The potential and costs of videoconferencing in dental education, dental vocational training and MFDS preparation.

This paper considers the potential role of videoconferencing technology for postgraduate dental and medical education. Drawing on work from the University of Bristol Dental School, it presents an analysis of the potential cost savings achievable by using videoconferencing compared to traditional face-to-face teaching across a range of scenarios. A summary of the feedback from trainees is also provided.

Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation.

The changing health care environment necessitates careful re-evaluation of all costly elective procedures. Low back surgery is a typical example. This article reviews the current literature addressing the efficacy of surgery and invasive percutaneous treatments for discogenic sciatica. It also discusses the prospects for the continuation of reimbursement for these procedures under a system of managed health care. Relevant articles were identified using the MEDLINE and Current Contents databases, from bibliographies of articles identified from these databases, from recommendations of experts in the field, and from the Canadian Cochrane++ Collaboration. The review includes randomized clinical trials, meta-analyses, published practice guidelines and large case series. The literature is classified and discussed in these quality strata. The review includes 9 randomized trials, 6 meta-analyses or review articles, one evidence-based practice guideline, 38 surgical case series and 35 additional references. Though incomplete, the existing evidence indicates that open discectomy shortens the duration of discogenic sciatica in selected patients. Neurologic outcomes are similar in operated and unoperated patients. Predominant leg pain, evidence of nerve root tension and concordant symptoms and imaging findings, are associated with favorable surgical results. Chemonucleolysis is also associated with more rapid pain relief than conservative treatment, but provides less certain benefit than standard discectomy. Available data on other percutaneous disc treatments do not currently support a statement on efficacy. Various percutaneous techniques are available but there is no solid scientific evidence of efficacy. The benefits of open discectomy, principally reduced duration of pain, appear to justify its use in carefully selected patients when discogenic sciatica fails to improve with conservative measures. Though elective, the procedure will probably continue to be available under managed care, but with increasing scrutiny of operative indications.

Determinants of emergency department use: are race and ethnicity important?

STUDY OBJECTIVE: To determine whether race/ethnicity is an important determinant of emergency department use. METHODS: We conducted a cross-sectional survey in a public ED to determine self-reported ED visits over the preceding 3 months. The study group comprised consecutive ambulatory patients (N = 1,049) with nonemergency medical problems. RESULTS: Blacks, whites, and Hispanics were equally likely to report one or more visits to an ED in the 3 months before study enrollment. Blacks were the most likely to report two or more ED visits in the preceding 3 months (19.0%), followed by whites (13.5%) and Hispanics (11.4%) (P = .01; unadjusted odds ratio, 1.82 for blacks versus Hispanics). In multivariate analysis, older age (P < .001), health insurance coverage (P < .001), regular source of care (P < .001), and difficulty obtaining transportation to a physician's office (P = .011) were positively associated with two or more previous ED visits. After adjustment for these variables, race/ethnicity was not significantly associated with ED use (P = .23; adjusted odds ratio for blacks versus Hispanics, 1.48 [95% confidence interval, .95 to 2.30]). CONCLUSION: Race/ethnicity was not an important determinant of ED use after adjustment for age, health insurance coverage, regular source of care, and barriers to health care. Population-based studies of ED use should be conducted to further evaluate whether racial/ethnic differences in ED use exist that are not explained by differences in demographics, health, socioeconomic status, access to care, or other determinants of ED use.

Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department.

OBJECTIVE: To determine the regular source of care and the relationship between usual provider and use of medical services among ambulatory emergency department patients. DESIGN: Cross-sectional survey. SETTING: A public hospital in Los Angeles County, California. PATIENTS: A total of 1190 stable, ambulatory adults presenting to the emergency department during a 2-week period. MAIN OUTCOME MEASURES: Self-reported regular source of care, usual health status, and recent physician visits. RESULTS: A total of 16% of the patients identified an emergency department as their regular source of care. One fourth of this group reported fair or poor health. African Americans and Latinos were more likely than whites to identify an emergency department as their regular source of care. Patients who identified an emergency department as their regular source of care had 25% fewer physician visits and were less likely to have seen a physician during the preceding 3 months than patients who were usually seen in an office or clinic (relative risk, 0.45; 95% confidence interval, 0.28 to 0.70). Of all patients, 56% identified a regular source of care other than an emergency department, but 24% to 36% of all their recent physician visits still occurred in an emergency department. CONCLUSION: Our patients rely heavily on emergency departments for ambulatory physician visits, regardless of their reported regular source of care. However, patients who identify an emergency department as their regular source of ambulatory care used physician services less frequently than patients with access to providers in other settings. These issues require further evaluation with population-based surveys.

Patients who leave emergency departments without being seen by a physician: magnitude of the problem in Los Angeles County.

STUDY OBJECTIVES: To determine the hospital characteristics associated with patients leaving emergency departments prior to physician evaluation. DESIGN: Cross-sectional design with data collection by mail and telephone survey. SETTING: Los Angeles County, California. TYPE OF PARTICIPANTS: Convenience sample of four public and 26 private hospital EDs with a combined monthly volume of 92,570. INTERVENTIONS: None. RESULTS: Questionnaires were returned from 83% of EDs surveyed. During 1990, 4.2% of patients at these EDs left without being seen by a physician. In all, 7.3% of public hospital patients left without being seen, and 2.4% of private hospital patients left without being seen (P < .001). The percentage of patients who left without being seen was significantly higher at EDs with longer waiting times, higher fraction of uninsured patients, and at hospitals with accredited residency training programs (P < .001 for each comparison). A logistic regression model, used to simultaneously evaluate the effects of multiple correlated factors, revealed that waiting time, fraction of patients uninsured, and teaching status had independent positive associations with patients who left without being seen. CONCLUSION: More than 4% of patients who seek care at EDs in Los Angeles County leave without being seen by a physician. A greater proportion of patients leave without medical evaluation from EDs with long waiting times for ambulatory patients and from those that serve uninsured populations. These findings should be interpreted in light of existing data on the health consequences faced by patients who leave hospital EDs without treatment.

Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences.

OBJECTIVE: To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. DESIGN: Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. SETTING: A public hospital's emergency department in Torrance, Calif. PATIENTS: All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. MAIN OUTCOME MEASURES: At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. RESULTS: Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. CONCLUSION: Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.