Modifiable determinants of delayed hospital admission following a cerebrovascular accident

OBJECTIVE: To identify the modifiable determinants of delayed hospital admission of stroke patients. DESIGN: Multicentre observational study. METHOD: In the period from 1 October 1998 to 31 May 1999, before thrombolysis was an accepted treatment for ischaemic stroke in the Netherlands, we interviewed 252 consecutively admitted patients with stroke upon admission. The patients were asked to describe their symptoms and personal reaction to the stroke event in everyday language. The study was carried out in 14 regional hospitals and one university hospital in the Netherlands. The determinants of delay were calculated by means of multiple linear regression analysis. RESULTS: A total of 252 patients took part in the study: 136 men and 116 women, of whom 130 (52%) were 75 years of age or older. The median time from onset of symptoms to calling in any professional assistance was 60 minutes. The median time from onset of symptoms to arrival at the hospital was 5 hours and 10 minutes. One-third (n = 87; 34%) of the patients reached the hospital within 2.5 hours. Nearly half of the patients (46%) recognised their symptoms as a stroke. Patients who had not recognised their symptoms as a stroke (54%) and patients who had waited until their symptoms had worsened (20%) waited longer before calling in professional assistance than those who did not. Hospital admission was delayed in patients who had waited until their symptoms had worsened, and in those who had first called a family physician (87%). On the other hand, a more rapid admission was achieved in case of referral by the family physician by telephone and also after transportation by ambulance (77%). CONCLUSION: The modifiable determinants of delayed calling for professional help by stroke patients were the fact that they did not recognise the symptoms as a stroke, and the circumstance that they waited until the symptoms would disappear or become worse. This latter circumstance, referral by the family physician by telephone and transportation by ambulance, were modifiable determinants of delayed hospital admission.     

Delay in presentation after myocardial infarction.

Thrombolytic therapy reduces mortality in acute myocardial infarction (AMI), giving maximal benefit with early treatment. In the UK delayed presentation after AMI may reduce the advantages of thrombolysis. To assess this, 103 patients presenting with AMI to two London Hospitals were interviewed to determine the length and cause of delay from onset of chest pain to arrival at hospital. Forty-nine per cent of patients took longer than 2 h to arrive at hospital, and 21% took longer than 4 h. Patients who contacted their general practitioner (GP) had a significantly prolonged time delay (160 mins; 65-730: median; range) compared to those who went directly to hospital by ambulance (82 mins; 15-395; P < 0.0005), or on their own (90 min; 15-855; P < 0.005). Patients calling their GP took a similar duration to decide to seek help [decision time (30 min versus 25 mins) P = NS], but significantly longer to reach hospital once the decision was made (110 min versus 56 min; P < 0.0001), than those proceeding directly to hospital. Believing the pain was cardiac in origin significantly shortened decision time (15 min versus 45 min; P < 0.05), as did knowledge of the existence of thrombolysis (15 min versus 50 min; P < 0.05) and lack of prior cardiac symptoms (18 min versus 42 min; P < 0.05). Only 14% were aware of thrombolysis. Rank correlation confirmed that decision and total delay time were age independent. Delays of this magnitude may compromise the efficiency of thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Delay factors on the administration of thrombolytic therapy in patients diagnosed with acute myocardial infarction in a general hospital

OBJECTIVE: To identify factors that delay the onset of thrombolysis in patients with acute myocardial infarction (AMI). METHODS: A cohort study was carried out with 146 patients, each diagnosed with AMI and subjected to thrombolytic therapy. The data was extracted from medical records between January 2002 and December 2004. RESULTS: The average age of the studied population was 57.5 +/- 9 years, 64.4% were male. The average time between the onset of pain and arrival at the hospital was 254.7 +/- 126.6 minutes, 28.1% used an ambulance for the trip to the hospital, the door-to-electrocardiogram time averaged 19.4 +/- 7.3 minutes and the door-to-needle time was 51.1 +/- 14.9 minutes. There was no significant difference between the time of arrival to the hospital and the method of transportation used (P= 0.81), and those seen by cardiologists and during the nightshift had a reduction in the door-to-needle time, respectively (P=0.014) and (P=0.034). CONCLUSIONS: Study results show that the delay in the search for medical service, and the long time taken from door-to-electrocardiogram and to reach the AMI diagnosis were the factors involved in the delay of thrombolytic treatment.     

Delay in the presentation of breast symptoms for consultant investigation

Summary Women referred to hospital outpatients with breast symptoms were interviewed to ascertain the interval between first noticing a breast symptom and first consulting a doctor (patient delay). Later, the hospital notes of each patient were examined to determine the intervals between this first consultation and referral by a doctor (doctor delay) and between referral and outpatient attendance (hospital delay), as well as the diagnosis (benign or malignant). The study found that the largest component of delay between noticing symptoms and outpatient attendance was patient delay, with 20 per cent of the women delaying for more than 12 weeks. Analysis of this group revealed that long delays were related to both age and subsequent diagnosis, but that these two variables were not independent of each other. The findings that there were longer delays in older women and that symptoms other than lumps, which could indicate breast cancer, were associated with long delays, have implications for health education. Generally, doctors in the community distinguished between benign and malignant cases, with 86 per cent of the latter referred within a week. Most women waited 2 weeks or less for an outpatient appointment, with none of those subsequently found to have breast cancer waiting more than 4 weeks. This study was supported by a grant from the Department of Health and Social Security through the Wessex Regional Cancer Organisation.     

卒中入院延迟的社会决定因素分析

目的 了解我国卒中患者院前延迟的现状和社会决定因素,为制定卒中防治策略与措施提供参考.方法 采用自制问卷,对多家三级医院住院部的脑卒中患者进行调查.采用SPSS 18.0进行单因素分析和logistic回归分析.结果 共收回有效问卷778份.决定就医用时,363（47.27％）例患者少于1h,24.35％超过3h;转运用时,62.14％少于2h,21.67％超过3h.入院延迟的患者达到62.60％.logistic回归显示居住在农村的患者决定就医用时和转运用时都较长,入院延迟的发生率高.结论 卒中患者尤其是农村患者,决定就医用时和转运用时仍较长,院前延迟问题仍很严重.     

Incidence, delay and survival in the Belfast MONICA Project coronary event register

During the 1983-85 period, the Belfast MONICA Project registered coronary events in 2,512 individuals (1,913 men and 599 women). The attack rates in men and women per 1,000 person years were 5.9 and 1.7 respectively, and the corresponding mortality rates were 2.4 and 0.61; both rates were heavily age-dependent. There were statistically significant differences in the age and sex-standardised rates for the 107 electoral wards of the Study. The median delay time from onset to delivery of care was 2 hours 30 minutes and 3 hours 2 minutes for men and women, respectively. Delays were shorter in younger and married individuals, and in those with previous infarctions. Unmarried individuals and those with chronic ischaemic heart disease were at significantly increased risk of pre-care death. Sixty per cent of deaths within 28 days of onset occurred before the patient could be admitted to hospital. Sixty-four per cent of males and 67% of females were alive at 28 days. Manual workers and their spouses had a poorer survival at 28 days. Married men and women were at lowest risk of death in the first 28 days, and this could not be attributed to the effects of age.     

The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms

BACKGROUND: The psychological processes involved in the delay between noticing breast symptoms and seeking medical care are not well understood. METHODS: We evaluated 85 women referred to a specialist breast clinic prior to their clinic appointment. We assessed the relationship between delay and the type of breast symptom, immediate emotional response to the symptom, perceived risk of breast cancer, fear of breast cancer treatment, and disclosure of the breast symptom to others. RESULTS: Delay was unrelated to demographic factors but was related to the type of breast symptom; women who had a breast lump waited a significantly shorter time period before visiting the doctor than those without a breast lump. Initial symptom distress on the discovery of the breast symptom was also significantly related to delay. Knowledge of a friend or family member with breast cancer, perceived risk of breast cancer and fear of breast cancer treatment, and disclosure of the symptom to a partner or other person were all unrelated to delay. CONCLUSIONS: The results show the importance of the type of symptom and initial emotional distress in delay and highlight the importance of widening public perceptions of breast symptoms other than breast lumps in order to reduce delay times.     

Evaluation of the status of access to emergency care of subjects with myocardial infarction

This study, undertaken in the Bas-Rhin area of France by the MONICA Register, presents the evaluation of the procedures followed for 323 subjects under 65 years old suffering from an acute myocardial infarction and subsequently hospitalized for this reason. We observe that 87.5% of the patients first consult a private practitioner -- for the most part a non specialist -- while 9% first contact a mobile coronary unit. 3.5% of patients go directly to hospital. Concerning delays in hospitalization, 35% of patients more than 6 hours to consult a doctor, while the median time between the onset of symptoms and the first call for medical aid is 2 hours. The median delay between the onset of symptoms and arrival at hospital is 5hrs 45 min., 28% of the subjects requiring more than 24 hours to be hospitalized.     

Prehospital delay and independent/interdependent construal of self among Japanese patients with acute myocardial infarction

Reducing the time from symptom onset to reperfusion therapy is an important approach to minimizing myocardial damage and to preventing death from acute myocardial infarction (AMI). Previous studies suggest that certain ethnic or national groups, such as the Japanese, are more likely to delay in accessing care than other groups. The aims of this paper were the following; (1) to examine whether culture (defined as independent and interdependent construal of self) is associated with delay in accessing medical care in Japanese patients experiencing symptoms of AMI; (2) to determine if the relationship between independent and interdependent construal of self and prehospital delay time is mediated by cognitive responses and/or emotional responses; and (3) to determine if independent and interdependent construal of self independently predicts choice of treatment site (clinic vs. hospital). A cross-sectional study was conducted at hospitals in urban areas in Japan. One hundred and forty-five consecutive patients who were admitted with AMI within 72 h of the onset of symptoms were interviewed using the modified response to symptoms questionnaire and the independent and interdependent construal of self scale. The interdependent construal of self scores were significantly associated with prehospital delay time, controlling for demographics, medical history, and symptoms (p<.001). However, the relationship between independent and interdependent self and prehospital delay times was not mediated by cognitive or emotional responses. In multiple logistic regression analysis, patients with high independent construal of self were more likely to seek care at a hospital rather than a clinic compared to those with lower independent construal of self. In conclusion, cultural variation within this Japanese group was observed and was associated with prehospital delay time.     

Patient delay in women presenting with advanced breast cancer: an Iranian study

INTRODUCTION: Due to the lack of systematic screening programmes for early detection of breast cancer in Iran and the predominance of advanced cases, we aimed to study the extent and determinants of patient delay in women with advanced breast cancer. MATERIALS AND METHODS: In this 1-year cross-sectional study, all consecutive women with advanced breast cancer (stages IIb, III or IV) who initially presented to a university hospital were studied. RESULTS: Sixty-eight percent (136/200) of cases had delayed their first visit by >1 month and 42.5% by >3 months. The median patient delay was 12 weeks. Delay was associated with: older age, being married, lower income, less education, place of residence (small cities), negative family history of breast cancer, belief in the fatality of breast cancer, lack of access to health care services, lack of knowledge of breast cancer symptoms, and denying the importance of breast self-examination. The main reasons given for the delay were: lack of knowledge regarding the necessity of such a visit, fear, negligence, lack of access to physicians, and poverty. DISCUSSION: In contrast to some other studies, this study found that married women and those with a negative family history of breast cancer waited longer than others before seeking care. Public education initiatives focused on encouraging women (especially high-risk groups such as older women, married women, and those living in small cities or villages) to see a doctor promptly for evaluation of breast symptoms can decrease delay and improve patient outcome.     

The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study

We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75?years, are also observed in the elderly (i.e. ≥75?years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2?%) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55-64, 65-74, 75-84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75-84?year-olds (OR?=?1.26; 95?% CI 1.09-1.47) and ≥85?year-olds (OR?=?1.26; 1.00-1.58), and a higher 28-day case-fatality in both 75-84?year-olds (OR?=?1.26; 1.06-1.50) and ≥85?year-olds (OR?=?1.36; 0.99-1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85?year-olds (OR?=?1.20; 0.99-1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75?years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.     

Pre-hospital attitudes adopted by patients faced with the symptoms of acute myocardial infarction

This case series aimed to evaluate the behavior adopted by patients during the pre-hospital phase of acute myocardial infarction (AMI). A total of 115 AMI sufferers with ST-segment elevation were evaluated. The chi-square and Fisher's exact tests were applied. The individuals that did not associate the symptoms with cardiovascular disease most often attributed them to the following sources: gastrointestinal (38%), musculoskeletal (29.7%), food and/or medication poisoning (8.5%) and arising from the respiratory apparatus (6.3%). The proportion of major outcomes and of patients that arrived in the emergency department after 12 hours was higher among women, individuals with monthly income of up to one minimum wage, those who used analgesics and did not associate the symptoms with cardiovascular disease. It was found that individuals in unfavorable socioeconomic conditions, who interpreted the symptoms incorrectly, arrived later at the emergency department and had worse intra-hospital outcomes.     

Isolated headache in general practice: Determinants for delay in referral in patients with subarachnoid haemorrhage

Abstract Background: A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom. Objective: To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP). Methods: For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (>?2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Results: Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral. Conclusion: In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.     

不同性别急性心肌梗死患者3h内静脉溶栓的临床疗效分析

目的探讨不同性别急性心肌梗死（AMI）患者3h内静脉溶栓近期疗效的差异及危险因素。方法选择本院心内科收治的符合静脉溶栓适臆证,无禁忌证的AMI患者共98例。根据性别分为男性组76例,女性组22例。两组均于3h内给予静脉溶栓治疗。结果（1）接受静脉溶栓治疗的急性心肌梗死（AMI）患者男性年龄较女性提前（P〈0．05）;（2）两组住院病死率无明显差异（P〉0．05）;（3）男性梗死相关血管再通率大于女性（P〉0．05）;（4）AMI易患因素中,高血压因素两组比较无显著性差异（P〉0．05）;女性高血脂及糖尿病高于男性（P〈0．05）;男性吸烟史显著高于女性（P〈0．01）;（5）女性组并发心力衰竭及房室传导阻滞明显高于男性（P〈0．05）。结论急性心肌梗死（AMI）患者3h内静脉溶栓近期疗效,女性不如男性。     

Decreased blood selenium and risk of myocardial infarction

The relationship between whole blood selenium levels and risk of acute myocardial infarction was investigated in a community-based control study in Auckland, New Zealand. A pilot study in 14 patients admitted to hospital within 4 hours of onset of symptoms demonstrated that selenium levels were stable in the first 16 hours after admission for an acute myocardial infarction. Some 252 cases (199 men, 53 women) presenting to hospital within 20 hours of onset of acute myocardial infarction were compared with 838 controls (500 men, 338 women), group-matched for age and sex. Myocardial infarction patients had significantly lower mean selenium levels: 82.8 and 87.9 micrograms/l in male cases and controls (p = 0.003) and 82.1 and 88.5 micrograms/l in female cases and controls (p = 0.02) respectively. The relative risks of myocardial infarction in participants with selenium levels below the median level (85 micrograms/l) in comparison with participants above the median were 1.6 (95% CL 1.1-2.2) and 1.7 (95% CL 0.9-3.5) in men and women respectively. The effects of a low selenium level on risk of myocardial infarction were confined to cigarette smokers. These results suggest the hypothesis that a decreased blood selenium in the presence of cigarette smoking is a risk factor for coronary heart disease.     

Acute myocardial infarction incidence and hospital mortality: routinely collected national data versus linkage of national registers

Background and Objective To compare levels of and trends in incidence and hospital mortality of first acute myocardial infarction (AMI) based on routinely collected hospital morbidity data and on linked registers. Cases taken from routine hospital data are a mix of patients with recurrent and first events, and double counting occurs when cases are admitted for an event several times during 1 year. By linkage of registers, recurrent events and double counts can be excluded. Study Design and Setting In 1995 and 2000, 28,733 and 25,864 admissions for AMI were registered in the Dutch national hospital discharge register. Linkage with the population register yielded 21,565 patients with a first AMI in 1995 and 20,414 in 2000. Results In 1995 and 2000, the incidence based on the hospital register was higher than based on the linked registers in men (22% and 23% higher) and women (18% and 20% higher). In both years, hospital mortality based on the hospital register and on linked registers was similar. The decline in incidence between 1995 and 2000 was comparable whether based on standard hospital register data or linked data (18% and 20% in men, 15% and 17% in women). Similarly, the decline in hospital mortality was comparable using either approach (11% and 9% in both men and women). Conclusion Although the incidence based on routine hospital data overestimates the actual incidence of first AMI based on linked registers, hospital mortality and trends in incidence and hospital mortality are not changed by excluding recurrent events and double counts. Since trends in incidence and hospital mortality of AMI are often based on national routinely collected data, it is reassuring that our results indicate that findings from such studies are indeed valid and not biased because of recurrent events and double counts. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Hours worked by general practitioners and waiting times for primary care

The decline in the working hours of general practitioners (GPs) is a key factor influencing access to health care in many countries. We investigate the effect of changes in hours worked by GPs on waiting times in primary care using the Medicine in Australia: Balancing Employment and Life longitudinal survey of Australian doctors. We estimate GP fixed effects models for waiting time and use family circumstances to instrument for GP's hours worked. We find that a 10% reduction in hours worked increases average patient waiting time by 12%. Our findings highlight the importance of GPs' labor supply at the intensive margin in determining the length of time patients must wait to see their doctor.     

Lay public's knowledge and decisions in response to symptoms of acute myocardial infarction

Despite public health initiatives targeting rapid action in response to symptoms of myocardial infarction (MI), people continue to delay in going to a hospital when experiencing these symptoms due to lack of recognition as cardiac-related. The objective of this research was to characterize lay individuals’ knowledge of symptoms of acute myocardial infarction (AMI) and associated decision processes for timely action. Thirty participants were interviewed about their knowledge of AMI, then presented with unrelated, unfamiliar and familiar scenarios of AMI symptoms and instructed to “think aloud” as they made decisions in response to the scenarios in order to capture the decision process directly. Data were analyzed using qualitative and quantitative methods to identify the semantic relationships between knowledge and decisions. Results showed that most participants (80%) identified three symptoms or less (e.g., chest pain: 93%; dyspnea: 53%). All participants identified urgent actions (calling 911, going to ED) as the appropriate response to AMI symptoms. Urgent action decisions increased with familiarity of symptoms (57% for unrelated symptoms to 83% for most familiar symptoms), and was highest for the cardiac group. Lay knowledge of AMI is necessary, but not sufficient for people to develop required heuristics for timely action. This ineffective decision increases as a function of ambiguous and unfamiliar situations. Health education interventions should focus on teaching clusters of problems with varying levels of familiarity and complexity to increase flexibility in making decisions.     

Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004

As emergency department (ED) patient volumes increase throughout the United States, are patients waiting longer to see an ED physician? We evaluated the change in wait time to see an ED physician from 1997 to 2004 for all adult ED patients, patients diagnosed with acute myocardial infarction (AMI), and patients whom triage personnel designated as needing "emergent" attention. Increases in wait times of 4.1 percent per year occurred for all patients but were especially pronounced for patients with AMI, for whom waits increased 11.2 percent per year. Blacks, Hispanics, women, and patients seen in urban EDs waited longer than other patients did.