Alternatives to hospital care: what are they and who should decide?

OBJECTIVE--To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds. DESIGN--Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants. SETTING--One hospital for acute admissions in a rural area of the South and West region of England. SUBJECTS--Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels. MAIN OUTCOME MEASURES--Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care. RESULTS--Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels. CONCLUSION--About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.     

Nuclear medicine in district general hospitals.

Nuclear medicine is a recognised clinical specialty both nationally and internationally. Compared with other countries, it is inadequately developed in Britain, particularly in district general hospitals. To create clinical radioisotope services at district level physicians or radiologists with experience in nuclear medicine need to be trained and appointed. Such appointments would allow facilities to evolve that would provide either a comprehensive nuclear medicine service formed around a physician or an imaging service based on a radiologist. Such units would improve the care of patients at a reasonable recurring cost of 15 pounds--30 pounds per investigation.     

PEDIATRICIAN'S POINT OF VIEW

Medical care for rural populations is an important problem facing the medical profession nationally and locally. The mechanism for solution lies in the existing American Medical Association and California Medical Association committees on rural medical service and further development of “local health councils.”Additional emphasis on training of physicians for general practice is essential through medical school graduate and postgraduate periods.The problem of providing additional adequately equipped and staffed hospitals must receive much consideration.Recognizing that passiveness invites aggressive non-medical agencies to foster bureaucratic dictation inimical to the practice of medicine, the rural physician must act through medical and community organizations to correct weaknesses in the structure of medical practice.     

PEDIATRICIAN'S POINT OF VIEW

Medical care for rural populations is an important problem facing the medical profession nationally and locally. The mechanism for solution lies in the existing American Medical Association and California Medical Association committees on rural medical service and further development of "local health councils."Additional emphasis on training of physicians for general practice is essential through medical school graduate and postgraduate periods. The problem of providing additional adequately equipped and staffed hospitals must receive much consideration.Recognizing that passiveness invites aggressive non-medical agencies to foster bureaucratic dictation inimical to the practice of medicine, the rural physician must act through medical and community organizations to correct weaknesses in the structure of medical practice.     

The Canadian general internist: education and future role.

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

The Primary Care Network: A New Type of HMO for Private Practice Physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year.Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah.This plan represents an attempt by physicians to control costs without government regulation.     

The Intensive Respiratory Care Unit—An Approach to the Care of Acute Respiratory Failure

An organized approach for the management of acute respiratory failure in an intensive general care unit utilizes a team of consultants including a general physician, a surgeon, respiratory care nurses, physical therapists and a blood gas technician. Because this team provides consultation and technical assistance in respiratory care and provides the equipment as well as the monitoring of care, this approach is suitable for any hospital interested in the management of acute respiratory emergencies.     

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

Background:

Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

Methods:

We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient’s most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

Results:

We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72–1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient’s condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39–8.42] d for most experienced quartile; 7.63 [95% CI 7.13–8.14] d for least experienced quartile).

Interpretation:

For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.Many jurisdictions have instituted compulsory recertification of physicians on the assumption that quality of care declines with experience. Although a systematic review reported that 32 of 62 studies found decreasing performance with increasing physician experience, most of these studies evaluated performance on examinations or hypothetical vignettes rather than actual quality of care provided to patients, and most of the studies were done decades ago, before the widespread availability of tools to readily facilitate evidence-based medicine.¹Experience is strongly related to better outcomes in surgery and obstetrics, but studies examining the association between physician experience and quality of care for medical patients have reported mixed results.^1–8 Many of the studies reporting an inverse association between experience and quality of care have focused on the provision of “guideline recommended tests or therapies” as a proxy for quality of care. However, guideline recommendations might not be appropriate in every situation.An evaluation of broader quality metrics may be more appropriate to answer this question. For example, in-hospital mortality and readmission rates or mortality postdischarge are commonly used as markers for quality of inpatient care, are endorsed by the Centers for Medicare & Medicaid Services and are included in the Patient Protection and Affordable Care Act.^9,10 However, to our knowledge, few studies have examined the association between these broader quality metrics and physician experience, and these studies have been limited. They either focused on single diagnoses,¹¹ excluded older adult patients,² examined data from only 1 hospital⁸ or combined data⁷ for both surgeons and physicians.Patients admitted to general internal medicine services at Alberta teaching hospitals are distributed between wards purely on the basis of bed availability, and attending physicians rotate every 1–4 weeks. For these reasons, the distribution of patients between attending physicians is quasirandom. We took advantage of this natural experiment to evaluate the association between attending physician experience (years since medical school graduation) and outcomes for patients admitted to general internal medicine wards in Alberta.     

The need for acute,subacute, and nonacute care at 105 general hospital sites on Ontario

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario''s general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

Secondary care beyond Tomlinson: an opportunity to be seized or squandered?

The Tomlinson report''s emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson''s recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.     

Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Where have all the giants gone? Reconciling medical education and the traditions of patient care with limitations on resident work hours

The Accreditation Council for Graduate Medical Education recently approved regulations that would prohibit residents from working more than 80 hours per week and more than 24 hours at a stretch. These regulations are scheduled to take effect in all U.S. teaching hospitals on 1 July 2003. Those who approve of the proposed regulations argue that house staff fatigue is responsible for physician error, depression, anger, and a lack of compassion for patients. But critics point to the adverse effects on key goals of house staff training--the development of accountability and responsibility. Can the rigorous discipline of medical education and the long tradition of medicine as a profession be reconciled with the current calls for limiting resident duty hours and on-call schedules? The intensity of patient care in teaching hospitals today is far greater than it was in the past. These changes in medical care make it critical to develop new programs that will reconcile rigorous, scientifically based humanistic medicine with the needs of patients and physicians. This will require imaginative and creative solutions that take a larger view of medical education and medical care than mere manpower calculations and numerical solutions focused simply on compliance with an 80-hour work week.     

Health Data and the Physician

California Health Data Corporation was formed to create better health data resources under the direction of hospitals and medicine. Highest priority is being given to developing information systems that will serve physicians, as well as those who are usually considered health data users. This is illustrated in CHD''s first major activity, sponsorship of a medical record information system for California hospitals. This system is designed first of all to provide better information for medical staff committees, and as a byproduct to provide data flow into a CHD data bank. For the practicing physician, the significance of CHD is that the organization will attempt to develop information systems that will help the medical profession maintain its central role in guiding the present and future patterns of health care.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

Psychiatric and nonpsychiatric facilities in the care of psychogeriatric patients.

The care of elderly patients who are mentally impaired requires reorganization in the delivery of mental health services to these patients. In this paper recommendations are made for the improvement of such services. These include the development of comprehensive psychogeriatric assessment services, which should be based mainly in general hospitals, the rationalization of the roles of facilities that provide nonpsychiatric long-term care, the development of specialized facilities for demented elderly patients, and a focus on education in psychogeriatrics for both undergraduate and postgraduate students in medicine and in other health care professions.     

Community-based mental health care in Africa: mental health workers’ views

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.     

Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.

OBJECTIVE: To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams. DESIGN: One year retrospective and a 2 1/2 year prospective study. SETTING: Two hospitals in West London and 88 general practitioners in 72 general hospitals. SUBJECTS: 209 adults with HIV infection. INTERVENTION: General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced. MAIN OUTCOME MEASURES: Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners. RESULTS: The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved. CONCLUSIONS: This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.     

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.