Emergency department visits and primary care among adults with chronic conditions.
ABSTRACT An emergency department (ED) visit may be a marker for limited access to primary medical care, particularly among those with ambulatory care sensitive chronic conditions (ACSCC).
In a population with universal health insurance, to examine the relationships between primary care characteristics and location of last general physician (GP) contact (in an ED vs. elsewhere) among those with and without an ACSCC.
A cross-sectional survey using data from 2 cycles of the Canadian Community Health Survey carried out in 2003 and 2005.
The study sample comprised Québec residents aged ≥18 who reported at least one GP contact during the previous 12 months, and were not hospitalized (n = 33,491).
The primary outcome was place of last GP contact: in an ED versus elsewhere. Independent variables included the following: lack of a regular physician, perceived unmet healthcare needs, perceived availability of health care, number of contacts with doctors and nurses, and diagnosis of an ACSCC (hypertension, heart disease, chronic respiratory disease, diabetes).
Using multiple logistic regression, with adjustment for sociodemographic, health status, and health services variables, lack of a regular GP and perceptions of unmet needs were associated with last GP contact in an ED; there was no interaction with ACSCC or other chronic conditions.
Primary care characteristics associated with GP contact in an ED rather than another site reflect individual characteristics (affiliation with a primary GP and perceived needs) rather than the geographic availability of healthcare, both among those with and without chronic conditions.
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ABSTRACT: The number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further. Zusammenfassung Die Anzahl an Patienten mit funktionellen Einschränkungen, kognitiver Einschränkung oder Behinderung, die ungeplant in Kontakt mit der Notaufnahme eines Krankenhauses kommen und akutmedizinischer Versorgung bedürfen, nimmt zu. Damit stellt sich zunehmend das Problem, wie ältere Patienten mit Bedarf einer akut-geriatrischen Behandlung identifiziert werden können. Die Durchführung eines umfassenden geriatrischen Assessments bei Erstkontakt könnte eine Lösung sein. Allerdings gilt das umfassende geriatrische Assessment als zu aufwendig und komplex, um sinnvoll in der Notaufnahme umsetzbar zu sein. Deshalb wurden verschiedene Screening-Instrumente entwickelt und vorgeschlagen. Das in verschiedenen Versorgungszusammenhängen und unterschiedlichen Ländern am besten untersuchte Instrument ist derzeit das ‚Identification of Seniors At Risk‘ (ISAR) Screening Instrument. Es besteht aus sechs einfachen Fragen, die rasch angewendet und auch in dringlichen Situationen erhoben werden können. In den letzten Jahren wurde die Validität des ISAR-Instruments in verschiedenen europäischen Ländern getestet. Die meisten Studien, eine Studie aus Deutschland und eine aktuelle systematische Übersicht eingeschlossen, bestätigen die Validität. Die Ergebnisse sind aber nicht widerspruchsfrei. Einige Studien haben nur einen schwachen oder gar keinen Zusammenhang zwischen ISAR und negativen Gesundheitsfolgen gefunden. Andere Instrumente wurden deutlich weniger gut untersucht und scheinen keinen offensichtlichen Vorteil zu bieten. Trotz der zunehmenden Evidenz zum Thema bleiben etliche Unsicherheiten bestehen. Weitere Studien werden benötigt, um bestehende Inkonsistenzen aufzulösen und zu klären, wie im Screening positive Patienten am besten weiter behandelt werden können.Zeitschrift für Gerontologie + Geriatrie 01/2015; 48(1):4-9. DOI:10.1007/s00391-014-0852-1 · 1.02 Impact Factor
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ABSTRACT: Background Most national and provincial commissions on healthcare services in Canada over the past decade have recommended that primary care services be strengthened in order to guarantee each citizen access to a family physician. Despite these recommendations, finding a family physician continues to be problematic. The issue of enrolment with a family physician is worrying in Canada, where nearly 21% of the country¿s population reported not having a family physician in the last Commonwealth Fund survey.To respond to this important need, centralized waiting lists have been implemented in four Canadian provinces to help `orphan,¿ or unaffiliated, patients find a family physician. These organizational mechanisms are intended to better coordinate the demand for and supply of family physicians. The objectives of this study are: to assess the effects of centralized waiting lists for orphan patients (GACOs) implemented in the province of Quebec and to explain the variation among their effects by analyzing factors influencing implementation process.Methods This study is based on two complementary and sequential research strategies. The first (objective 1) is a quantitative longitudinal design to assess the effects of all the GACOs (n¿=¿93) in Quebec using clinical-administrative data. The second (objective 2) involves using four case studies to explain variations in effects through in-depth analysis of the various factors contributing to the observed effects. The primary source of data will be key actors involved in the GACOs. We expect to conduct around 40 semi-structured interviews.DiscussionThis will be the first study in Canada to evaluate the implementation of this innovation. It will provide an exhaustive picture of the effects of GACO implementation in Quebec and to assess their potential for generalization elsewhere in Canada. At the theoretical level, this study will produce new knowledge on the factors having the greatest influence on the implementation of primary care innovations in professional environments.Implementation Science 09/2014; 9(1):117. DOI:10.1186/s13012-014-0117-9 · 3.47 Impact Factor
The Journal of the American Board of Family Medicine 07/2014; 27(4):444-6. DOI:10.3122/jabfm.2014.04.140156 · 1.85 Impact Factor