Emergency department use as a component of total ambulatory care: a population perspective.

OBJECTIVES: (a) To describe the overall proportion of ambulatory care provided in emergency departments for a complete urban population, (b) to describe the variation across small geographic areas in the overall proportion of ambulatory care provided in emergency departments and (c) to identify attributes of small-area populations that are related to the provision of high proportions of total ambulatory care in emergency departments. DESIGN: Cross-sectional ecologic study combining 4 sources of secondary data on health service utilization and socioeconomic status. SETTING: Winnipeg. PARTICIPANTS: A total of 657,871 residents of metropolitan Winnipeg in the period April 1991 to March 1992, grouped into 112 neighbourhoods. MAIN OUTCOME MEASURE: A proportion calculated, for each neighbourhood population, from the estimated count of emergency department visits divided by the population's use of total ambulatory care for a sample of 55 days in the study period. RESULTS: The overall proportion of ambulatory care provided in emergency departments was 4.9% (range 2.6% to 10.8%), representing 35.5 emergency department visits per 100 person-years. Neighbourhoods with a higher proportion of total ambulatory care provided in emergency departments were characterized by lower mean household income, a higher proportion of emergency department visits for mental illness and a higher proportion of residents with treaty Indian status. Measures of need for medical care for were not consistently associated with the proportion of ambulatory care received in emergency departments. CONCLUSIONS: In a health care system with an adequate supply of primary care physicians and universal insurance, this study has documented significant variation across small geographic areas in the proportion of total ambulatory care received in emergency departments. In the absence of strong evidence that this variation was associated with underlying need, the results suggest that attention be paid to the accessibility of conventional primary care.

Paradigm change and uncertainty about funding of public health research: social and scientific implications.

Since the 1970s two fundamental shifts have occurred in health research funding: a reduction in the buying power of research dollars, and an increase in the competition for resources. Most fields have also seen a decrease in the dollars available for research. Pressures for justifying the relevance of research activities have become increasingly pragmatic. The thesis of this paper is that scientific creativity and innovation are compromised by the highly uncertain and competitive funding environment of contemporary health research. This is largely because criteria of scientific excellence predicated on an investigation's presumed future impact support the status quo of methods and subject matter in funded research. Extraordinary rationality among scientists seeking and allocating resources promotes the survival of the existing system over time, yet inhibits progressive development through the transformation of conceptual models. Therefore, despite a growing unrest about the way research on population health is conducted, new conceptions of the relationship between theory and methods have been slow to emerge. Amelioration of a disjunction between the institutionalized rules governing science and the culturally sanctioned goals of science requires commitment to a dialectic between orthodoxy and dissent.

Physicians and breastfeeding: beliefs, knowledge, self-efficacy and counselling practices.

A pilot-tested questionnaire was mailed to 325 obstetricians, pediatricians, family practitioners and general practitioners of a British Columbian maternity hospital to measure aspects relating to physicians' attitudes toward breastfeeding counselling. Response rate was 67.3%. The measures of self-efficacy, knowledge and beliefs were added to a regression model containing measures of gender, specialty, years in practice and personal or spousal breastfeeding experience to determine whether additional variance in counselling behaviour could be accounted for. Physicians attempted to convince women to breastfeed if: 1) they believed in the immune properties of breastmilk (OR = 1.23, SE = 0.07) and 2) they were confident in their own breastfeeding counselling (OR = 1.88, SE = 0.36). Likewise, encouraging women to continue breastfeeding in the face of breastfeeding problems was related to confidence in breastfeeding counselling (OR = 1.22, SE = 0.10) and belief in the immune properties of breastmilk (OR = 2.83, SE = 0.45).

The value of two-dimensional echocardiography and Doppler examination in the assessment of hypertensive patients: a pilot study.

There has been hesitation in accepting the routine use of echocardiography in patients with hypertension. The concept of "limited" or "focused" echocardiography has been introduced but incompletely evaluated. In this prospective observational cohort study, 100 consecutive hypertensive adults underwent comprehensive two-dimensional echocardiography and Doppler assessment regardless of referral question. Patients were categorized on the basis of echocardiographic referral questions into two groups: (1) determination of left ventricular mass only (limited echocardiography) and (2) determination of left ventricular mass and associated cardiac problems. In group 1, missed diagnoses were rare (5%). Additional, clinically relevant information was provided by comprehensive echocardiography in 9% of patients. Doppler echocardiography did not provide any additional useful information in group 1 but was useful in group 2. In both groups, echocardiography affected clinical management. In patients referred for determination of left ventricular mass only, the equivalent of limited echocardiography, missed diagnoses are rare. Additional, clinically relevant information is provided in only a small number of patients by comprehensive two-dimensional echocardiography. Comprehensive two-dimensional echocardiography, including Doppler echocardiography, was useful in selected patients referred with hypertension and other cardiac problems and should be part of the echocardiographic assessment of such patients. With careful selection of hypertensive patients, limited echocardiography can be a cost-effective strategy.

Disability and the years of potential productivity lost: modifying the years of potential life lost and the investment-production-consumer model by disability level.

The full impact and the loss to society from disability are seldom evaluated. We suggest a modification of the years of potential life lost (YPLL) by the overall percentage of permanent disability to obtain estimates of years of potential productivity lost (YPPL). We compare YPPL with the maximal years of potential productivity of an individual by difference and ratio measures. We employ similar methodology to modify valued years of potential life lost (VYPLL) according to the investment-producer-consumer model. We demonstrate the methodology by an example using data on disabled veterans.

Who really determines your patients' prescriptions?

KIE: The authors deplore a recent incident that highlights the impact of the media and the pharmaceutical industry on the practice of medicine. The publication of a study comparing the changes in cholesterol levels and glucose metabolism of hypertensive patients treated with a diuretic and with an angiotensin converting enzyme inhibitor (captopril) was publicized by the pharmaceutical company that manufactures the latter drug. Alarmed by popular media reports that diuretics could raise heart attack risks, thousands of hypertensive patients being treated with diuretics contacted their physicians. A decrease in the number of new prescriptions for oral diuretics occurred in the months after the study's release. Citing data to show that diuretic therapy is still safe, effective, and relatively inexpensive in the management of hypertension, the authors call for physicians to take a stand against prescribing pressures generated by the media and by pharmaceutical industry promotion campaigns.^ieng

Cost considerations of ambulatory blood pressure monitoring.

Automatic blood pressure monitoring has proved valuable in testing new antihypertensive drugs, providing greater precision at less cost. Results obtained by this method are better correlated with target-organ damage (e.g. left ventricular hypertrophy) than conventional office blood pressure measurements. A number of clinical conditions are better evaluated with ambulatory blood pressure monitoring than with conventional measurements, e.g. office (white coat) hypertension, episodic hypertension and intermittent hypertensive symptoms. An economic model suggests that appropriately constrained ambulatory blood pressure monitoring can be highly cost-effective in patients who are initially diagnosed as mildly hypertensive on the basis of repeated casual blood pressure measurements. Normative data are needed for populations by age, race, gender, body habitus and conditions such as pregnancy.

Practice patterns of family physicians with 2-year residency v. 1-year internship training: do both roads lead to Rome?

Are there differences in patterns of practice between actively practising physicians who have been certified after a 2-year family practice residency and matched physicians without certification who have completed the standard 1-year internship? With the use of billing files prepared by the British Columbia Medical Association a group of 65 family practice certificants in active practice in British Columbia was compared with a control group of 130 internship trainees matched by year and school of graduation, category of billing (i.e., solo or group) and region. A wide range of practice features was assessed for the fiscal years 1984-85, 1985-86 and 1986-87. No differences were detected between the groups in 1986-87 for the following practice variables: number of patients (1888 and 1842 respectively), number of personal services billed for (7265 and 7173), number of personal services per patient (3.9), amount of funding for personal services ($140,192 and $140,100) and amount per patient for personal services ($77 and $79). Age-adjusted costs for male and female patients were similar in the two groups. Of six services thought to be influenced by type of training, only maternity care generated a significantly higher number of billings in the study group (341 v. 249). These results suggest that there is no demonstrable effect of training on patterns of practice. However, the question of the effect of training on quality of care and whether the 2-year residency may have a longer effect on practice patterns should be the focus of future research.

Evaluation of a postocclusive reactive circulatory hyperaemia (PORCH) test for the assessment of ulnar collateral circulation.

This prospective double-blind study compared Doppler assessment of the ulnar collateral circulation with the Allen's test and a postocclusive reactive circulatory hyperaemia (PORCH) test in 144 patients (288 hands). The PORCH test involves inflation of a blood pressure cuff on the upper arm to a supra systolic (+50 mmHg) pressure for two minutes. Prior to cuff deflation, both radial and ulnar arteries are occluded at the wrist; the cuff is then deflated and a 15-second period allowed so as to restore blood flow down to the wrist. Ulnar artery compression is now released and the time to revascularization measured. Fifty-eight per cent of hands with an abnormal Allen's test had a normal ulnar collateral circulation. Results of Allen's test were not significantly affected by patients' sex or smoking status (p greater than 0.1) but there was a significant difference (p = 0.001) in the false positive rates between patients over 40 years of age (0.2) and those under 40 years of age (0.03). Results of the PORCH test were not significantly affected by patients' age, sex or smoking status (p greater than 0.1). With a revascularisation time of 19 sec as a "cut off" for ulnar abnormality the PORCH test, unlike the Allen's test, was perfectly predictive of an abnormal ulnar collateral circulation and had no false positives.

The assessment of diagnostic tests: a comparison of medical literature in 1982 and 1985.

To determine whether improvements have occurred since a survey of the 1982 literature assessing diagnostic tests, the authors evaluated all English-language articles that assessed clinical diagnostic tests in abridged Index Medicus journals in 1985, and that had the terms sensitivity and specificity in the title, abstract, or key words. The 89 articles were assessed against seven methodologic criteria, including use of a well-defined "gold standard," clearly defined test interpretation, blinding, clear data presentation, correct use of sensitivity and specificity, calculation of predictive values, and consideration of prevalence. In comparisons of 1985 vs. 1982 articles, there were significant improvements in five of the seven criteria. For example, the proportion of articles using a well-defined "gold standard" rose from 68% to 88%. Overall, the frequency of papers demonstrating five or more of the seven criteria increased from 26% to 47%. However, predictive values were discussed in only 54% of the articles without, necessarily, consideration of the influence of prevalence as well. This study raises the concern that while the concepts of sensitivity and specificity are now accepted, predictive values remain less well understood. Although there has been an improvement in the assessment of diagnostic tests in published research, attention to accepted methodologic standards is still needed on the part of researchers, reviewers, and editors.

The assessment of diagnostic tests. A survey of current medical research.

To study current diagnostic test evaluation, 129 recent articles were assessed against several well-known methodological criteria. Only 68% employed a well-defined "gold standard." Test interpretation was clearly described in only 68% and was stated to be "blind" in only 40%. Approximately 20% used the terms sensitivity and specificity incorrectly. Predictive values were considered in only 31% and the influence of disease prevalence and study setting was considered in only 19%. Overall, 74% failed to demonstrate more than four of seven important characteristics and there was an increased proportion of high specificities reported in this group. Articles assessing new tests reported high sensitivities and specificities significantly more often than articles assessing existing tests. These results indicate a clear need for greater attention to accepted methodological standards on the part of researchers, reviewers, and editors.

Pheochromocytoma: current status and changing trends.

From 1971 through 1980, 106 patients underwent operations for pheochromocytoma. Twelve patients had a pheochromocytoma as a manifestation of the multiple endocrine neoplasia type 2 syndrome. Twenty patients were found to have extra-adrenal paragangliomas. Fifteen patients (14%) had malignant tumors; eight of these tumors were encountered in the group with extra-adrenal lesions. The cumulative survival probability at 5 years was 53%. Determination of urinary metanephrines and vanillylmandelic acid were the most sensitive diagnostic aids, with accuracy rates of 95% and 89%, respectively. In recent years, the measurement of fractionated urinary and plasma catecholamine levels has greatly increased the diagnostic accuracy. Preoperative localization of pheochromocytoma has improved during the last decade. Nephrotomography, selective angiography, and venous sampling have essentially been abandoned in favor of computed tomography. With an accuracy of more than 90%, computed tomography represents the major step forward in the overall management of pheochromocytoma during the past decade.

Hypertension.

Hypertension, a health problem of epidemic proportions, has not been controlled successfully. Screening efforts are increasing the detection of cases, and current emphasis on treatment rather than detailed evaluation is increasing the incidence of control of hypertension. Patient compliance is crucial, however, because all of the currently available treatments require daily taking of pills by patients who commonly do not understand their disease or the need for treatment. Efforts at increased public education and improved doctor-patient relationships are important if the epidemic is to be overcome. This paper reviews diagnosis, evaluation, treatment, public education, and patient compliance.