Future provision of out of hours primary medical care: a survey with two general practitioner research networks

OBJECTIVE

To ascertain general practitioners' views about the future provision of out of hours primary medical care.

DESIGN

Self completing postal questionnaire survey.

SETTING

Wessex and north east England.

SUBJECTS

116 general practitioners in the Wessex Primary Care Research Network and 83 in the Northern Primary Care Research Network.

MAIN OUTCOME MEASURES

Intention to reduce or opt out of on call; plans for changing out of hours arrangements; the three most important changes needed to out of hours care; willingness to try, and perceived strengths and limitations of, three alternative out of hours care models--primary care emergency centres, telephone triage services, and cooperatives.

RESULTS

The overall response rate was 74% (Wessex research network 77% (89/116), northern research network 71% (59/83)). Eighty three per cent of respondents (123/148) were willing to try at least one service model, primary care emergency centres being the most popular option. Key considerations were the potential for a model to reduce time on call and workload, to maintain continuity of care, and to fit the practice context. Sixty one per cent (91/148) hoped to reduce time on call and 25% (37/148) hoped to opt out completely.

CONCLUSIONS

General practitioners were keen to try alternative arrangements for out of hours care delivery, despite the lack of formal trials. The increased flexibility in funding brought about by the recent agreement between the General Medical Services Committee and the Department of Health is likely to lead to a proliferation of different schemes. Careful monitoring will be necessary, and formal trials of new service models are needed urgently.

One-year prospective study of cases of suspected acute myocardial infarction managed by urban and rural general practitioners

BACKGROUND

The role of the general practitioner in the management of patients with suspected acute myocardial infarction is important and specific. It has been recommended that eligible patients should receive thrombolysis within 90 minutes of alerting medical or ambulance services. The administration of prehospital thrombolysis by general practitioners is controversial. Most research into the management of acute myocardial infarction has been hospital based and has not explored differences between urban and rural general practice.

AIM

In 1993-94 a one-year prospective survey was undertaken of samples of urban and rural general practitioners to examine their management of cases of suspected acute myocardial infarction and to determine whether differences in management existed between the two settings.

METHOD

General practitioners were recruited through the continuing medical education faculty network of the Irish College of General Practitioners. Participating general practitioners completed a report form for cases of suspected acute myocardial infarction. Six-week follow-up forms were also completed.

RESULTS

A total of 113 general practitioners (54 urban and 59 rural) participated in the study. A total of 57 general practitioners contributed 195 cases, 49 from urban and 146 from rural areas. The mean number of cases of suspected acute myocardial infarction per participant for urban and rural doctors was 0.9 and 2.5, respectively. Median delay time from onset of symptoms to contacting the general practitioner was 90 minutes for both urban and rural patients. Median general practitioner response times for urban and rural doctors were 10 and 15 minutes, respectively. Median estimated journey times from location of the patient to hospital for urban and rural patients were 10 and 40 minutes, respectively (P<0.001). Rural doctors were more likely, in comparison with their urban counterparts, to administer aspirin (given to 40% of patients versus 16%, P<0.01) but less likely to administer intravenous morphine (26% versus 41%, P<0.05). Twenty one patients (11%) died at the scene; follow-up forms were received for 94% of the remaining patients. Of these 163 patients, 99% were admitted to hospital; 49% were discharged with a diagnosis of acute myocardial infarction and a further 25% had final diagnoses consistent with acute coronary heart disease.

CONCLUSION

This study suggests that the management of patients with suspected acute myocardial infarction differs in urban and rural settings. Delay times suggest that in order to meet current guidelines, prehospital thrombolysis must become a reality in rural areas.

Urban/rural elderly health status differences: the dichotomy reexamined

Health policy research analyzes urban/rural differences as a simple dichotomy. Research characterizes the rural elderly as having a higher incidence of sickness, dysfunction, disability, restricted mobility, and acute and chronic conditions than their urban counterparts. However, population density as a dichotomy may obscure urban, rural, or urban/rural differences. Interviews measuring health status were conducted with a representative sample of 2,300 elderly people in six Northeastern Ohio counties constituting an urban/rural continuum. On medical condition, use of medical aids, and symptoms, health status improved significantly when moving from rural to urban, but correlations were small. Using dichotomies, urban elderly reported fewer medical conditions and symptoms than rural elderly, but four other health-status variables revealed no significant association and results differed depending on how dichotomies were defined. When individual communities were compared few urban/rural patterns emerged. Controlling for demographics did not change interpretations. Findings question blanket assertions about urban/rural health-status differences. Medical resources may be misallocated. Rather than assuming poor health status among the rural elderly, researchers must verify differences through community-based research.

Effect of adenosine on the management of supraventricular tachycardia by urban paramedics

STUDY OBJECTIVE

To determine the effect of the addition of adenosine, as a standing-order medication, on the prehospital management of supraventricular tachycardia (SVT) in a large urban emergency medical services (EMS) system.

DESIGN

Prospective observational case series with historical controls.

SETTING

Large urban municipal EMS system staffed by paramedics and emergency medical technicians trained to operate automatic or semiautomatic defibrillators (EMT-Ds).

PARTICIPANTS

We observed a consecutive sample of prehospital patients who presented with an initial ECG rhythm of SVT, as interpreted by the treating paramedics, between July 1 and December 31, 1993. We used patients from the same 6-month period in 1992 as our control group. Indications for treatment were chest pain, evidence of myocardial ischemia, or shock. Adenosine had been introduced as a first-line medication to be used under standing orders in cases of unstable SVT before a physician was contacted for medical control options.

RESULTS

We studied 239 cases and 228 controls. Acceptable call reports with pretreatment and posttreatment ECGs were available for 140 (59%) of the study cases and 104 (46%) of the controls. The two groups were similar in terms of age, sex, and initial vital signs. In the control group, 75 patients had indications for treatment, and 16 were treated (21%). In the study group, 127 had indications for treatment and 103 (81.1%) were treated (odds ratio, 15.83; 95% confidence interval, 7.38-34.4).

CONCLUSION

The introduction of adenosine as a standing-order medication into an urban EMS system increased the proportion of patients who received advanced life support treatment. Paramedics were able to accurately diagnose and begin treatment of SVT with adenosine without direct medical supervision.

Measuring the call-receipt-to-defibrillation interval: evaluation of prehospital methods

STUDY OBJECTIVE

Successful resuscitation of cardiac arrest depends partly on the time of first defibrillation. An accurate, practical method of measuring this time has not been devised. We attempted to determine the interval from receipt of a call by emergency medical services personnel to first defibrillation (total defibrillation interval) with synchronized clocks between computer-aided dispatch operations and an event-recording defibrillator.

DESIGN

A 7-month prospective study measuring the total defibrillation interval. An automated code summary was to be submitted for each participant.

SETTING

An urban, all-advanced life support, public utility model system.

PARTICIPANTS

All primary ventricular fibrillation patients seen during the study period.

RESULTS

Ninety-two patients met study criteria. Data are presented as median (interquartile range). The total defibrillation interval was 9.8 minutes (7.9 to 11.8 minutes). The call-receipt-to-vehicle-at-scene interval was 5.98 minutes (4.4 to 7.3 minutes). The vehicle-at-scene-to-defibrillation interval was 3.6 minutes (2.5 to 4.6 minutes).

CONCLUSION

The use of synchronized clocks in automated event-recording systems may provide a method of accurately measuring the time elapsed before defibrillation.

An assessment of barangay health midwives' knowledge regarding tuberculosis case finding and treatment procedures in urban health centers of metropolitan Manila, Philippines

A survey was done from August to September, 1992 to determine the level of knowledge of 48 barangay health midwives (BHW) from urban health centers in Metropolitan Manila with regards to tuberculosis case finding and treatment procedures, as recommended by the National Tuberculosis Control Program (NTCP) of the Department of Health. Questionnaires were administered by personal interview. A cut-off mark of 17 correct answers out of 23 or 74% was arbritrarily chosen to signify a satisfactory level of knowledge. Results revealed that a substantial proportion of midwives still have inadequate knowledge regarding casefinding, case holding and NTCP policies. Type of training (p < 0.01) and age (p < 0.05) were found to be significant factors affecting level of knowledge while length of service was found to be marginally insignificant (p = 0.06). It is therefore highly recommended that urban health midwives be subjected to more regular formal training to increase their level of competence in attaining the goals of the NTCP.

Clinical audit of malaria diagnosis in urban primary curative care clinics, Zimbabwe

Clinical audit was performed on the accuracy of malaria diagnosis by nursing staff within Harare City Health Department using diagnosis by doctors as the reference standard. This was found to be about 10 pc based on symptoms. The criteria for diagnosis of malaria as in ZEDAP manuals and in-house training were not being utilised. Pyrexia was not present in 40 pc of the patients. Serious illnesses were occasionally dismissed as malaria and not treated appropriately or reviewed. The most common misdiagnosis was of acute respiratory tract infections which also have clear guidelines for diagnosis. More appropriate training methods need to be developed to improve the diagnostic capacity of nursing staff who are frontline providers of primary health care. This study shows the importance of performing an audit for process evaluation, compared to set standards and to be used for improving the quality of services.

Teleradiology: the practice of radiology enters Cyberspace

Teleradiology refers to the use of computers and electronic communication networks to transmit diagnostic images acquired at one location to another location for review and interpretation. The use of teleradiology has grown tremendously during the past few years. Many of the early problems with teleradiology are being resolved by the rapid advances taking place in telecommunications and computer technologies, while changes in health care economics are driving the need to establish cost-effective and efficient communications links between rural and urban health care providers and tertiary care specialists. Effective arguments can be made both for and against the role of teleradiology in improving patient care. These arguments, as well as an overview of the impact of teleradiology on the the practice of radiology, are discussed in this article.

A shot in the arm. M.D. Health Plan launches an immunization program that especially benefits infants in the inner city

When you marry a solid public relations campaign to a genuine commitment to wellness, any number of good things can result. In Connecticut the result was "Smart Start," a campaign by M.D. Health Plan and other participants to launch an infant immunization program. It's been a real shot in the, er...arm.

[Comparative trial of the clinical efficacy and tolerance of cefatrizine (Cefaperos) and cefpodoxime proxetil (Orelox) in superinfections of chronic obstructive bronchopneumopathies in adults in urban practice]

In order to compare the clinical efficacy and safety of cefatrizine (Cefaperos) and cefpodoxime proxetil (Orelox) in the treatment of secondarily infected chronic obstructive pulmonary disease (COPD) in adults, a multicentre, randomized, open study was conducted by 60 general practitioners in two parallel groups of patient suffering from COPD complicated by an acute episode of superinfection (Anthoniesen stages 2 and 3). After verification of the eligibility criteria, written consent and randomization, the patients received, for 10 days, either cefatrizine at the dose of 1 g/day or cefpodoxime proxetil at the dose of 400 mg/day. A self-assessment form was given to the patient. A telephone visit was planned for D3. The final visit on D11 +/- 1 evaluated clinical efficacy (success or failure) and safety. The study population was composed of 250 patients with a mean age of 59.9 +/- 15.9 years (sex ratio M/F = 1.5). The principal etiology of COPD was chronic bronchitis in 67.5% of patients, longstanding asthma in 24.5% and emphysema in 6.8%. The mean history of the disease was 13.0 +/- 10.8 years. The Anthoniesen score was equal to 2 in 73.6% of patients, 3 in 8.8% of patients and 1 in 17.6% of patients. No significant difference concerning these criteria was observed between the two study groups. The clinical success rate was equivalent in the two groups. The time to regression of clinical signs tended to be shorter, up until the sixth day (mainly between D4 and D6) for patients treated with cefatrizine (p = 0.09; NS). The clinical safety was considered to be good and was comparable in the two study groups. This study concluded on the equivalent clinical efficacy of cefatrizine and cefpodoxime proxetil in the treatment of superinfections of COPD in general practice (97.5% and 99%, respectively), with a satisfactory and comparable safety, but with a much lower cost of treatment for cefatrizine. This conclusion is particularly important in the context of opposable medical references, as, although the treatment of superinfections of COPD by second and third generation cephalosporins is frequently proposed, the prescription of a less expensive cephalosporin appears to be more relevant.

Beliefs and practices regarding childhood vaccination among urban pediatric providers in New Jersey

BACKGROUND

In 1991, the fourth largest measles outbreak in the nation (824 cases) occurred in the Jersey City, New Jersey area. Data from a subsequent intervention trial in Jersey City demonstrated that vaccinations were more likely to be delayed for children who had received care from private rather than public clinic providers. In addition, failure to administer multiple indicated vaccines at a single visit was associated with vaccination delay, and reluctance to administer multiple vaccines was more common among private providers. These findings prompted an investigation of vaccination beliefs and practices among urban pediatric providers.

METHODS

A telephone survey of vaccination beliefs and practices was administered to all pediatric providers in both private and public clinics in the Paterson and Jersey City areas.

RESULTS

Private providers were less likely than public clinic providers to consider vaccinating children during emergency room visits (relative risk [RR] = 2.2; 95% confidence interval [CI] = 1.2-4.2) or hospital admissions (RR = 13.2; 95% CI = 1.9-92.7) and less likely to believe that all recommended vaccine doses should be administered simultaneously (RR = infinite; lower 95% confidence limit = 3.0). Private providers were less likely to consider administering live-virus vaccines to children with minor acute illnesses and low-grade fever (RR = 2.2; 95% CI = 1.2-3.8) or killed-virus vaccines to children with minor acute illnesses without fever (RR = 3.4; 95% CI = 1.4-8.5) or with low-grade fever (RR = 2.2; 95% CI = 1.2-3.9). Private providers were more likely to believe that multiple injections should be avoided because of potential psychological and physical trauma to the child (RR = 4.0; 95% CI = 1.3-12.3).

CONCLUSIONS

Adherence to Standards for Pediatric Immunization Practices by pediatric providers could improve vaccine coverage rates among urban children.

Dialysis survival in a large inner-city facility: a comparison to national rates

Impoverished patients may represent a high-risk population with poor survival. With 1993 U.S. Renal Data System survival tables (to adjust the risk of death for differences in age, race, and ESRD diagnosis), the mortality rates of patients over 3 yr in a large inner-city dialysis facility using high-flux technique were compared with national averages. At least 93.7% of patients were African-American, 50% had incomes below $7,000 per year, and employment was 5% or less. Observed and expected deaths (the latter derived from the U.S. Renal Data System tables) were used to calculate a standardized mortality ratio (observed deaths/expected deaths); the U.S. average is 1.0. The standardized mortality ratio at this facility for each year was < 0.600 and was significantly lower than the U.S. average in 1991, in 1992 (P < 0.05), and for all 3 yr (P < .001). Over all 3 yr, it was lower for females (0.540, P < 0.05), males (0.620, P < 0.05), patients with diabetes (0.593, P < 0.05), and glomerulonephritis (0.318, P < 0.05). For the 3 yr, a Cox regression analysis revealed independent associations between mortality and age (P = 0.004), serum albumin (P = 0.02), Kt/V (P = 0.02), and dialysis for more than 2 yr (P = 0.01). Patients with economic hardship can attain survival significantly better than the national average with the provision of adequate dialysis, nutrition, and support services.

A comparative study of prescribing pattern at different levels of health care delivery system in Bangalore district

A study of prescribing pattern in tertiary, primary and urban general practice levels of the Indian health care delivery system was undertaken by analyzing 1810 prescriptions for 3932 drugs. The study evaluated feasibility of data acquisition methods and compared the prescribing frequency of various drug groups and of individual drugs in three commonly used categories. The mean number of drugs per prescription was highest in urban general practice (2.41). The four most frequently prescribed drug groups were antibacterials, vitamins, nonsteroidal antiinflammatory drugs (NSAIDs) and respiratory drugs. The study delineates the differences in prescribing frequency of drug groups and individual drugs across the three levels of health care and the results suggest intervention strategies to promote rational drug therapy.

Urban trauma transport of assaulted patients using nonmedical personnel

OBJECTIVE

To describe one urban trauma transport system to clarify the impact of transport by nonmedical personnel on patient outcome.

METHODS

Retrospective data were assembled over a six-year period through the use of the state trauma registry for an urban county served by seven state-accredited trauma centers. A subset of 4,767 consecutive assaulted patients was analyzed using the TRISS method to estimate survival probability. An unexpected death index (UDI), calculated as the difference between expected (TRISS method) and observed death rates, also was determined. Outcomes for patients transported by fire medics (FMs) vs nonmedical, police personnel (NPs) were compared.

RESULTS

FMs transported 2,108 (44%) and NPs transported 1,356 (29%) of the injured assault victims. The FM-transported patients had a lower expected probability of survival than had the NP-transported patients (p < 0.001). This also was true within the penetrating-injury subgroup (p < 0.001), but not the blunt-injury subgroup. The observed death rate was higher for all the FM-transported patients than it was for the NP-transported patients (15% vs 11%; p < 0.01). The UDIs were not different overall, although the NP-transported patients who had blunt trauma had a significantly lower UDI (p < 0.01).

CONCLUSIONS

NP transport of assaulted patients is generally associated with equivalent outcomes in comparison with FM transport in this urban environment. However, these data also provide evidence of an on-scene implicit triage with more severely injured patients generally transported by FMs.

Community service as an integral component of undergraduate medical education: facilitating student involvement

Urban poverty, of which New York City has the highest incidence, is associated with unmet needs and inappropriate use of emergency rooms and hospitals. Community-based medical practitioners can ameliorate these situations. Medical students from New York City-area schools often are willing to help. The New York Academy of Medicine instituted an Urban Health Initiative to coordinate student and faculty involvement in community service and to emphasize the social responsibilities of medicine. The experience may provide a model for integrating community service into medical school curricula.

Home care in the urban setting--a challenge to medical education

The rapid growth in the use of the home as the site of care delivery necessitates that the home setting be incorporated as a teaching site into the curriculum of medical schools. Urban medical schools have a unique advantage in that they have a large population base readily available to students and preceptors as well as an array of allied health providers. Urban institutions can be in the forefront of developing programs that simultaneously promote: clinically competent care; the maximal function of large numbers of acutely and chronically ill persons; research into issues of cost-effectiveness; and, most importantly, professional humanism. Specific educational objectives are included.

Effectiveness of a specialized asthma clinic in reducing asthma morbidity in an inner-city minority population

Asthma is the most common chronic disease of childhood and a leading cause of morbidity in adults. Despite significant advances in medical therapy, asthma morbidity and mortality rates have risen dramatically over the past two decades, especially in minority and socioeconomically disadvantaged populations. Numerous intervention programs have been designed in an attempt to reduce asthma morbidity but few have targeted poor or minority populations. The purpose of this study was to assess whether an outpatient intervention program specifically targeted at a high-minority population in East Harlem, in New York City, was successful in reducing asthma morbidity. A retrospective chart review of 84 patient records was conducted. The patients were divided into two groups, an intervention group (n = 45), who were followed by an asthma specialist (allergist/immunologist), and a nonintervention group, followed by a general internist or pediatrician. Outcome variables including clinic walk-in visits, emergency room visits, and hospitalizations were determined and compared in the pre- and postintervention period in both groups. Patients in the intervention group had reduced total walk-in visits (73 vs. 27, p < 0.001), emergency room visits (30 vs. 5, p < 0.001), and hospitalizations (16 vs. 2, p < 0.001). In contrast, patients in the nonintervention group had no change in total walk-in visits (88 vs. 72), increased emergency visits (7 vs. 22, p < 0.05), and no change in hospitalizations (5 vs. 2), respectively. The outpatient intervention program has been successful in reducing asthma morbidity in the high-risk minority community of East Harlem. Future larger studies are warranted to extend this pilot program to other high-risk minority populations.

Injury prevention in an urban setting: challenges and successes

The Harlem Hospital Injury Prevention Program (HHIPP) was established in 1988 with the goal of reducing injuries to children in central Harlem by providing safe play areas, supervised activities, and injury prevention education. To achieve this goal, a broad-based coalition was formed with state and local governmental agencies interested in injury prevention and with community groups, schools, parents, and hospital staff. An evaluation of the program in terms of both process and outcome formed a critical element of this effort. Since 1988 the HHIPP, as the lead agency for the Healthy Neighborhoods/Safe Kids Coalition, developed or participated in two types of programs: injury-prevention education programs and programs that provide safe activities and/or environments for children. The educational programs included Window Guards campaign; Safety City Program; Kids, Injuries and Street Smarts Program (KISS); Burn Prevention Curriculum and Smoke Detector Distribution; Harlem Alternative to Violence Program; Adolescent Outreach Program; and Critical Incident Stress Management Teams. The safe activities and environmental programs included the Bicycle Safety Program/Urban Youth Bike Corps; Playground Injury Prevention Program; the Greening of Harlem Program; the Harlem Horizon Art Studio; Harlem Hospital Dance Clinic; Unity through Murals project; baseball at the Harlem Little League; winter baseball clinic; and the soccer league. Each program was conceived using injury data, coupled with parental concern and activism, which acted as catalysts to create a community coalition to respond to a specific problem. Data systems developed over time, which monitored the prevalence and incidence of childhood injuries in northern Manhattan, including central Harlem, became essential not only to identify specific types of childhood injuries in this community but also to evaluate these programs for the prevention of injuries in children.