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).     

Quality of stroke care within a hospital: effects of a mobile stroke service

OBJECTIVE: An Australian stroke services study (SCOPES) has developed a framework to compare different forms of acute stroke services, the gold standard being localised stroke units. We aimed to use this framework to assess changes in the quality of stroke care over time as a sequential audit process. DESIGN AND SETTING: A retrospective medical record audit comparing 100 sequential stroke admissions (July 2002 to June 2003) two years after institution of a mobile stroke service (MSS) with 100 historical controls (September 1998 to October 1999) at a 260-bed hospital in Melbourne. The MSS results were also compared with stroke units in SCOPES. MAIN OUTCOME MEASURES: Adherence to quality indicators and standard measures of outcome (complications, length of stay and discharge disability) after implementing the MSS. RESULTS: Significant improvements were seen in prophylaxis for deep-vein thrombosis, incontinence management, premorbid function documentation, frequent neurological observations and early occupational therapy. The MSS demonstrated fewer severe complications (9% versus 24%; P = 0.004), reduced median length of stay (discharged patients: 12.0 days versus 18.5 days; P = 0.003) and more patients were independent at discharge (32% versus 9%; P < 0.001). Comparison with SCOPES stroke units showed our MSS could improve in incontinence management and appropriate use of antiplatelet therapy. CONCLUSION: Institution of the MSS was associated with improvements in the quality of stroke care. This study demonstrates application of an audit procedure for quality improvement in hospital stroke management and the potential to improve stroke services in smaller centres.     

Orthostatic haemodynamic responses in acute stroke

Little is known about orthostatic blood pressure regulation in acute stroke. We determined postural haemodynamic responses in 40 patients with acute stroke (mild or moderate severity) and 40 non-stroke control in-patients, at two days ('Day 1') and one week ('Week 1') post-admission. Following a 10-minute supine rest and baseline readings, subjects sat up and blood pressure and heart rate were taken for 5 minutes. The procedure was repeated with subjects moving from supine to the standing posture. Haemodynamic changes from supine data were analysed. On standing up, the control group had a transient significant fall in mean arterial blood pressure on Day 1 but not Week 1. No significant changes were seen on either day when sitting up. In contrast to controls, the stroke group showed increases in mean arterial blood pressure on moving from supine to the sitting and standing positions on both days. Persistent postural hypotension defined as > or = 20 mmHg systolic fall occurred in < 10% of either of the study groups on both days. Sitting and standing heart rates in both groups were significantly faster than supine heart rate on both days. The orthostatic blood pressure elevation is consistent with sympathetic nervous system overactivity which has been reported in acute stroke. Upright positioning as part of early rehabilitation and mobilisation following mild-to-moderate stroke would, therefore, not predispose to detrimental postural reductions in blood pressure.     

Primary care physicians and AIDS. Attitudinal and structural barriers to care

OBJECTIVE--To explore the extent to which primary care physicians are providing health care for people with human immunodeficiency virus (HIV) infection and to document barriers to HIV care giving. DESIGN--National random-sample mailed survey. PARTICIPANTS--Population-based random sample of 2004 US general internists, family physicians, and general practitioners in 1990. Response rate was 59%. MAIN OUTCOME MEASURES--HIV treatment experience, willingness to treat HIV-infected patients, negative attitudes toward homosexuals and intravenous drug users, fear of contagion of the acquired immunodeficiency syndrome (AIDS), perceived lack of information about AIDS, and time demands of HIV care. RESULTS--Most physicians (75%) had treated one or more patients with HIV infection. A majority (68%) believed that they had a responsibility to treat people with HIV infection, yet half (50%) indicated that they would not, if given a choice. Over 80% of respondents believed that they lacked information about AIDS and that caring for people with AIDS is time consuming. Further, 35% of respondents agreed that they "would feel nervous among a group of homosexuals" and 55% expressed discomfort about having intravenous drug users in their practice. Physicians who had treated 10 or more HIV-infected patients expressed less negativity toward members of these stigmatized groups who are likely to be HIV infected. CONCLUSIONS--These data suggest that many primary care physicians are responding professionally to the AIDS epidemic but that attitudinal barriers may be hindering some physicians from providing treatment to HIV-infected patients.