Appropriateness,Reasons and Independent Predictors of Consultations in the Emergency Department (ED) of a Dutch Tertiary Care Center: A Prospective Cohort Study

Objective

Consultations occur frequently in the emergency department (ED) of tertiary care centres and pose a threat for patient safety as they contribute to ED lengths of stay (LOS) and overcrowding. The aim of this study was to investigate reasons and appropriateness of consultations, and the relative impact of specialty and patient characteristics on the probability of a consultation, because this could help to improve efficiency of ED patient care.

Methods

This prospective cohort study included ED patients presenting to a Dutch tertiary care centre in a setting where ED physicians mostly treat self-referred and undifferentiated patients and other specialists treat referred patients. Consultations were defined as appropriate if the reason of consultation corresponded with the final advice, conclusion or policy of the consulted specialty. Multivariable logistic regression analysis was used to assess the relative contribution of specialty and patient characteristics on consultation.

Results

In the 344 (24% (95% CI 22 to 26%)) of the 1434 inclusions another specialty was consulted, resulting in a 55% increase of ED LOS. ED physicians more often consulted another specialty with a corrected odds ratio (OR) of 5.6 (4.0 to 7.8), mostly because consultations were mandatory in case of hospitalization or outpatient follow-up. Limited expertise of ED physicians was the reason for consultation in 7% (5 to 9%). The appropriateness of consultations was 84% (81 to 88%), similar between ED physicians and other specialists (P = 0.949). The patient characteristics age, comorbidity, and triage category and complaint predicted consultation.

Conclusion

In a Dutch tertiary care centre another specialty was consulted in 24% of the patients, mostly for an appropriate reason, and rarely because of lack of expertise. The impact of consultations on ED LOS could be reduced if mandatory consultations are abolished and predictors of a consultation are used to facilitate timely consultation.     

Effect of computer use in the consultation on the delivery of care.

The effects of the use of a computer on the delivery of care in consultations in general practice were examined. In this trial a computer system provided for the review and update of patients'' medical histories, notes on doctor-patient contacts, and information on repeat prescribing. Thirty consultations in which the computer system was used and 30 consultations in which no computer was used were matched individually for the doctor consulted, the sex and age of the patient, and the presenting problem(s). Six independent general practitioners blind rated each consultation for the standard of care attained. A minor negative effect of computer use on the doctors'' clinical performance was found. We suggest, however, that this small effect would disappear if a computer system was used routinely.     

Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study

In western Europe, UK has the highest teenage pregnancy rate among 15-19 year olds. Although general practice is one source of provision of contraception, it has been suggested that teenagers are reluctant to seek advice because of difficulty in gaining access and fears about confidentiality. This case-control study determined patterns of consultation in general practice and provision of contraception before teenage pregnancy. A total of 240 cases with a recorded conception before age 20 and 719 matched controls were identified. Overall, results show that most teenagers who became pregnant attended a general practice in the year before pregnancy, and many had sought contraceptive advice. Cases were more likely to have consulted a doctor in the year before conception than controls (odds ratio, 2.70; 95% confidence interval, 1.56-4.66). An association between provision of emergency contraception and pregnancy ending in termination was found. This finding emphasizes the need for continuing follow-up of teenagers consulting for this form of contraception.     

How much personal care in four group practices?

OBJECTIVE--To establish the degree of continuity of care in general practice. DESIGN--Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING--Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS--776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES--Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS--In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS--Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health''s recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.     

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patient''s daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.     

Attitudes to tobacco smoking among Warsaw's physicians

Physicians in the majority of countries in which tobacco-smoking has successfully been reduced stopped smoking themselves as the first professional group. Physician's attitude towards smoking patients plays an important role. Sometimes a single medical consultation helps some tobacco-abused patients to quit smoking for ever. However, the time of such a consultation should be adequately long. Out of all methods to control smoking such a consultation has the widest social extend and produces the most favourable effect; about 3% of the tobacco abusers quit smoking. These results are even better if physician consultation is supplemented with other activities such as supply with proper literature, reference to antinicotine center and return to the subject at any further consultation. It means that half a million smokers would quit this habit if every physician employed in the primary carek in Poland would have consulted each smoking patient. We attempted to check physician's attitude towards tobacco-smoking and their activity in this field.     

Use of deputising services and night visit rates in general practice.

Examining all of the claim forms for night visits submitted to the Nottingham Family Practitioner Committee over a three month period allowed us to calculate the night visit rate for all 184 practices in Nottinghamshire. To take all of the practices together the mean night visit rate (covering all visits requested and made between 11 00 pm and 7 00 am) was 15.5 visits per 1000 patients a year, range 1.2 to 46.1. Whether or not a deputising service is used accounted for 12% of the total variance detected, while the other factors studied, such as area of practice, patient list size, and number of partners, accounted for approximately 1% each. The local deputising service responds to 97% of night calls with a visit to the patient, whereas the patient''s own doctor is more likely to provide advice over the telephone. The ability to provide telephone advice, however, will vary according to the breakdown of the practice by age and social class.     

Time intervals to care and health service use experiences of uninsured cancer patients treated under public financing in Mexico City

BackgroundThe present study assesses the time intervals from symptom discovery to treatment start and describes the health service use experiences of uninsured patients with cancer of the breast, cervix uteri, testicle, and prostate before their arrival to the cancer hospital.MethodsThis cross-sectional study included 1468 patients who were diagnosed between June 2016 and May 2017 and received treatment for the selected cancers in two of the largest public cancer hospitals in Mexico City, financed through Seguro Popular. Data was collected through a survey administered via face-to-face interviews with patients and a review of their medical files.ResultsThe median time between detection (symptom discovery or first abnormal screening test) and treatment start was 6.6 months. For all types of cancer, the longest interval was the diagnostic interval –between the first use of healthcare services and the confirmation of cancer. Less than 20% cancer patients were diagnosed in the earliest stages that are associated with the best chances of long-term survival. The participants described a high use of private services for their first consultation, the use of several different types of health services and multiple consultations before arrival to the cancer centers, and 35% perceived being misdiagnosed by the first doctor they consulted.ConclusionsMost cancer patients treated in the two largest public institutions available for the uninsured faced long delays to get diagnosed and started treatment at advanced stages. Strengthening quality and access for effective early cancer diagnosis and treatment is key to improve patient outcomes in low and middle-income settings.     

Equity and consultation rates in general practice.

An attempt was made to distinguish different types of consultations and their variation by social class by a secondary analysis of the second national morbidity survey in general practice. The greatest difference in consultation rates, comparing patients in social classes IV and V with those in classes I and II, was for life threatening, urgent, chronic, or incapacitating conditions, thus matching the presumed difference in need. For more trivial conditions and for symptoms not specifically diagnosed the difference between social classes was less, and for married women in various ways consultation rates suggested less care seeking by patients in the lower social classes. The different uses made of primary care is more illuminating and more relevant to the question of equality in use of services than crude overall consulting rates by social class.     

Decision making by general practitioners in diagnosis and management of lower urinary tract symptoms in women.

OBJECTIVE--To identify factors influencing decision making by general practitioners in the diagnosis and treatment of lower urinary tract symptoms in women. SETTING--Two suburban London general practices. SUBJECTS--Women presenting to their family doctor with lower urinary tract symptoms. DESIGN--After each consultation the doctor completed a questionnaire on presenting symptoms; clinical examination; investigations undertaken; presence of psychological, social, and menstrual problems; patients'' requests for antibiotics; antibiotic prescribing; knowledge of the patient; attitude towards the consultation; and any other factors assisting in diagnosis and management. Finally, doctors predicted the presence or absence of clinically important bacteriuria. Each woman completed a demographic questionnaire, the 12 item general health questionnaire, and the modified menstrual distress questionnaire, after which each provided a clean catch midstream urine sample. Case notes were examined for information on previous reports of results of urine analysis. RESULTS--When the general practitioners did not know the patients well they were 4.5 times more likely to assume that there was a clinically important infection. When they knew the patient well, they were four times more likely to make a correct prediction of the test result and 12 times less likely to prescribe antibiotics. Doctors were five times more likely to predict the test result correctly in patients from social classes 1 and 2 and were six times more likely to prescribe antibiotics for the older women in the sample. CONCLUSIONS--In women presenting with urinary tract symptoms, these family practitioners seemed to take no particular regard of physical, psychological, or menstrual factors in making their assessments. They were most accurate in their prediction of the result of urine analysis and least likely to prescribe antibiotics when they had a good general knowledge of the patient. Which came first, the diagnosis or prescribing, is difficult to say and probably differed in individual cases. Doctors tended to be more conservative in their management of older women and those whom they knew less well.     

Patients who usually consult the trainee in general practice.

An analysis of every tenth case record from each year of birth and for both sexes from a patient list in a practice with three partners showed that 13% of patients who attended the health centre at least twice a year had usually consulted a trainee. These patients were usually young adults, free from known important long term health problems, and they had closely similar clinical characteristics to those patients who did not usually consult the same principal. Few patients usually consulted each trainee over three years.     

Telematics: a new tool for epidemiological surveillance of diarrhoeal diseases in the Aquitaine sentinel network.

A sentinel health information system using telematics and a network of general practitioners was set up in Aquitaine in south western France in 1986. Among the health problems under surveillance was acute diarrhoea. Data for each patient who fulfilled the usual case definition for acute diarrhoea were reported by general practitioners using home terminals (Minitels) connected to a central computer by telephone. Over one year 2234 cases of diarrhoea were reported, the incidence varying from 0.8 to 1.5 cases per doctor per week. Seasonal variations in incidence were observed, with peaks in the winter and in the summer. Only 379 (17%) episodes of diarrhoea were classified as severe, and these patients consulted their general practitioners earlier than patients whose diarrhoea was less severe. Foreign travel was rarely found in the patients'' histories, but clusters of cases were found in communities (4.6%) and in families (22.3%). The advantages of this system were easy reporting and immediate feedback, but it was difficult to extrapolate the data, and the system was inadequate for intervening in outbreaks of diarrhoeal disease. Our knowledge of diarrhoeal diseases in south west France improved.     

Evaluating care of patients reporting pain in fundholding practices.

OBJECTIVE--To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. DESIGN--Questionnaire and record based study. SUBJECTS--Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. SETTING--Six practice groups in pilot fundholding scheme in Scotland. MAIN OUTCOME MEASURES--Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. RESULTS--About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992; about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded "much better" to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. CONCLUSIONS--Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.     

Symptoms of respiratory tract infection and associated care-seeking in subjects with and without obstructive lung disease; The Tromso Study: Tromso 6

ABSTRACT: BACKGROUND: Respiratory tract infections (RTIs) may be more severe in those with asthma or COPD and these patients are more frequently in need of health care. The aim of the study was to describe the frequency of RTI symptoms in a general adult population and how care-seeking is associated with the presence of obstructive lung disease. METHODS: Cross-sectional data including spirometry and self-reported chronic diseases were collected among middle-aged and elderly subjects in the Tromso population survey (Tromso 6). Self- reported RTI symptoms, consultations and antibiotic use were the main outcome variables. Possible predictors of RTI symptoms were evaluated by multivariable logistic regression. RESULTS: Of the 6414 subjects included, 798 (12.4 %) reported RTI symptoms in the previous week. RTI symptoms were reported less frequently by subjects aged 75 years or above, than by those younger than 55 years (OR 0.5). Winter season (OR 1.28), current smoking (OR 1.60), low self-rated health (OR 1.26) and moderate to severe bronchial obstruction (OR 1.51), were also statistically significant independent predictors of RTI symptoms, but these variables did not predict RTI symptoms that had started within the previous seven days. Among subjects with RTI symptoms, 5.1 % also reported a consultation with a doctor. In those with bronchial obstruction by spirometry, who did not report asthma or COPD, this frequency was 2.4 %. Antibiotic treatment was reported by 7.4 % of the participants, among whom one third had consulted a doctor. Antibiotics were taken more frequently when asthma or COPD was reported (13.7 %), but not in subjects with bronchial obstruction who did not report these diseases (7.2 %). CONCLUSIONS: RTI symptoms seldom led to consultation with a doctor and not even in subjects with obstructive lung disease. This was in particular the case in subject who did not know about their obstructive lung disease. Strategies for early diagnosis of COPD and providing health care to subjects with such disease cannot rely on their doctor visits due to respiratory symptoms.     

Adolescent self harm patients: audit of assessment in an accident and emergency department.

OBJECTIVE--To examine the assessment of adolescent self harm patients attending an accident and emergency department. DESIGN--Retrospective assessment of case notes. SETTING--Accident and emergency department, Leicester Royal Infirmary. PATIENTS--210 adolescent patients (aged 9-19 years) attending the department during 1 January 1989-31 December 1989 after deliberate self poisoning; records were available for 200. MAIN OUTCOME MEASURES--Numbers of admissions, discharges from department without either a psychiatric consultation or some form of follow up, and discharges with either of these; scoring of adequacy of psychiatric and social assessment by accident and emergency doctor. RESULTS--89 patients were admitted (mean score 5.1, excluding 22 patients too drowsy or unforthcoming for proper assessment), 80 were discharged without specific psychiatric consultation or other follow up (mean score 5.4), and 31 were discharged with psychiatric consultation or other follow up (mean score 9.1). The percentage of patients in each group whose assessment by the accident and emergency doctor was considered to be adequate or better than adequate over 10 headings ranged from 0%-40% for admitted patients, 0%-50% for those discharged without psychiatric assessment, and 0%-61% in the remaining group. Overall, in almost half (49%, 54/111) of all of those discharged documentation of the suicidal state was inadequate. CONCLUSION--The assessment of many adolescent self harm patients in this clinic was unsatisfactory. IMPLICATIONS--Doctors working in accident and emergency departments should be encouraged to liaise with child psychiatrists before discharging such patients.     

Screening for psychosocial problems among primary care patients: a pilot study.

The symptoms that a patient presents to the doctor are often not the underlying concern that prompted the consultation. The success of consultations involving a hidden diagnosis depends on how well the patient can express his or her concerns to the doctor and on how skilfully the doctor can encourage this. This study tested the feasibility and acceptability of having patients complete a brief health index questionnaire designed to help them describe their underlying concerns to the doctor. In two family medicine centres 996 patients were asked to complete a questionnaire while waiting to see the doctor; 724 (73%) did so. An evaluation of their responses showed the method to be acceptable to most. The doctors judged that it added valuable information in 41% of all consultations and in 73% of consultations in which the patient presented with psychologic complaints. There was, nevertheless, considerable variation among the physicians in their acceptance of the approach. This variability is discussed in the light of alternative models of how, in practical terms, to treat the psychosocial dimensions of a patient''s complaint.     

Attitudes Toward Women Physicians: A Study of 500 Clinic Patients

A questionnaire was administered to 500 clinic patients and their replies about men and women physicians were analyzed. Ninety-six percent stated that the typical doctor is a man, and 78 percent expressed a preference for a male doctor. A significant number of patients said they would be unwilling to discuss certain subjects with a woman doctor or to follow her advice. Women physicians were considered less competent and less experienced than their male counterparts.Attitudes toward women doctors were correlated with patients'' sex, age, ethnicity, occupation, and chief complaint. Most impressive statistically were the negative attitudes of Spanish-speaking patients and the positive responses of obstetrics and gynecology patients and black women patients. Patients who had previously consulted women physicians were more favorable toward them, suggesting that increased exposure may lead to reduced prejudice.