/bmj.289.6447.728. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Jamrozik K., Vessey M., Fowler G., Wald N., Parker G., Van Vunakis H. Controlled trial of three different antismoking interventions in general practice. Br Med J (Clin Res Ed) 1984 May 19;288(6429):1499–1503. doi: 10.1136/bmj.288.6429.1499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Leese B., Bosanquet N. High and low incomes in general practice. BMJ. 1989 Apr 8;298(6678):932–934. doi: 10.1136/bmj.298.6678.932. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Marmot M. G., Shipley M. J., Rose G. Inequalities in death--specific explanations of a general pattern? Lancet. 1984 May 5;1(8384):1003–1006. doi: 10.1016/s0140-6736(84)92337-7. [DOI] [PubMed] [Google Scholar]
  18. Morrell D. C., Evans M. E., Morris R. W., Roland M. O. The "five minute" consultation: effect of time constraint on clinical content and patient satisfaction. Br Med J (Clin Res Ed) 1986 Mar 29;292(6524):870–873. doi: 10.1136/bmj.292.6524.870. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Pill R., Stott N. Invitation to attend a health check in a general practice setting: the views of a cohort of non-attenders. J R Coll Gen Pract. 1988 Feb;38(307):57–60. [PMC free article] [PubMed] [Google Scholar]
  20. Pringle M. The quality divide in primary care. BMJ. 1989 Aug 19;299(6697):470–471. doi: 10.1136/bmj.299.6697.470. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Ridsdale L., Carruthers M., Morris R., Ridsdale J. Study of the effect of time availability on the consultation. J R Coll Gen Pract. 1989 Dec;39(329):488–491. [PMC free article] [PubMed] [Google Scholar]
  22. Ridsdale L. General practitioners' workload. BMJ. 1990 Sep 8;301(6750):455–456. doi: 10.1136/bmj.301.6750.455. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Robson J., Boomla K., Fitzpatrick S., Jewell A. J., Taylor J., Self J., Colyer M. Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial. BMJ. 1989 Feb 18;298(6671):433–436. doi: 10.1136/bmj.298.6671.433. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Russell M. A., Wilson C., Taylor C., Baker C. D. Effect of general practitioners' advice against smoking. Br Med J. 1979 Jul 28;2(6184):231–235. doi: 10.1136/bmj.2.6184.231. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Savage R., Armstrong D. Effect of a general practitioner's consulting style on patients' satisfaction: a controlled study. BMJ. 1990 Oct 27;301(6758):968–970. doi: 10.1136/bmj.301.6758.968. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Smith A. Summing up. Postgrad Med J. 1984 Jan;60(699):42–43. doi: 10.1136/pgmj.60.699.42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Smith G. D., Bartley M., Blane D. The Black report on socioeconomic inequalities in health 10 years on. BMJ. 1990 Aug 18;301(6748):373–377. doi: 10.1136/bmj.301.6748.373. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Smith W. C., Lee A. J., Crombie I. K., Tunstall-Pedoe H. Control of blood pressure in Scotland: the rule of halves. BMJ. 1990 Apr 14;300(6730):981–983. doi: 10.1136/bmj.300.6730.981. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Stott N. C., Davis R. H. The exceptional potential in each primary care consultation. J R Coll Gen Pract. 1979 Apr;29(201):201–205. [PMC free article] [PubMed] [Google Scholar]
  30. Thomas K., Birch S., Milner P., Nicholl J., Westlake L., Williams B. Estimates of general practitioner workload: a review. J R Coll Gen Pract. 1989 Dec;39(329):509–513. [PMC free article] [PubMed] [Google Scholar]
  31. Thompson N. F. Inviting infrequent attenders to attend for a health check: costs and benefits. Br J Gen Pract. 1990 Jan;40(330):16–18. [PMC free article] [PubMed] [Google Scholar]
  32. Wallace P. G., Brennan P. J., Haines A. P. Drinking patterns in general practice patients. J R Coll Gen Pract. 1987 Aug;37(301):354–357. [PMC free article] [PubMed] [Google Scholar]
  33. Wallace P., Cutler S., Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988 Sep 10;297(6649):663–668. doi: 10.1136/bmj.297.6649.663. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Waller D., Agass M., Mant D., Coulter A., Fuller A., Jones L. Health checks in general practice: another example of inverse care? BMJ. 1990 Apr 28;300(6732):1115–1118. doi: 10.1136/bmj.300.6732.1115. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Watt G. C., Edwards C., Hart J. T., Hart M., Walton P., Foy C. J. Dietary sodium restriction for mild hypertension in general practice. Br Med J (Clin Res Ed) 1983 Feb 5;286(6363):432–436. doi: 10.1136/bmj.286.6363.432. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Watt G. C., Foy C. J., Hart J. T., Bingham G., Edwards C., Hart M., Thomas E., Walton P. Dietary sodium and arterial blood pressure: evidence against genetic susceptibility. Br Med J (Clin Res Ed) 1985 Nov 30;291(6508):1525–1528. doi: 10.1136/bmj.291.6508.1525. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Watt G. C., Foy C. J., Hart J. T. Comparison of blood pressure, sodium intake, and other variables in offspring with and without a family history of high blood pressure. Lancet. 1983 Jun 4;1(8336):1245–1248. doi: 10.1016/s0140-6736(83)92697-1. [DOI] [PubMed] [Google Scholar]
  38. al-Bashir M. M., Armstrong D. Preferences of healthy and ill patients for style of general practitioner care: implications for workload and financial incentives under the new contract. Br J Gen Pract. 1991 Jan;41(342):6–8. [PMC free article] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES