Natural history of abdominal pain in family practice: Longitudinal study of electronic medical record data in southwestern Ontario.

OBJECTIVE: To examine the frequency, natural history, and outcomes of 3 subtypes of abdominal pain (general abdominal pain, epigastric pain, localized abdominal pain) among patients visiting Canadian family practices. DESIGN: Retrospective cohort study with a 4-year longitudinal analysis. SETTING: Southwestern Ontario. PARTICIPANTS: A total of 1790 eligible patients with International Classification of Primary Care codes for abdominal pain from 18 family physicians in 8 group practices. MAIN OUTCOME MEASURES: The symptom pathways, the length of an episode, and the number of visits. RESULTS: Abdominal pain accounted for 2.4% of the 15,149 patient visits and involved 14.0% of the 1790 eligible patients. The frequencies of each of the 3 subtypes were as follows: localized abdominal pain, 89 patients, 1.0% of visits, and 5.0% of patients; general abdominal pain, 79 patients, 0.8% of visits, and 4.4% of patients; and epigastric pain, 65 patients, 0.7% of visits, and 3.6% of patients. Those with epigastric pain received more medications, and patients with localized abdominal pain underwent more investigations. Three longitudinal outcome pathways were identified. Pathway 1, in which the symptom remains at the end of the visit with no diagnosis, was the most common among patients with all subtypes of abdominal symptoms at 52.8%, 54.4%, and 50.8% for localized, general, and epigastric pain, respectively, and the symptom episodes were relatively short. Less than 15% of patients followed pathway 2, in which a diagnosis is made and the symptom persists, and yet the episodes were long with 8.75 to 16.80 months' mean duration and 2.70 to 4.00 mean number of visits. Pathway 3, in which a diagnosis is made and there are no further visits for that symptom, occurred approximately one-third of the time, with about 1 visit over about 2 months. Prior chronic conditions were common across all 3 subtypes of abdominal pain ranging from 72.2% to 80.0%. Psychological symptoms consistently occurred at a rate of approximately one-third. CONCLUSION: The 3 subtypes of abdominal pain differed in clinically important ways. The most frequent pathway was that the symptom remained with no diagnosis, suggesting a need for clinical approaches and education programs for care of symptoms themselves, not merely in the service of coming to a diagnosis. The importance of prior chronic conditions and psychological conditions was highlighted by the results.

A Daytime Fast Track Improves Throughput in a Single Physician Coverage Emergency Department.

OBJECTIVES: Fast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity. METHODS: A daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS). RESULTS: WT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates. CONCLUSIONS: Implementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

Characteristics of chronic pain patients in a rural teaching practice.

OBJECTIVE: To describe the characteristics of chronic noncancer pain (CNCP) patients taking oxycodone or its derivatives in a rural teaching practice. DESIGN: Characteristics of CNCP patients taking oxycodone over a 5-year period (September 2003 to September 2008) were compared with those of patients not taking opioid medications using a retrospective chart audit. SETTING: A rural teaching practice in southwestern Ontario. PARTICIPANTS: A total of 103 patients taking chronic oxycodone therapy for CNCP and a random sample of 104 patients not taking opioid medication. MAIN OUTCOME MEASURES: Number of visits, health problems, sex, and previous history of addiction and mental illness. RESULTS: Patients with CNCP taking oxycodone had significantly more health problems (P < .001), including drug and tobacco addictions. They had more than 3 times as many clinic visits during the same period of time as patients not taking opioid medication (mean of 39.0 vs 12.8 visits, P < .001). CONCLUSION: Patients with CNCP in this rural teaching practice had significantly more health issues (P < .001) and were more likely to have a history of addiction than other patients were. They created more work with significantly more visits over the same period compared with the comparison group.

Accuracy of the Broselow tape in estimating the weight of First Nations children.

INTRODUCTION: During resuscitation, the Broselow tape (BT) is the standard method of estimating pediatric weight based on body length. The First Nations population has a higher prevalence of obesity and experiences more injury than the non-First Nations population. The prevalence of obesity has raised the concern that the BT may not accurately estimate weight in this population. The purpose of this study was to validate the BT in 8 First Nations communities. METHODS: We performed a search of the electronic medical records of 2 community health centres that serve 8 local First Nations communities. We searched for the most recent clinic visit during which height and weight had been recorded in the records of patients less than 10 years of age with a postal code indicating residence in a First Nations community. The patients' actual weight was compared with their BT weight estimates using the Bland-Altman method. The Spearman coefficient of rank and percentage error was also calculated. RESULTS: A total of 243 children were included in the study (119 girls, 124 boys). The mean age was 33.3 months (95% confidence interval [CI] 29.7 to 36.9), mean height was 91.8 cm (95% CI 89.0 to 94.6), mean weight was 16.2 kg (95% CI 15.0 to 17.3)and mean BT weight was 14.0 kg (95% CI 13.1 to 14.8). The Bland-Altman percent difference was 11.9% (95% CI -17.3% to 41.1%). The Spearman coefficient of rank correlation was 0.963 (p < 0.001). The BT had a percentage error greater than 10% error 51.8% of the time, with 49.4% being underestimations. CONCLUSION: The BT was often not accurate at estimating the weight of children in 8 First Nations communities; it underestimated their weight almost half of the time.