Incorporating the family into a computerized office registration system.

BACKGROUND AND OBJECTIVES: New office computer systems provide physicians with the opportunity to link together the medical records of all members of a family. The purpose of this report is to describe our experience with a computerized family grouping system in a practice of 12,000 patients. METHODS: Using a computerized patient registration system, we developed a six-digit numbering scheme that signified how various members of a household were related to one another. When first instituting the system, we initially linked individuals who shared the same phone number. Subsequently, information was updated and corrected by patients when they came to the office. RESULTS: Costs for the system included the cost of an 80386 computer with a 200 megabyte hard disk and software. In addition, initial entry of patient data cost approximately $0.36 per patient. Costs were lower ($.08 per patient) once the system was established. Several problems were noted in instituting the system, including staff difficulty in adjusting to new routines and errors in data entry and reports. CONCLUSIONS: Computerized patient registration systems permit linkage of medical records and registration information of all individuals in a family or household. Integrating such systems into medical offices requires acceptance of new routines by staff.

What would you have done? A case of functional abdominal pain.

So many situations in family medicine will not fit the nice, neat formulae of history, physical, findings and treatment that are presented in traditional `grand rounds'. Frequently, the most logical, or the most medically sensible course of action is not possible. The family physician is left negotiating a situation in which there is not necessarily a `right' way to act, as in this case. Responses, with comments from the presenter of the case, will be published in upcoming issues. Readers are invited to submit similar cases from their own experience.

Definition of the catchment area for a small rural hospital near a large city.

Practicing physicians, hospital directors, members of the hospital's board of directors and government health care planners can benefit from an accurate description of a hospital catchment area. The sociodemographic and geographic characteristics of the catchment area of Wakefield, PQ.'s 31-bed Gatineau Memorial Hospital (GMH) were studied. A randomized, door-to-door survey was conducted among permanent residents in the catchment area. The response rate was 96.1%. We found language to be an important and complex determinant of hospital utilization patterns. Orientation towards the city also affected the pattern of hospital use; those who lived between Wakefield and Ottawa-Hull were more likely to use a city hospital, as were those who had recently moved to the area, or who commuted to work in the city.

Topics for family medicine research in obstetrics.

Primarily because of improvements in care of the low-birthweight neonate, Canada's neonatal mortality rates have declined significantly over the last 20 years. To make further improvement, research is now focused on the prevention of prematurity. However, benefits from the implementation of such research and the maintenance of the current neonatal mortality rate depend on the availability of obstetric care providers in rural areas. The recent trend among family physicians to drop the practice of obstetrics significantly jeopardizes access to obstetric care for inhabitants of rural areas, and a significant body of literature suggests that such declines in access will be accompanied by an increase in the neonatal death rate. A logical research agenda for rural family physicians would include the forecasting of the effect of the decrease in obstetric care manpower, follwed by the study of factors behind this trend, and the evaluation programs designed to prevent family physicians abandoning obstetric practice.

Emergency department medicine in a rural cottage hospital.

The demographic and medical characteristics of patients using the emergency department of the Gatineau Memorial Hospital in Wakefield, Quebec were studied. These characteristics are compared with those reported in the medical literature. A youthful, predominantly male population presented to the emergency department, usually because of trauma or respiratory illness. Seventy-five percent of the patients were seen within 20 minutes of their arrival. Medications were prescribed slightly over 50% of the time, but laboratory and radiology services were infrequently used. Of the patients seen, 6.4% were transferred to larger city hospitals. These transferred patients most frequently were trauma victims needing complicated surgery or specialized services.

Rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community.

OBJECTIVE: To determine whether a small, isolated hospital that has no facilities to perform cesarean section and handles fewer than 50 deliveries annually can provide acceptably safe obstetric and perinatal care. DESIGN: Cohort study. SETTING: Southern region of the Queen Charlotte Islands, BC, served by a 21-bed hospital and medical clinic in Queen Charlotte City. The hospital and clinic are staffed by five family practitioners without local obstetric, pediatric, anesthetic or surgical support. PATIENTS: All women beyond 20 weeks' gestation who gave birth from Jan. 1, 1984, to Dec. 31, 1988; 33% were primiparous and 20% native. Of the 286 women 192 (67%) delivered locally, 33 (12%) were transferred after admission because of antepartum or intrapartum complications, and 61 (21%) delivered elsewhere by choice or on their physician's recommendation. OUTCOME MEASURES: Perinatal mortality rate and adverse perinatal outcome (death, birth weight of less than 2500 g, neonatal transfer or Apgar score of less than 7 at 5 minutes). MAIN RESULTS: There were six perinatal deaths, for a perinatal mortality rate of 20.8 (95% confidence interval [CI] 4.4 to 37.2). The hospital-based rate of adverse perinatal outcome was 6.2% (12 of 193 newborns) (95% CI 2.8% to 9.6%). CONCLUSIONS: The perinatal mortality rate is not a meaningful way to assess small populations; about 85 years of data would be required to decrease the 95% CIs from within 16 to within 4. The rate of adverse perinatal outcome in our study was consistent with the rate in other studies. Collaboration of small, rural hospitals is required to increase cohort size so that the correlation between the currently accepted standard, the perinatal mortality rate, and other outcome measures can be determined.

Randomized controlled study of customized preventive medicine reminder letters in a community practice.

OBJECTIVE: To test the effectiveness of customized, family-oriented reminder letters in activating patients to seek appropriate preventive services. DESIGN: Randomized clinical trial. One group received computer-generated, customized letters explaining recommended preventive procedures for each family member. A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups. A third group (control group) received no letters. SETTING: A private medical centre, without university affiliation, in rural Quebec. PARTICIPANTS: From 8770 patients who met study criteria, 719 families were randomly selected. Data were available for 1971 of 1998 patients in these families. MAIN OUTCOME MEASURES: The Family Received Index is the proportion of all procedures for which a family was overdue that they received. The Family End-of-study Up-to-date Index is the proportion of procedures for which the family was eligible and for which they were up-to-date at the end of the study. RESULTS: The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters (Kruskal-Wallis P = .0139). Comparison of the Family End-of-study Up-to-date indices also demonstrated that families of patients sent customized letters were more likely to be up-to-date than families not sent letters (Kruskal-Wallis P = .0054). No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group. CONCLUSIONS: This study demonstrates a clinically small but statistically significant value to customizing reminder letters.