A prospective study of rural drinking water quality and acute gastrointestinal illness.

BACKGROUND: This study examined the relationship between the bacteriological contamination of drinking water from private wells and acute gastrointestinal illness (AGII), using current government standards for safe drinking water. METHODS: A prospective cohort study was conducted using 235 households (647 individuals) randomly selected from four rural hamlets. Data were collected by means of a self-administered questionnaire, a self-report diary of symptoms and two drinking water samples. RESULTS: Twenty percent of households sampled, had indicator bacteria (total coliform or Escherichia coli (E. coli)) above the current Canadian and United States standards for safe drinking water. No statistically significant associations between indicator bacteria and AGII were observed. The odds ratio (OR) for individuals exposed to E. coli above the current standards was 1.52 (95% confidence interval (CI), 0.33-6.92), compared to individuals with levels below current standards. The odds ratio estimate for individuals exposed to total coliforms above the current standards was 0.39 (95% CI, 0.10-1.50). CONCLUSIONS: This study observed a high prevalence of bacteriological contamination of private wells in the rural hamlets studied. Individual exposure to contaminated water defined by current standards may be associated with an increased risk of AGII.

Improved disease reporting: a randomized trial of physicians.

OBJECTIVES: To determine if a heightened, passive surveillance system increases the number of physicians reporting two notifiable diseases during a six-month period. METHODS: We conducted a randomized trail among 145 community-based primary care physicians in two counties in Eastern Ontario. Intervention group physicians received a three-part intervention aimed at improving their communication with the health unit to whom all physicians are mandated to report notifiable diseases. The control group physicians remained part of the usual disease reporting system. The outcome was assessed by a relative risk comparing the number of physicians reporting among the intervention group to that in the control group. RESULTS: Seventy physicians received the intervention and 75 physicians were in the control group. The relative risk for the number of physicians reporting at least one case was 5.9 (95% CI 2.6-13.2). CONCLUSIONS: The intervention had an impact on reporting of notifiable diseases by physicians.

Fatal and hospitalized agricultural machinery injuries to children in Ontario, Canada.

OBJECTIVES: To assess rates and patterns of agricultural machinery injuries in farm children in order to both determine priorities and develop strategies for injury control in this population. METHODS: Coroners' files and hospital discharge data were examined for Ontario farm children aged 0-19 who had agricultural machinery injuries over a five year period ending 31 March 1990. Injury rates were described by age, sex, geographic region, type of machinery, and mechanism of injury. Common patterns of injury deserving of priority for prevention were then identified and described. RESULTS: 283 machinery injuries to children were identified. Injury rates were 116 and 25/100,000/year for boys and girls respectively. Boys were at increasing risk relative to girls as their ages increased. Young children were at greatest risk for fatal injury. There is a prominent summer peak in occurrence. The farm tractor was the machine most commonly associated with these injuries (33.2%), and entanglement, usually of clothing, was the mechanism cited most often (36.3%). The case fatality ratio (ratio of hospitalizations:deaths) was generally low whether assessed by machinery type or by mechanism of injury. This provides an indication of the lethality of these injuries. Common patterns associated with injury risk included: (1) inadequate supervision of small children; (2) permitting children to be in the area of moving or unguarded machinery; (3) allowing children to accompany workers using farm machinery; and (4) having children performing work related tasks inappropriate for their age. CONCLUSIONS: Machinery related injuries are not uncommon in farm children and have a high case fatality rate. These rates changed little over the five year study period. Feasible strategies for prevention of these injuries, four of which are presented here, need to be developed and implemented by public health professionals working in cooperation with members of the agricultural industry.

Visits to physicians before and after exposure to urea formaldehyde foam insulation.

The average number of visits to a physician made by a sample of 351 residents of homes insulated with urea formaldehyde foam insulation in Montreal in the one year period before exposure was 5.25, and in the year following 5.62, an increase of 7 per cent (odds ratio 1.07, 95% CI = 1.00, 1.15). The increase in visits in the post insulation year was limited to subjects who had the product installed in the winter (OR = 1.48, 95% CI = 1.18,1.85), and was not seen for study subjects who insulated their homes during other seasons of the year.

Distribution of patients between faculty and residents in a teaching hospital clinic.

The authors tried to determine whether housestaff are systematically assigned clinic patients who are more "difficult": the elderly, the poor, those with many problems, and those who cannot speak English. This cross-sectional study was carried out in the outpatient department of a university health care insurance. A systematic sample of 1,870 patient visits to the medical clinic from 1980 to 1986 was studied. Housestaff were more likely to see patients who did not speak English, who had four or more medical problems, who had visited the clinic five or more times, who had been admitted to the hospital or emergency ward, or who had a skin problem. Multivariate analysis of these individual factors, allowing for the effect of each upon the others, showed that only previous hospital or emergency ward admission, native language, and skin disease retained a significant association with housestaff physicians. None of these factors was strongly associated with physician status, as shown by poor predictive accuracy when the multivariate models were used to predict accuracy when the multivariate models were used to predict physician status in 105 patient visits in 1987. While some factors were statistically associated with physician status, the magnitude of the effect of each was small. An explantation, other than bias in patient assignment, was usually apparent. It is possible to organize an outpatient clinic where housestaff care for patients who are similar to those seen by faculty.

Improving appointment-keeping by patients new to a hospital medical clinic with telephone or mailed reminders.

A randomized trial of telephone and mailed reminders was conducted to assess their effect in reducing the rate of failure to keep appointments among patients new to a general medical clinic. Only 10% of the patients who received a telephone call and 12% of those who received a letter failed to keep their appointments compared with 20% of the control group (p less than 0.05). The most common reason given for failure to keep the appointment was lack of awareness of the appointment. Thus, telephone or mailed reminders can lower the rate of failure to keep appointments and result in greater satisfaction by patients and health care personnel.

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.

Subspecialty consultations in a teaching hospital.

A chart review of 60 consultations by the nephrology service of a teaching hospital was carried out to determine their diagnostic and therapeutic utility. General medicine residents on elective rotations in nephrology performed 72% of the consultations, only 26% being written by residents in the subspecialty. Consultants made an average of 2.2 diagnoses per patient, of which 57% confirmed the working diagnosis already in the medical record. They made an average of 3.0 recommendations for further investigation per patient, but referring physicians implemented only 58% of these. An average of 1.6 recommendations for therapy were made per patient, of which 64% were implemented. The apparent neglect of the consultant's advice for investigation and therapy suggests that the written consultation to some extent fails to convey information useful for the referring physician and the patient. Further study is needed to determine if this failure reflects inadequate training of house officers as consultants.

Expanding the nurse's role to improve preventive service in an outpatient clinic.

To help resolve the conflicting demands of primary and secondary care in hospital medical clinics, a program was developed whereby, with the physicians' agreement, nurses would select and vaccinate clinic patients eligible for influenza vaccination. In a controlled trial the nurses offered vaccination to half of the eligible patients attending morning sessions and vaccinated 35% of them. In contrast, physicians in the afternoon sessions, who were unaware of the program, vaccinated only 2% of similar patients. These results show that, although these physicians agree with guidelines for influenza vaccination, they are not currently providing the service. The use of nursing personnel to provide this and other types of primary medical care for clinic patients is a reasonable alternative.

Interobserver and intraobserver variability in lung scan reading in suspected pulmonary embolism.

The interobserver and intraobserver variability in lung scan reading and interpretation was tested using a consecutive series of 96 lung scans done for patients clinically suspected to have pulmonary embolism. Lung scans were also done on 37 reference patients who were matched to a suspect case and consented to the procedure. Two experienced readers blindly read all films twice. Intraobserver agreement was low, especially for lung scans showing minor defects. Kappa, a measure of agreement beyond chance, was consistently less than .500. Interobserver agreement was lower. Only 4.3% of the suspect cases had lobar defects on the lung scan. The distribution of abnormalities in suspect and reference cases was similar. The results indicate that the reproducibility of lung scan readings is probably to low to be clinically useful, for readings involving defects that are segmental or smaller. The reproducibility for lobar defects could not be determined adequately because of their low frequency in this study.

Hospital emergency room utilization in Montreal before and after Medicare: the Quebec experience.

The impact of the introduction of Medicare in Quebec on hospital emergency room services was examined in Metropolitan Montreal. After Medicare, the emergency room visit rate increased 14 per cent per year compared to a 7 per cent per year increase in the five years preceding Medicare. The outpatient clinic visit rate continued an upward trend (4 per cent per year). In six of the hospitals selected for more detailed studies, patient interviews revealed that before Medicare 33 per cent of emergency room attenders attempted to contact a physician before reporting to the emergency room and 63 per cent were successful in speaking to the physician. After Medicare, 39 per cent attempted but only 38 per cent were successful. Before Medicare, 47 per cent of patients said that their usual source of care was a private physician, and only 17 per cent usually sought care in the emergency room. After Medicare 58 per cent reported a private physician and 31 per cent the emergency room. These findings together with the increased population density of physicians and increased annual number of physician visits per person suggest that there has been a substantial rise in demand from the public for medical care of which one important early manifestation is an increased reliance on emergency rooms.

Hospital admission before and after Medicare in Quebec.

A 1 in 60 random sample of Quebec hospital admission records ("separations") for the years 1966 through 1974 was studied for evidence of change associated with the introduction in 1970 of universal health insurance. Non-surgical separation rates continued to decline in Montreal and remained steady in the rest of the province. In contrast, separations following surgical operation did not decline in Montreal and have increased substantially since 1970 in the rest of the province. Ten operative procedures accounting for 41 per cent of all surgical admissions were selected for separate study: of these, cholecystectomy, hysterectomy and hernia repairs conformed most closely to the new pattern. Directly or indirectly, Medicare may have contributed to these changes but more study is required to confirm or explain this.