Primary care for nontraumatic illness at the emergency department and the family physician's office.

A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians'' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days'' care and were less likely to receive more than 31 days'' care; those without a family physician more often received additional care (were referred, admitted or asked to return).     

Physician time-saving by employment of expanded-role nurses in family practice

Registered nurses working in five family practices in Kingston, Ontario, were given a period of in-service training and supplementary formal instruction at Queen''s University to expand their skills and enable them to undertake prescribed procedures in the physicians'' offices. Operational data collected from the five practices before and after training was analysed to assess the saving of physician time effected by the expansion of the nurses'' activities in providing primary medical care. Physician time was saved in all cases but the amount varied. The results are presented and discussed in relation to staff, physical premises and patterns of practice of the participating physicians. Under the most advantageous practice circumstances in this study, a 33.7% saving in original physician time was obtained. The mean time-saving for the five practices was 18.2%.     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

Emergency physicians and sexual involvement with patients: an Ontario survey

OBJECTIVE: To describe Ontario emergency physicians'' knowledge of colleagues'' sexual involvement with patients and former patients, their own personal experience of such involvement, and their attitudes toward postvisit relationships. DESIGN: Mailed survey. SETTING: Ontario. PARTICIPANTS: Emergency physicians practising in Ontario. RESULTS: Of 974 eligible mailed surveys, 599 (61.5%) were returned. Of these respondents, 52 (8.7%) reported being aware of a colleague in emergency practice who had been sexually involved with a patient or former patient. When describing their own behaviour, 37 respondents (6.2%) reported sexual involvement with a former patient. However, of this group, only 9 (25.0%) had met the patient in an emergency department. Thus, of the total number of respondents, only 1.5% (9/599) reported sexual involvement arising out of an emergency department visit. Most respondents (82.4%) agreed that it is inappropriate behaviour to ask a patient for a date after an emergency assessment and before the patient''s departure, and 66.4% felt that it is inappropriate to contact the patient after discharge. However, only 10.6% believed it to be unacceptable to request a social meeting after encountering a patient previously cared for in the emergency department in a nonprofessional setting. Most respondents (96.5%) did not believe that sexual involvement could ever be therapeutic for the patient. However, only 66% felt that it was always an abuse of power and 62.4% supported zero tolerance of all sexual involvement between physicians and patients. CONCLUSIONS: Vague regulatory guidelines currently in place have failed to dispel confusion regarding what is acceptable social behaviour for physicians providing emergency care. Our results support the need for clarification, and suggest a basis for guidelines that would be acceptable to the emergency medical community: that an emergency visit should not form the basis for the initiation of personal or sexual relationships, yet neither should it preclude their development in nonmedical settings.     

Cost of primary health care services in the emergency department and the family physician's office.

An attempt has been made to determine the true cost of providing primary health care for nontraumatic conditions in the emergency departments of two hospitals in Ontario and in the offices of family physicians. A total of 1117 patients presenting with 1 of 10 common symptom/sign complexes at the emergency departments or the offices of 15 participating family physicians were studies with regard to number of visits made, type of assessment by the physician, investigations undertaken, management, therapy and outcome of the illness. Costs were calculated from the charges that would be made against the provincial health services insurance plan and from the system of hospital financing in effect in the province. The average true cost per illness episode of this type of care was $14.63 in hospital A, $14.20 in hospital B and $15.90 in the family physician''s office.     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

Reductions in Inpatient Mortality following Interventions to Improve Emergency Hospital Care in Freetown,Sierra Leone

Background

The demand for high quality hospital care for children in low resource countries is not being met. This paper describes a number of strategies to improve emergency care at a children''s hospital and evaluates the impact of these on inpatient mortality. In addition, the cost-effectiveness of improving emergency care is estimated.

Methods and Findings

A team of local and international staff developed a plan to improve emergency care for children arriving at The Ola During Children''s Hospital, Freetown, Sierra Leone. Following focus group discussions, five priority areas were identified to improve emergency care; staff training, hospital layout, staff allocation, medical equipment, and medical record keeping. A team of international volunteers worked with local staff for six months to design and implement improvements in these five priority areas. The improvements were evaluated collectively rather than individually. Before the intervention, the inpatient mortality rate was 12.4%. After the intervention this improved to 5.9%. The relative risk of dying was 47% (95% CI 0.369–0.607) lower after the intervention. The estimated number of lives saved in the first two months after the intervention was 103. The total cost of the intervention was USD 29 714, the estimated cost per death averted was USD 148. There are two main limitation of the study. Firstly, the brevity of the study and secondly, the assumed homogeneity of the clinical cases that presented to the hospital before and after the intervention.

Conclusions

This study demonstarted a signficant reductuion in inpatient mortality rate after an intervention to improve emergency hospital care If the findings of this paper could be reproduced in a larger more rigorous study, improving the quality of care in hospitals would be a very cost effective strategy to save children''s lives in low resource settings.     

A rural emergency department.

The appropriate use of emergency departments is of growing concern. By knowing which patients are more likely to make inappropriate visits to these departments, efforts can be directed to encourage more suitable care. Our study was done in a rural county hospital in eastern New Mexico. Data were collected from all emergency department visits over a 4-week period. Patient and physician questionnaires were administered to assess aspects of emergency department use, including appropriateness based on published criteria, physicians'' opinion of appropriateness, groups who made inappropriate visits, and the perception of the need for and the urgency of a visit. We found that 32% of visits were inappropriate based on published criteria and 24% were considered inappropriate by physician opinion. Two groups with a high rate of inappropriate visits were Hispanics and Medicaid recipients. Patients and physicians have differing opinions of the urgency of a visit and of how soon medical treatment is required. To decrease the frequency of inappropriate use of emergency departments, educational efforts should be focused on the subgroups with high rates of such use.     

Walk-in clinics: implications for family practice.

To understand better the reasons for the growth in popularity of walk-in clinics in Canada we surveyed 321 patients with a regular physician in Toronto who attended a walk-in clinic in the same city over a 16-day period in February 1988. They were asked their reason for attending the clinic, their perception of the urgency of their problem, their choices as alternatives to walk-in clinics and their satisfaction and concerns with the type of care received at the clinic. The three most common reasons for attending the clinic were convenient location (in 33% of the cases), inability to see their regular physician soon enough (in 16%) and no appointment needed (in 13%). Most (80%) of the patients felt that they needed medical attention within 24 hours after the onset of their problem. Most (83%) of the respondents would have sought medical attention at another walk-in clinic, from their regular physician or at an emergency department had the clinic been closed. Only 36% and 18% of the patients respectively responded that their regular physician worked evenings or weekends. Most of the visits to the clinic were outside regular weekday business hours. The level of satisfaction with the service received at the clinic was high. The extended hours and no-appointment philosophy of walk-in clinics, coupled with family physicians'' reluctance to work evenings and weekends, have made such clinics an attractive option for patients with primary care problems that they believe require prompt attention.     

Barriers to prenatal care for low-income women.

Inadequate prenatal care is associated with poor birth outcomes. Recognizing barriers to care is necessary to improve results. Postpartum in-hospital interviews were conducted with women admitted through emergency departments with no physician of record (n = 69) in 8 Sacramento hospitals during April and May 1991. A focus group of local obstetrician-gynecologists was used to determine physicians'' attitudes about caring for low-income women. We undertook the study in response to an increased number of "no doc" births. The inability to find a physician willing to accept them was reported by the women as the single largest barrier to obtaining care, cited by 64% of women overall and 96% of those who tried but were unable to obtain care. Transportation difficulties were a problem regardless of women''s success in obtaining care and were ranked as the top barrier by women who never tried to obtain care. Physicians cited administrative difficulties and reimbursement levels of Medi-Cal plus extra care requirements and resource dependency of low-income patients as barriers to caring for this population. The value ascribed to prenatal care by women and physicians'' perceptions of women''s attitudes about care contrasted sharply. The link between poor women and physicians providing obstetric services can be fragile. The difficulty finding physicians willing to take them indicates that these women need special support services to ensure adequate care during pregnancy.     

Screening for hypertension in a high school population.

Of 15 594 high school students (ages, 15 to 20) whose blood pressure was measured in a screening program, 350 (2.2%) has hypertensive readings (150 mm Hg or more systolic, or 95 mm Hg or more diastolic, or both). The mean blood pressure for the boys was 125.0 plus or minus 12.1/71.8 plus or minus 10.9 mm Hg, and for the girls, 119.8 plus or minus 10.2/72.3 plus or minus 9.2 mm Hg. The parents of the students with hypertensive readings were advised to send their children to a physician. By 6 months, of the 232 who were followed up, 156 (67.2%) has visited a physician and in 19 cases (12.2%) the physician had confirmed the hypertensive readings. Only one student, an asymptomatic 17-year-old boy whose hypertension had not previously been detected, was found to have secondary hypertension, which was relieved surgically. Of the 18 hypertensive students 4 are currently receiving antihypertensive medication and 8 continue to have their blood pressure monitored. The mean blood pressures recorded in the physicians'' offices averaged 23.7/11.1 mm Hg less than those recorded in the schools. One reason for this was that none of the physicians used pediatric cuffs, but these were required by 62.4% of the students at the screening. Hence, the intravascular blood pressure was probably underestimated in a number of cases in the physicians'' offices.     

Health care cost effects of public use of a regional poison control center.

Poison control centers in the United States are threatened with closure, and attempts at a cost-benefit analysis of these services have been indeterminate. The purpose of this study was to compare the operating costs of a regional poison control center resulting from public use of its telephone hotline services with those of hypothetical alternative sources of advice and care. We conducted a follow-up telephone survey among 589 public callers to the San Francisco Bay Area Regional Poison Control Center who had been managed at home without medical referral after an unintentional poisoning. All survey respondents were asked what alternative action they would have taken had the poison control center not been available to assist them by telephone consultation. We then surveyed emergency departments and physicians'' offices cited as alternatives by the callers to determine their response and charges for evaluating a suspected poisoning case. A total of 464 (79%) of the callers surveyed would have sought assistance from their local emergency health care system had the poison control center not been available. We conservatively estimated that the total charges for such evaluations would be +71,900. Comparatively, the total actual operating cost of services provided by the poison control center for all 589 poisoning cases was +13,547. Most of the study subjects (429 [73%]) had private insurance coverage. Direct public access to these services probably reduces the use of emergency health care resources, thus lowering health care costs.     

Can more efficient use be made of x ray examinations in the accident and emergency department?

Increasing workloads in our radiology department prompted a study of casualty officers'' use of x ray examinations, of which there were 5463 in the period. While casualty officers were in post referrals for x ray examination did not become more selective, but skills in interpreting films improved. Overall, 4.9% of trauma radiographs were misinterpreted, but this fell from 7.1% to 2.9% during tenure of post. One in four errors was clinically important. Clinical guidelines for selective radiography produced a significant and sustained reduction in the number of x ray examinations requested by the department. Analysis of one common injury indicated that the quality of patient care was not adversely affected. The number of x ray examinations carried out in the accident and emergency department can be reduced by using guidelines, and this does not compromise the quality of patient care. Appreciable savings may be made in patients'' waiting times and radiodiagnostic expenditure.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians'' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

Results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

This paper describes the experience of the College of Physicians and Surgeons of Ontario in developing and conducting a program for the peer assessment of physicians'' office practices that would allow the standards of medical practice to be reviewed and assessed. Following two pilot projects in 1978 and 1979 that demonstrated the need, the feasibility and the acceptance of a peer assessment program the office practices of 391 randomly selected physicians were reviewed in 1981 and 1982. Included in the sample were 255 general/family practitioners and 136 specialists in seven fields. Serious deficiencies were found in the medical records of or in the care provided by 30 of the general/family practitioners and 3 of the specialists, accounting for 8% of the practices studied. The difference between the two groups of physicians was statistically significant (p less than 0.01). No predictors of significance were demonstrated in the general/family practitioner group. When follow-up assessments were done most of the physicians were found to have made the improvements that had been recommended.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.     

Effect of Supervised Students' Involvement on Diagnostic Accuracy in Hospitalized Medical Patients �� A Prospective Controlled Study

Background

During internships most medical students engage in history taking and physical examination during evaluation of hospitalized patients. However, the students'' ability for pattern recognition is not as developed as in medical experts and complete history taking is often not repeated by an expert, so important clues may be missed. On the other hand, students'' history taking is usually more extensive than experts'' history taking and medical students discuss their findings with a Supervisor. Thus the effect of student involvement on diagnostic accuracy is unclear. We therefore compared the diagnostic accuracy for patients in the medical emergency department with and without student involvement in the evaluation process.

Methodology/Principal Findings

Patients in the medical emergency department were assigned to evaluation by either a supervised medical student or an emergency department physician. We only included patients who were admitted to our hospital and subsequently cared for by another medical team on the ward. We compared the working diagnosis from the emergency department with the discharge diagnosis. A total of 310 patients included in the study were cared for by 41 medical students and 21 emergency department physicians. The working diagnosis was changed in 22% of the patients evaluated by physicians evaluation and in 10% of the patients evaluated by supervised medical students (p = .006). There was no difference in the expenditures for diagnostic procedures, length of stay in the emergency department or patient comorbidity complexity level.

Conclusion/Significance

Involvement of closely supervised medical students in the evaluation process of hospitalized medical patients leads to an improved diagnostic accuracy compared to evaluation by an emergency department physician alone.