Access to primary care from the perspective of Aboriginal patients at an urban emergency department

In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.     

Access and care issues in urban urgent care clinic patients

Background  

Although primary care should be the cornerstone of medical practice, inappropriate use of urgent care for non-urgent patients is a growing problem that has significant economic and healthcare consequences. The characteristics of patients who choose the urgent care setting, as well as the reasoning behind their decisions, is not well established. The purpose of this study was to determine the motivation behind, and characteristics of, adult patients who choose to access health care in our urgent care clinic. The relevance of understanding the motivation driving this patient population is especially pertinent given recent trends towards universal healthcare and the unclear impact it may have on the demands of urgent care.     

Referrals from an emergency room to primary care practices at an urban hospital.

Three hundred ninety-eight patients treated in the emergency room for non-urgent complaints who stated that they had no regular source of primary medical care were referred to one of several medical care centers in the area. Overall, 34 per cent of such patients complied with the referral. Correlates of compliance were: age (very young and very old), patient-perceived health status, medically determined need for follow-up care, and having an appointment made by the emergency room provider. Another group of 500 successfully referred patients became excellent users of the primary care office, complying with requested health maintenance and follow-up visits. However, emergency room utilization by the successfully referred patients did not decrease more than among referred patients who did not enroll in the primary care source.     

Evaluating the treatment of sexually transmitted diseases at an urban public hospital outpatient clinic.

Sexually transmitted diseases occur disproportionately among the poor, are often treated in public hospitals and clinics, and have not been subjected to quality-of-care evaluation. We designed a medical record abstraction system using well-established, specific process-of-care criteria drawn from the medical literature and experts and grouped into three levels of quality: excellent, adequate, and minimal. One hundred seventy-six consecutive patients were identified from the clinic logbook and their medical records abstracted. Deficiencies in history taking, physical examination, laboratory testing, treatment, and public health reporting were identified.     

Utilisation of private care by public primary care clinic attenders with diabetes: relationship to health status and social factors

Private health care provision is important in most middle-income countries but factors influencing the demand for private care have not been well defined. This paper evaluated the relationships of health status and socio-economic variables with utilisation of private care by public primary care clinic attenders. The sample included 2117 randomly selected subjects with clinical diabetes attending 35 government health centres in Trinidad and Tobago. Measures included attendance at a private doctor, the type 2 Diabetes Symptom Checklist, the SF36 questionnaire, and indicators of socio-economic status. Of the sample, 1256 (59%) reported attending a private doctor, 577 (27%) attended a private doctor for diabetes, and 378 (18%) attended a private doctor regularly. Attendance at a private doctor was associated with lower SF36 scores. The odds ratio for a 10 unit increase in SF36 physical component score was 0.81, 95% confidence interval 0.72-0.91. After adjusting for demographic and social factors the relative odds were 0.89, 0.80 to 1.00. After allowing for differences in health status, the relative odds of attending for private care for those without a pipe borne water supply in the home, compared with those with water in the home, were 0.77, 0.63-0.94. Those living alone were less likely to attend a private doctor than those living with their children and partner (odds ratio 0.60, 0.43-0.83). Among people attending public clinics, the decision to utilise private care is sensitive to health status. After adjusting for health status, there was evidence for horizontal inequity in access to private care in relation to household amenities and composition.     

Trust in primary care providers and antiretroviral adherence in an urban HIV clinic

Interpersonal trust is an integral component of the patient-provider relationship and has been associated with patient adherence to medications. Studies suggest African Americans may have lower levels of trust in their health care providers than non-Hispanic Whites. This study examines the association between trust in one's primary care provider (PCP) and antiretroviral (ARV) adherence among 175 patients at an urban HIV clinic. Interviews elicited participants' level of trust in their current PCP using a multiple-item trust scale and assessed ARV adherence with a seven-day recall questionnaire. Logistic regression was used to ascertain the effect of trust in PCP on ARV adherence. High trust in PCP was significantly associated with increased odds of ARV adherence compared with low trust (adjusted odds ratio, 2.67; 95% confidence interval, 1.24 to 5.76; p=.01). Enhancing trust in PCPs may be a good target for interventions to improve ARV adherence, particularly among African American patients.     

Offering routine trichomonas vaginalis testing to patients presenting for abortion at an urban hospital-based clinic

IntroductionThe Centers for Disease Control and Prevention recommend considering screening asymptomatic women for trichomonas in high-prevalence settings. Whether urban abortion clinics constitute such a setting is unknown.Material and MethodsWe offered trichomonas screening to patients presenting for abortion from October 2018 to February 2019 as a practice improvement and conducted a chart review.ResultsNinety-two percent (593/644) of patients underwent testing. Trichomonas prevalence was 10.0% (95% CI 7.7?12.6). Ninety five percent of patients diagnosed were treated. Testing only symptomatic patients would have missed 98% of infections.ConclusionsTrichomonas was highly prevalent, and universal testing and treatment was feasible in an urban abortion clinic.     

Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic

Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.     

Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic

Objective: Describe the sociodemographic and clinical characteristics of patients with Hepatitis C Virus (HCV) attending an urban Indigenous primary health clinic (IPHC) in Brisbane, Australia. Methods: A retrospective chart review of sociodemographic characteristics, presence of liver disease and treatments, lifestyle behaviours and comorbidities in patients with a HCV infection was conducted between October 2015 and March 2016. Results: One hundred and thirteen patients with confirmed HCV infection were aged between seven and 63 years; 66% were male, and 84% were Indigenous. Sixty‐nine per cent had been incarcerated; 41% had experienced conflict or domestic violence; 47% were injecting drugs; 72% had depression; and 61% had anxiety. Cirrhosis was present in 7/95 patients with adequate data and associated with age (p=0.02). Eleven patients had commenced direct acting antiviral (DAA) therapy in the 18 months that it had been available. Conclusions: The study highlights the opportunities for enhancing treatment of patients with HCV infection. Opportunities to improve treatment rates in an Indigenous primary healthcare include optimising diagnostic pathways, improving patient engagement, and general practitioner and peer worker participation. Implications for public health: HCV poses a serious threat to public health in Australia and IPHCs are key sites to addressing this for Indigenous people. Optimising care of patients with HCV attending IPHC requires recognition of the complex health needs and social context, to reduce the incidence and consequences of HCV infection.     

Characteristics of first trimester abortion patients at an urban Indian clinic

Of the 5,918 clients undergoing early abortions at a subsidized, widely advertised clinic in New Delhi, India, in 1980 and 1981, an unexpectedly high percentage were both young and nulliparous. An estimated 85 percent were married and the mean gestation period was six to eight weeks. Another significant characteristic of these women was the small percentage of single-para patients relative to both the nulliparous and the two-parity patients; 35 percent had no children, 19 percent had one child, and 27 percent had two children. Only 20 percent had more than two children. Newspaper ads attracted about two-thirds of the abortion clients.     

Causes of death in an urban public hospital

For the study reported here, we examined the charts and autopsy reports of every death in the Department of Medicine at Cook County Hospital for the year 1983. In that period, there were 11,677 admissions to the Department and 476 deaths, yielding a mortality of 4.1 percent. There were 50 percent more deaths in the intensive care unit than on the general wards. Malignancies accounted for greater than one-third of all deaths. Lung cancer, which occurred in one of every six deaths in the department, was the single most-common diagnosis. The other leading causes of death were cirrhosis, gastrointestinal malignancies and cerebrovascular accidents. Cardiovascular mortality was somewhat less than expected. These figures reflect some of the serious diseases of the urban indigent population, which are, in turn, associated with cigarette smoking, alcoholism and hypertension. Decreases in morbidity and mortality are likely to be influenced by preventive medical measures and early detection campaigns. Department of medicine curricula and outpatient clinic programs should devote attention and resources to these areas.     

Regional perinatal care in crisis: a case study of an urban public hospital

Regionalized perinatal care is intended to guarantee pregnant women and neonates access to appropriate care regardless of ability to pay. Its effectiveness depends on the willingness of hospitals to transfer high-risk patients according to established protocols and affiliations. This study examines maternal transfers (n = 896) to Cook County Hospital (CCH), a public facility and a designated perinatal center in Chicago. In 1987 and 1988, the majority (68%) of maternal transfers to CCH came from out-of-network hospitals, and 52% of these came directly from another perinatal center. The data indicate that 62% of the out-of-network transfers who delivered were medically high-risk. The study also documents the transfer of women in active labor, a violation of federal law. The term "perinatal dumping" is introduced to mean the transfer of high-risk pregnant women between hospitals for economic rather than medical reasons. Strategies for safeguarding the integrity of regionalized perinatal care are discussed.     

Health care costs of medical patients at an urban care center

Many cost containment strategies advocate that physicians should use fewer or less costly resources. In order to place these strategies in perspective, components of charges (costs) for medical patients at an urban center were examined to ascertain their contribution to the total health care bill. Contributions to total costs by location of service were: inpatient, 77.9%; outpatient, 17.1%; emergency room, 5.0%. Contributions by cost category were: facility charge, 52.8%; tests, 25.6%; pharmaceuticals, 11.0%. A goal to reduce total costs by 5% would require reducing pharmaceuticals by 45.4% or tests by 19.5%. In contrast, the same goal could be accomplished by reducing hospitalization by only 6.4%. If a strategy increased ambulatory costs by 5%, but resulted in a 7.5% decrease in hospitalization, the total health care costs would still decrease by 5%. Thus, rather than using fewer and less costly resources, physicians are encouraged to use more resources in ambulatory care to prevent morbidity requiring hospitalization.     

Association between iron deficiency and low-level lead poisoning in an urban primary care clinic.

OBJECTIVES: The purpose of this study was to examine the association between iron deficiency and low-level lead poisoning. METHODS: Data were collected in an urban primary care clinic from 3650 children aged 9 to 48 months. Iron deficiency was defined as a red cell mean corpuscular volume (MCV) of less than 70 fL and a red cell distribution width (RDW) of more than 14.5 in children younger than 2 years, and an MCV of less than 73 fL and RDW of more than 14.5 in those 2 years or older. RESULTS: After adjustment for age, hemoglobin concentration, and insurance status, the odds ratios for iron deficiency predicting blood lead levels greater than or equal to 5 micrograms/dL and greater than or equal to 10 micrograms/dL were 1.63 (95% confidence interval [CI] = 1.29, 2.04) and 1.44 (95% CI = 1.004, 2.05). CONCLUSIONS: Iron deficiency is significantly associated with low-level lead poisoning in children aged 9 to 48 months.     

Using mail to reach patients seen at an urban health care facility

Urban American Indians/Alaska Natives (AI/ANs) are highly mobile, and little is known about ways to include them in research or clinical activities. We evaluated postal mailings as a means of reaching patients seen at an urban Indian health care facility (60% of whom were AI/AN) and identified factors associated with receipt of mail. As part of a clinical trial, a Native art calendar was sent via first class mail to 5,633 clients seen at the urban Indian clinic during the prior two years. A multi-step address verification process was conducted, including telephone contacts, Web searches, and in-person visits. Logistic regressions examined the association of client characteristics with accurate addresses. Based on initial mailings and in-person location efforts, we estimated that only 61% of clients actually received the calendars. The multi-step address verification process was significantly less likely to identify working addresses for clients who were AI/AN and clients who were seen more than 3 months before the study. Reaching urban AI/ANs for research activities and health care is difficult. Innovative strategies are needed to locate this highly mobile and understudied population.     

Perceptions of diabetes among patients in an urban health care system

Objectives. A major problem facing health care providers today is adherence to treatment regimens by patients. Adherence is of even greater significance for patients with diabetes who shoulder a great deal of responsibility in their disease management. Perceptions of diabetes have been found to play a major role in adherence. The effects of race and socioeconomic status on the disease perceptions remain unclear. This exploratory study encompassed two themes: (1) assessing perceptions of diabetes among African American and white American adults with diabetes who were patients in 1994 in a large Midwestern urban health care system and (2) examining the psychometric properties of the measurement instruments used to study perceptions. Design. A stratified random sampling scheme (by race and socioeconomic status (SES)) was used. Diabetes perceptions were measured using three scales from the Meaning of Illness Questionnaire assessing the impact loss and stress associated with diabetes. Perceptions of physician efficacy were also measured. The study population consisted of 50 (68% response rate) African American and white American patients aged 18-65 years. Results. No differences in SES were found between the African American and white American participants ( p = 0.44). However the African Americans in the study indicated a greater sense of loss associated with diabetes than the white Americans in the study ( p < 0.05). In the combined racial group the reliability coefficients as measured by Cronbach's alpha were 0.76 0.78 0.68 and 0.68 for the Impact Loss Stress and Perceptions of Physician Efficacy scales respectively. However the results of within-racial-group analyses tell a different story. The Impact scale fitted the African American and white American subgroups although there was some item variation by racial group. The Loss scale did not fit the white American subgroup and the Stress and Perceptions of Physician Efficacy scales did not fit the African American subgroup.