Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Relationship between use of increased primary health care and other out-patient care in a Swedish urban area. I. Utilisation of public primary health care

The Swedish National Health and Medical Care program is currently undergoing a change. The aim of this gradual change is a more decentralized system where the primary care service is expanded to cater for the transfer of patients from the hospitals over to primary care. This study, which is one part of a longitudinal design aims to show changes in public utilization of the services of general practitioners and district nurses after the expansion of the Matteus Primary Health Care Centre (MPHCC), city of Stockholm. The analysis is based partly on the annual statistical records and partly on medical chart studies of visits to the general practitioner by a selected population. The results showed that the population in the study district made twice as many visits to general practitioners and district nurses after the establishment of the MPHCC. It was also shown that the number of individuals visiting the general practitioners more than doubled during an 18-month period following the expansion of MPHCC. These results corresponds well with the aims associated with the expansion in primary care in future medical care services.     

Problem of objective performance assessment of primary health care physicians.

Training programmes for primary health care physicians often lack methods for valid and reliable performance assessment of the trainees. A set of rating scales has been developed with the aim of increasing the objectivity of measurement of practical skills required for the management of cardiac failure. To prove the validity of the content and structure, as well as the inter-observer reliability, the scales were tested by the method of "competent judges" with the use of video-recorded clinical simulation. Calculated Kendall's coefficient of concordance W was at the minimum acceptable level of 0.5. The results reveal considerable differences among examiners (competent judges) regarding internal criteria of acceptable level of performance, and they point out the need for further search for more objective methods of performance assessment.     

A three-year training programme for primary health care physicians in Poland

A three-year training programme was developed and implemented by the Medical Centre of Postgraduate Education in Poland with the aim of improving the knowledge and skills of primary health care physicians working in the State Health Services' community centres. The programme creates several learning and self-assessment opportunities with the general principle of not distracting a doctor from his daily duties in a community health centre for more than one day a month. Preliminary assessment of the programme revealed its positive impact on both the health services system and primary health care physicians themselves. It increased health authorities' activity in creating new learning opportunities and doctors' motivation to learn. Self-assessment made by the first group of trainees who completed the three-year programme (results obtained by means of a questionnaire) revealed substantial increase in professional competence resulting from the participation in the programme.     

Relationship between use of increased primary health care and other out-patient care in a Swedish urban area. II. Utilisation of out-patient hospital services

The expansion of the primary care services and its effect on utilization of the out-patient services in hospitals by the public have been analysed by a number of authors. Evaluation of the links vary: some studies state that an expansion of primary care goes together with an increase or an unchanged utilization of hospital visits - out-patient clinics, while others say that a decrease occurs. The present study analyses this problem in Stockholm city. This study has a longitudinal design and it covers a study district and a control district. The results support the hypothesis that the expansion of primary care in the study area results in a significant decrease in hospital visits in this area. The decrease occurred in most age groups among men as well as women, regardless of the type of visit (emergency or by appointment); it also occurred in the usual speciality areas in the general practitioner's everyday work.     

Urgent neurology consultation from the ED for transient ischemic attack

Objective

The objective of this study was to evaluate the association between urgent neurology consultation and outcomes for patients with transient ischemic attack (TIA).

Methods

In a secondary analysis of data from 1707 emergency department patients with transient ischemic attack from March 1997 to May 1998, we compared presentation, management, and outcomes by neurology consultation status using generalized estimating equations to adjust for ABCD² score and clustering by facility and survival analysis for outcomes.

Results

Consultation was obtained f28% of patients. Median ABCD² scores were comparable, but consultation was associated with hospital admission (odds ratio, 1.35 [1.02-1.78], P = .04) and use of antithrombotics (odds ratio, 1.88 [1.20-2.93], P = .005). The cumulative stroke risk was significantly lower within 1 week (5.3% versus 7.5%, P = .02) but not at 90 days (9.9% versus 11.0%, P = .21).

Conclusions

Consultation was not targeted to high-risk patients but was associated with some quality of care measures and improved early outcomes; however, improvement in 90-day outcomes was not established.     

Selective access: prioritizing referrals at the primary care/community mental health team interface

Objective: To examine how community psychiatric nurses (CPNs) in a nurse-led system for dealing with referrals to community mental health teams (CMHTs) from primary care prioritized referrals.Design: A retrospective survey of patients’ assessment records.Setting: Four CMHTs in Salford which provide specialist mental health care for the adult population (16–65 age group).Participants: A cohort of 874 patients referred by GPs and seen by CPNs for initial assessment.Measures: Referral outcome, demographic characteristics, general ICD-10 diagnosis and the Health of the Nation Outcome Scales.Results: Access to support appeared to be restricted to patients with diagnosable disorders, as opposed to sub-threshold problems of living. Three main factors were identified which explained how patients were prioritized: diagnosis; previous history; and the severity of their presenting problems.Conclusion: The findings suggested that providing a single gateway to the CMHT may help to clarify the referral process and help to manage the demand for care at the primary care/CMHT interface.     

Urologic skills for primary care physicians

The urologic procedures discussed in this article are within the area of competence of most primary care physicians. Incorporating these procedures into the practice enhances the professional life of physicians and allows their patients greater convenience and cost-effectiveness.     

Allergy testing by primary care physicians

Primary care physicians will treat allergy to some degree purely because of supply and demand. The effectiveness of treatment depends on their interest and involvement. A thorough history and physical examination are essential. Physicians should not depend on a remote, computerized plan for diagnosis and treatment. Various diagnostic tests are available, some appropriate to nearly all levels of interest. Primary care physicians must choose between referral, pharmacotherapy, or more extensive involvement in allergy care. Immunotherapy involves some risk and a better possibility of pure result, but it requires additional training. Food allergy cannot be diagnosed by in vitro tests. Elimination and challenge with subsequent long-term elimination of offending foods is the only practical course for primary care physicians.     

Relationship between use of increased primary health care and other out-patient care in a Swedish urban area. IV. Use of private and other non public out-patient care

In 1979 Stockholm County Council began a study of increased primary health care (PHC) at Matteus Primary Health Care Centre (MPHCC) in Stockolm city. The aims were to analyse changes in utilization of out-patient care (OPC). This article analyses the changes in the population's visits to non-public employed physicians. The study has a longitudinal design and covers a study and two control districts. The method is an enquiry before and after establishment of the MPHCC in the northern part of Stockholm city. In this study it was shown that increased PHC in the study district resulted in a significant decrease (27%) of the population's visits to private-, occupational- and school health physicians. Furthermore, the study shows a significant decrease of the number of individuals in the study district who visit these non-public employed physicians during a 12-month-period.     

Evidence-based periodic health examination of adults: Memory aid for primary care physicians

PROBLEM ADDRESSED     

Family physicians and the primary care physicians workforce in 2004

In 2004, there were 91,600 family physicians (FPs) and general practitioners (GPs) and 222,000 primary care physicians actively caring for patients, one for every 1321 persons. These primary care physicians represent the largest and best-trained primary care physician workforce that has ever existed in the United States.     

保健门诊糖尿病健康教育的实施效果分析

目的探讨保健门诊开展糖尿病健康教育的形式及实施效果。方法将96例糖尿病患者随机分为2组,观察组51例,根据保健门诊特点设计系统的健康教育方案,采取个别教育与集体教育相结合的方法进行健康教育;对照组45例,进行一般的卫生知识宣传。追踪观察半年进行对照分析。结果观察组51例患者在健康教育知识掌握程度、血糖控制、糖化血红蛋白水平、自我管理能力、低血糖发生率、住院率等方面均明显优于对照组(P<0.01)。结论保健门诊健康教育是提高糖尿病患者自我管理能力的有效途径,能有效控制糖尿病的发展,预防和减少糖尿病并发症的发生,提高患者生活质量。     

保健门诊糖尿病健康教育的实施效果分析

目的 探讨保健门诊开展糖尿病健康教育的形式及实施效果.方法 将96例糖尿病患者随机分为2组,观察组51例,根据保健门诊特点设计系统的健康教育方案,采取个别教育与集体教育相结合的方法进行健康教育;对照组45例,进行一般的卫生知识宣传.追踪观察半年进行对照分析.结果 观察组51例患者在健康教育知识掌握程度、血糖控制、糖化血红蛋白水平、自我管理能力、低血糖发生率、住院率等方面均明显优于对照组(P＜0.01).结论 保健门诊健康教育是提高糖尿病患者自我管理能力的有效途径,能有效控制糖尿病的发展,预防和减少糖尿病并发症的发生,提高患者生活质量.