Background

1. Background Few studies of Multiple Sclerosis have been performed in the primary care setting and selecting a study population from hospital or outpatient clinics may exclude up to half the population with MS; the most and least able. There is a perception that disabled patients, particularly those with MS are inhibited from, or unable to participate in health screening programmes. Cheng and colleagues1 showed impairments in mobility related to a reduced use of preventative services by women. We wished to investigate how patients in a different system of healthcare complied with our NHS screening standards. Aim & Objectives To audit how a representative sample of MS patients in the community, registered with general medical practitioners comply with a range of health screening standards Methods The Data Retrieval in General Practice Project (DRGP) is a network of primary care practices in Northern Ireland with computerised diagnostic registers for about 193300 patients (13% of the total population of Northern Ireland). They are situated in inner city, suburban and rural settings and have a patient profile broadly representative of the population profile here. General Practitioners in these practices were asked to identify patients with MS, whether they were actively using hospital based neurology clinics or not. The diagnosis of MS was verified from hospital letters in the medical record. Case notes and computer records were then examined for records of blood pressure measurement, blood cholesterol measurement, and advice on smoking, alcohol, diet and exercise. The records of women under 65 years of age were examined for cervical smear results and those of women aged 50-65 were also examined for mammogram results. We counted services recorded in the five year period prior to this study. To allow comparison with the results of the study by Cheng and colleagues1 we analysed our results by dividing the sample into groups depending on their mobility. Fully ambulatory- can walk at least 90m without aid Ambulatory with help – can walk at least 4.5m with aids: (cane, crutch, brace or walker) Not ambulatory – unable to walk 4.5m with aids: (wheelchair bound) Standards Women’s health Cervical Screening: NHS general practitioners are responsible for cervical screening and have targets to meet for all women up to age 65.2 Breast Screening: Mammograms are organised centrally for women aged 50-65 and their general practitioner is informed of the result. Breast awareness is encouraged rather than physician examination.3 General health advice for men and women NHS general practitioners are also encouraged to regularly record blood pressure and give advice on smoking, alcohol, diet and exercise.4 There is no directive on for cholesterol measurement; in the absence of other risk factors it becomes more relevant with increasing age.5 Results The primary care medical records of 170 people with multiple sclerosis were examined. 112 were female, 58 were male. Of the total 65 (38%)were fully ambulatory, 56 (33%) were ambulatory with help and 49 (29%) were not ambulatory Women’s Preventative Health Services (Table1) *The percentage of women with up to date cervical smears recorded seems to decrease with decreasing mobility but fails to reach significance possibly due to the small numbers. If both ambulatory groups are combined and compared with non-ambulatory then a significant difference is shown (p<0.05). Cervical Screening : The overall uptake in eligible women was 84%, just below the lower target threshold for payment to general practitioners here. The percentage of women with an up to date smear decreases with decreasing mobility (Table1). There is a significant difference (p<0.05) between all ambulatory women combined (88% have up to date smear) when compared with wheelchair bound women (67% have up to date smear). Mammography: There were a small number of women eligible for mammography and no trend was seen relative to their disability. It is of note that 5 out of 6 wheelchair bound women have had mammograms in a population where it is not a popular procedure General Preventative Health Services (Table 2) Blood Pressure Measurement: Overall 82% records were in date. We found is a very significant relationship (p<0.001) between BP measurement and mobility particularly for women (Figure 1). Ambulatory women are much more likely to have BP checks than ambulatory men but for non ambulatory patients the rates are lower and show no sex difference. Lifestyle interventions: These showed an interesting trend where the fully ambulatory had lower rates than the ambulatory with help although both had higher rates than the wheelchair bound. (Figure 2) Cholesterol Measurement: 44% of people over 45 years old had blood cholesterol levels measured, more men than women in each group but trends did not reach significance. Smoking, Alcohol, Diet & Exercise Advice: There were significant differences with mobility (p<0.01) following the trend noted above (Figure 2). The differences were most significant for women. Overall men have lower rates of getting advice. Each of these four items were examined separately but the results were similar. They may be seen as a package of health promotion advice within the practice. Conclusion These results fit with reports from general practice that GPs prefer to offer health promotion advice opportunistically.6 The fully ambulatory patients may get caught for an occasional blood pressure check but it is the moderately disabled who are more likely to consult and thus benefit from lifestyle advice. The non ambulatory are disadvantaged by this system for receipt of preventative services. There has been some attention paid to wheelchair bound women but it would seem that non ambulatory men may also be a vulnerable group Participation by People with Multiple Sclerosis in Health Screening: a General Practice based AuditMacLurg K(1), Hawkins S (2), Reilly P(1)1. Department of General Practice, Queens University of Belfast. 2. Department of Neurology, Royal Victoria Hospital • References • Cheng E et al. Mobility impairments and use of preventive services in women with multiple sclerosis: observational study. BMJ 2001; 323: 968-969 • Department of Health. General Practice in the National Health Service, The 1990 Contract. London: HMSO; 1998 • Austoker J. Cancer Prevention in Primary Care: screening and self examination for breast cancer. BMJ 1994: 309; 168-174 • Department of Health. Our Healthier Nation: a contract for health. London: HMSO; 1998 • Anonymous. Joint recommendations on prevention of coronary heart disease in clinical practice. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, endorsed by the British Diabetic Association. Heart 1998; 80: S1-S29 • Coleman T, Murphy E, Cheater F. Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study. Br J Gen Pract 2000; 50: 207-210 • Acknowledgements • Funding was provided by the Multiple Sclerosis Society (GB &NI)