Elimination of after-hours care at a university health service.
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Humans↗
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Risk management in after-hours care.
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Emergencies↗
The after-hours call: a survey of United States family practice residency programs.
This article reports the results of a 1977 survey of 245 family practice residency programs providing after-hours care. The objectives of the study were: (1) to clarify the involvement of family practice residents in this aspect of medical care; (2) to investigate the organization of after-hours care in the family practice centers as a possible training model for future family physicians; and (3) to establish whether or not specific educational activity was based on after-hours calls. All the responding operational programs provided after-hours care to patients, using all levels of residents as providers. Most of the programs used an answering service. Only 67 percent documented all patient encounters in writing. Regular educational feedback to residents was undertaken by 71 percent of the residency programs.
Appointments and Schedules↗
The after-hours call in family practice.
Patient care after hours continues to be an important part of the work of family physicians, in spite of the trend towards increasing Emergency Room utilization. In this paper the literature concerning after-hours care in family practice is reviewed in terms of definition, demography, utilization, morbidity, and patient stereotypes. In the Family Practice Residency Program of the University of North Carolina, 4,760 after-hours calls were recorded over two years by residents and faculty physicians. Seventy-two percent of the calls were handled purely on the telephone with little variation for patient age groups. The overall call rate was 474 calls per 1,000 patients per year. Fever and skin wounds were the most frequent symptoms recorded and respiratory tract infections, minor trauma, and anxiety were the commonest diagnoses. Thirteen percent of the contacts engendered anger or frustration in the physician. A survey of patients calling after hours demonstrated a lack of congruence between physician and patient concerning the main reason for the call in over 30 percent of contacts.
Attitude of Health Personnel↗
Risk management in dentistry.
Risk management continues to define itself as an integral element in quality dental care. Issues reviewed range from periodontal record keeping to assessment of temporomandibular joint dysfunction and from cosmetic patients to after-hours emergency care. Two common denominators emerge throughout the articles reviewed. First, thorough and accurate documentation of all phases of patient contact and treatment remains at the heart of risk management. Communication, as a system of relationships between physician, staff, and patients, ensures understanding and agreement toward a common goal. Risk management remains a unifying principle that joins legal responsibilities with sound clinical practice.
Dental Records↗
Doctor's other office, an alternative to the emergency room.
Doctor's Other Office (DOO), a group of ten family physicians, offers after-hours and weekend health care to non-critical patients who might otherwise go to a hospital Emergency Room, even though their medical problems do not require expensive, elaborate facilities of the Emergency Room. Advantages to patients include less expense than the ER, care that is appropriate to their needs, and comprehensive, continuous care through dealing with physicians who will follow through with referral to a regular physician, often the patient's own family physician. DOO physician members enjoy a rational division of after-hours and weekend coverage among colleagues that permits more free time, yet assures that patients receive good quality, continuous care. The methods of operation are discussed, including personnel schedules, consultants, hospital coverage, and finances. The DOO income just meets office expenses, however, life insurance and other fringe benefits that physician members receive through the corporation aid in making this organization more financially attractive.
California↗
Emergency medical systems in Czechoslovakia.
The year 1987 witnessed the "velvet revolution" of Vaclav Havel and the beginning of democratic reform in Czechoslovakia. As the country struggles to build a market-based economy, it maintains a well-developed socialist system of health care that is patterned after the former Soviet system and is free to all (Am J Emerg Med 1984; 2:455-456). Formal private medical practice does not exist. Non-emergency care is provided by multispecialty, primary-care oriented clinics (polyklinka) where after-hours visits are possible due to the presence of on-call physicians. In small towns such an on-call doctor would be a general practitioner, but in large cities an internist, pediatrician, and surgeon might all be available.
Czechoslovakia↗
Editorial: After-hours deputizing services.
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Australia↗
Urgent care in the HMO: evolution of a system in Washington, D.C.
In 1961, Group Health Association, a large, non-hospital based, prepaid group practice in Washington, D.C. established an after-hours walk-in clinic on its premises for the care of medical problems requiring prompt attention. Within a year, this clinic's operation was extended to daytime hours for the use of the consumer-member at his own discretion. After 10 years, in the plan's main health center, the volume of adult visits to the acute care/walk-in center exceeded the number seen in the Department of Internal Medicine; most were of a routine rather than urgent nature. More visits to the acute care service were made during the day, when the full range of ambulatory services were available by appointment, than were made after hours. The choic of immediate first-come, first-served care over the conventional care-by-appointment by so many members was felt to have resulted in discontinuous suboptimal care, segregation of the membership along socioeconomic lines, as well as unnecessary and very costly duplications of service. The background of organizational behavior and community medical practices contribuing to this pattern of utilization are explored. Compared to traditional fee-for-service medicine, demands for outpatient services in the HMO tend to be greater. Acceptable alternatives to off-line channeling of patients with unexpected or acute conditions can be designed. In the general community today, utilization of medical services is strongly influenced by imbalances in available resources and by financial factors which are under no central control. In the HMO, all costs are prepaid and services are planned for a membership of known size. Even so, consumers' use of services in prepaid plans tends to follow the patterns seen in the community. More appropriate distribution of demands requires an active and ongoing system of patient education. A commitment by the HMO's providers and managers toward this goal is indispensable.
Ambulatory Care↗
The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice.
We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasi-experimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child-care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients.
Ambulatory Care↗
Prior approval in the pediatric emergency room.
Managed-care plans for low-income Americans are widely promoted to improve the quality and control the cost of medical care by reducing unnecessary specialty and emergency room (ER) care through the use of primary care physicians as case managers/gatekeepers. The purpose of this study was to evaluate one element of managed care, gatekeeping prior approval, for children who use the pediatric ER of one urban public hospital. Over a 6-month period, 518 children and adolescents insured under managed-care plans that required authorization from the primary care physician to receive treatment presented to the ER. Of the 385 records reviewed for this study, the majority (87%) received their primary care at community health centers or the hospital's own outpatient clinics. Most ER visits (72%) were made when primary care sites were closed. According to nursing triage assessment, 57% presented with urgent or emergent conditions, and 26% had a history of chronic illness. Nine percent required hospitalization. Although an elaborate system for gatekeeping was established, only 13 (3%) patients' requests for ER care were denied. Of these, 3 were seen in the ER without authorization, 6 received the recommended follow-up, and 4 were not seen in follow-up. Twenty-nine participating primary care physicians (74%) and 19 ER staff (63%) responded to a survey of their experience with and attitudes toward prior approval. For a variety of reasons, the majority of primary care physicians and ER staff found the gatekeeping policies for after-hours visits burdensome and inappropriate.(ABSTRACT TRUNCATED AT 250 WORDS)
Attitude of Health Personnel↗
Analysis of after-hours calls and visits in a family practice.
The after-hours encounter is an important aspect of primary care. This study examined the pattern of patient behavior after hours in a rural Ontario setting serving a mixed white and native population. Of the 83 telephone calls and 59 visits over a six-week period, approximately 60 percent were from females (52 percent of the clinic population), and 70 percnet were for new problems, with acute infection accounting for nearly one third of the contacts. Forty-seven percent of the calls were rated as highly necessary; 56 percent of the calls received visits. The following factors related to the preceding call increased the likelihood of a visit: (1) an early evening call; (2) a high necessity rating; (3) a classification of trauma: (4) caller at the limit of tolerance of symptoms: (5) white caller. The significance of the results and their implications are discussed.
Adolescent↗
Institution of a 'no narcotics' policy for after-hours telephone calls.
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Adult↗
Gender differences in practice patterns of Ontario family physicians (McMaster medical graduates).
This study examined the extent to which physician gender influences practice patterns. Data came from the Ontario Hospital Insurance Plan billing profiles of general practitioner and family medicine graduates of McMaster University School of Medicine. The women physicians studied were more likely to be certified in family medicine than the men and a higher proportion of their patients were female. Women were more likely to be working part time, billed during fewer months of the year, earned less, and saw fewer patients. They provided greater numbers of services in psychotherapy and counselling and ordered more laboratory tests; associated with this were higher costs per service and per patient. Women offered a less diverse mix of services than men. They provided fewer hospital, emergency room, and intrapartum services and a lower proportion of women included house calls, after-hours work, hospital, emergency room, surgical or intrapartum services in their service mix. Thus these women appeared more likely to restrict their practices to the office setting and to provide a higher proportion of psychosocial care. The overall impact of these sex differences in practice patterns on the health care system requires further exploration.
Family Practice↗
The effect of the initial family interview on a pediatric practice.
To examine the effect of initial family interviews by health care providers on patients' use of health services, 177 patients and their families were randomly assigned to an interviewed (I) or a non-interviewed (NI) subgroup. Initial interviews would encourage families to bring their children in for health supervision visits, but discourage families from making after-hour telephone calls, using the emergency room and bringing the children to the clinic frequently for problem visits. The I families had an initial interview, attended by all family members. Both a physician and a nurse elicited patient histories and explained use of the emergency room, when to make after-hour calls, how to schedule appointments and other information about the clinic. If I families failed to have an initial interview, they were deleted from the study. In the NI subgroup, patient histories were elicited during a routine health supervision visit without the entire family in attendance, and information about emergency room visits, after-hour calls and appointment scheduling was provided during the same visit. After one year (1987) into the study and two years (1988) into the study, all patient charts were examined. Data analysis was performed using analysis of variance for repeated measures (ANOVA) and step-wise multiple regression of Statistical Analysis System. For 1987, the interview intervention explained a significant (p = 0.01) amount of variance in the number of problem visits (less in I) after controlling for months in the study and age of the child.(ABSTRACT TRUNCATED AT 250 WORDS)
Family↗
Factors associated with the frequency of after-hours in-person patient consultations.
In this study, 901 after-hours calls to 26 second- and third-year family practice residents in a university based program were audited to determine patient and physician characteristics associated with after-hours rates of in-person consultation. In-person consultation frequency averaged 25.5%, but ranged from 9% to 53% among physicians (P = .02). Male patients were seen more frequently than female patients (P = .008) Younger patients were seen more frequently than older patients (P = .01). Calls for trauma, obstetrics, and respiratory complaints were more likely to result in in-person consultations than were calls for other problems (P less than .00001). Categorical modeling analysis, used for adjustment, confirmed differences in consultation frequencies both among physicians and due to the nature of the caller's complaint. Neither the time of the call, the patient's race, nor the physician's sex, marital status, level of training, distance lived from the family practice center, or personality type as measured by the Myers-Briggs Type Indicator were associated with the frequency of consultation. Additional research is needed to determine the factors responsible for physician differences in after-hours in-person consultation frequency.
Appointments and Schedules↗
Emergency and after-hours work performed in country hospitals.
Country doctors perform emergency work in addition to their conventional general practice role. Over a one-month period 17 general practitioners in four Hunter Region towns recorded all emergency calls describing the time they were called, the severity of the patients' conditions, the skills used and the time taken. A scale to measure severity of illness was devised and tested for this purpose. There were 1197 emergency calls, mostly seen at the local hospital, either in the outpatients department or on the wards. They were unevenly distributed in time, with fewer calls at night, but the doctors were disturbed during nearly half of their nights on call. Of the calls 15% were for trivial reasons, 34% were for patients who needed standard general practice care, and 50% were for patients who needed the services of the hospital or were already inpatients. Most attendances were brief, but 15% took more than 30 minutes and some much longer. Counselling skills were used for 47% of patients and technical skills in 22%. The strain of the work involved and the disturbance of personal life justify extra payments to country doctors, and the adequacy of current pay schedules is questioned. However, the peculiarities of funding result in the State Health Department underwriting most emergency costs in country towns, whereas in the cities the Commonwealth Department of Health pays for a larger proportion, leading to concern about the high apparent costs of country hospitals. The information in this survey may help improve planning for training and remuneration of country doctors to help ease the current shortage.
Clinical Competence↗
Factors in the physician practice location puzzle: a survey of New York State residency-trained family physicians.
BACKGROUND: For the past 5 years fewer medical students have selected primary care specialties, and one-third of all physicians have indicated they will move in the next 5 years. These two factors make family physicians one of the most recruited specialties in medicine. METHODS: A questionnaire about practice profiles and factors that have an impact on a physician's location decision was mailed to all physicians who graduated from New York State family medicine residencies between 1970 and 1989. Data from completed responses were analyzed by year of graduation from residency, community size, and whether the responder remained in New York State or chose to locate outside New York State. RESULTS: There were 711 (46 percent) physicians who responded. The number of minorities remained stable at 14 percent during these years, but women graduates increased from 12 percent to 21 percent. The graduates in the 1980s, when compared with those in the 1970s, were more likely to be salaried, make less money, and to believe employment for the physician's spouse to be important in practice location. The 38 percent of responders from communities of fewer than 25,000 were less likely to be salaried, were more likely to practice in a group, worked more hours, offered a broader range of services including obstetrics, made less money, and placed less importance on availability of hospital consultants. Extended family, previous negotiated obligations, and geographic or climate issues were the reasons 64 percent of out-of-state responders gave for leaving New York. Spouse's opinion, hospital consultants, hospital services, colleague interaction, and after-hours coverage were most frequently rated as important factors for family physician practice location. CONCLUSIONS: Factors important in attracting new physicians to a community include the spouse's opinion, institutional and colleague support, and lifestyle issues.
Adult↗