A trial of increased access to primary care

Evaluation of a task-based community oriented teaching model in family medicine for undergraduate medical students in Iraq

BACKGROUND

The inclusion of family medicine in medical school curricula is essential for producing competent general practitioners. The aim of this study is to evaluate a task-based, community oriented teaching model of family medicine for undergraduate students in Iraqi medical schools.

METHODS

An innovative training model in family medicine was developed based upon tasks regularly performed by family physicians providing health care services at the Primary Health Care Centre (PHCC) in Mosul, Iraq. Participants were medical students enrolled in their final clinical year. Students were assigned to one of two groups. The implementation group (28 students) was exposed to the experimental model and the control group (56 students) received the standard teaching curriculum. The study took place at the Mosul College of Medicine and at the Al-Hadba PHCC in Mosul, Iraq, during the academic year 1999-2000. Pre- and post-exposure evaluations comparing the intervention group with the control group were conducted using a variety of assessment tools.

RESULTS

The primary endpoints were improvement in knowledge of family medicine and development of essential performance skills. Results showed that the implementation group experienced a significant increase in knowledge and performance skills after exposure to the model and in comparison with the control group. Assessment of the model by participating students revealed a high degree of satisfaction with the planning, organization, and implementation of the intervention activities. Students also highly rated the relevancy of the intervention for future work.

CONCLUSION

A model on PHCC training in family medicine is essential for all Iraqi medical schools. The model is to be implemented by various relevant departments until Departments of Family medicine are established.

Continuity of care and patient outcomes after hospital discharge

BACKGROUND

Patients are often treated in hospital by physicians other than their regular community doctor. After they are discharged, their care is often returned to their regular community doctor and patients may not see the hospital physician. Transfer of information between physicians can be poor. We determined whether early postdischarge outcomes changed when patients were seen after discharge by physicians who treated them in the hospital.

METHODS

This cohort study used population-based administrative databases to follow 938833 adults from Ontario, Canada, after they were discharged alive from a nonelective medical or surgical hospitalization between April 1, 1995, and March 1, 2000. We determined when patients were seen after discharge by physicians who treated them in the hospital, physicians who treated them 3 months prior to admission (community physicians), and specialists. The outcome of interest was 30-day death or nonelective readmission to hospital.

RESULTS

Of patients studied, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% (95% confidence interval [CI], 4% to 5%) and 3% (95% CI, 2% to 3%) with each additional visit to a hospital physician rather than a community physician or specialist, respectively. The effect of hospital physician visits was cumulative, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had 1, 2, or 3 visits, respectively, with a hospital rather than a community physician. The effect was consistent across important subgroups.

CONCLUSIONS

Patient outcomes could be improved if their early postdischarge visits were with physicians who treated them in hospital rather than with other physicians. Follow-up visits with a hospital physician, rather than another physician, could be a modifiable factor to improve patient outcomes following discharge from hospital.

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PURPOSE

To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD).

SUBJECTS AND METHODS

We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days.

RESULTS

There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income.

CONCLUSION

Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.

Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care

OBJECTIVES

To identify, using a consensus development process, a list of common conditions likely to be ambulatory care sensitive (ACS); i.e. conditions for which practicable improvements in access to timely and effective ambulatory care in the English National Health Service would either reduce the incidence of the condition or avoid substantial proportions of current hospital admissions.

METHODS

Three panels of clinicians each reviewed about a third of an initial list of 174 conditions commonly recorded as hospital discharge diagnoses for residents of the North West Thames Region. For each condition, panellists estimated the proportion of cases currently admitted to hospital for which, given timely and effective ambulatory care: onset of disease could have been prevented; admission for existing disease could have been prevented; admission, once indicated, should take place within 48 hours. After an introductory meeting to discuss and clarify the task, panel members completed three rounds of a questionnaire, with postal feedback between each round, and a second meeting to discuss interim results before the final round. Seventeen general practitioners (GPs) and 17 hospital specialists working in the region comprised the panels.

RESULTS

The panels considered that for 30 of the 174 conditions at least 70% of admissions to hospital could be avoided, either by prevention of disease onset or timely and effective ambulatory care, though predominantly through the latter. For each of a further 66 conditions, 50-69% of admissions could be prevented. Within-panel agreement between hospital specialists and GPs was generally good, although the GPs tended to give slightly higher scores for avoidability of admissions than the specialists. There was marked convergence of scores in succeeding rounds.

CONCLUSIONS

Although a consensus-based list of ACS conditions cannot be definitive, the clear view of the panels was that the scope for avoiding admission through better ambulatory care is very substantial.

The meaning of ambulatory care sensitive admissions: urban and rural perspectives

Ambulatory care sensitive admission rates have been proposed as measures of access to health care. To test this, admissions for ambulatory care sensitive conditions (ACSC) were analyzed by multiple linear regression. The percentage of population below 200 percent of the federally defined poverty level, the percentage of black people, and the number of primary care providers per 1,000 population were found to be positively associated with ACSC admissions. Population density was negatively associated with ACSC admissions. There was no association between the location of the ZIP code in a health professional shortage area and ACSC admissions. Proximity to the hospital was found to be positively associated with ACSC admissions but was examined only in the most rural ZIP code group. The significant independent variables and the direction of their effects were the same across all ZIP code groups. The analysis suggests that high ACSC admissions may be a reflection of deficits in one or more of the following areas: primary care availability, accessibility, or appropriateness. In-depth study is needed to determine the relative importance of these factors in a given geographical area. There also may be environmental and social factors external to the health care system that contribute to ACSC admissions. The findings suggest that ACSC should be used cautiously as a measure of primary care system needs, and in conjunction with other health, demographic, or service utilization data.

The association of attributes of primary care with the delivery of clinical preventive services

OBJECTIVES

Evidence is building that primary care is associated with quality of care and cost effectiveness. Still, little is known of the contribution of specific attributes of primary care to important health outcomes, such as the delivery of preventive services. This study tests the association of specific attributes of primary care with a comprehensive measure of the delivery of preventive services.

METHODS

A cross-sectional multimethod study design was used to examine 2,889 patient visits to 138 community-based primary care physicians. Four primary care attributes were measured: patient preference for their regular physician, interpersonal communication, physician's accumulated knowledge of the patient, and coordination of care. Delivery of US Preventive Service Task Force-recommended services were based on data collected from direct observation and medical record review. Hierarchical linear regression models (HLM) were used to test the association of each of the primary care attributes with being up to date on screening, immunization, and health habit counseling preventive services. Each regression model was adjusted for patient age, race, health status, and insurance type.

RESULTS

Interpersonal communication and coordination of care scale scores were associated with being more up to date on screening services and health habit counseling. Accumulated knowledge and preference for regular physician were associated with being more up to date on immunizations.

CONCLUSIONS

The attributes of primary care measured in this study are associated with the receipt of preventive services. Fostering the tenets of primary care may have an impact on the delivery of preventive services and possibly other important health outcomes.