Out-of-hours service in Denmark: the effect of a structural change. (1/2311)

BACKGROUND: In Denmark, the provision of out-of-hours care by general practitioners (GPs) was reformed at the start of 1992. Rota systems were replaced locally by county-based services. The new out-of-hours service resulted in a considerable reduction in the total number of GPs on call. AIM: To describe how the patients experienced the change from a satisfaction point of view, and how the pattern of patient contact and the fee for GPs changed with the new system. METHOD: The county of Funen was chosen as the geographical area where data were collected. A questionnaire measuring patient satisfaction was posted before the change, immediately after the change, and three years later to a random selection of patients who had been in contact with the out-of-hours service within two weeks before the mailing date. All primary care services for the Danish population are stored in a database (National Health Service Registry). From this continuously updated database, the contact pattern and the fee for GPs were extracted for 1991, 1992, and 1995. RESULTS: The total number of patient contacts was reduced by 16% in the first year, but by only 6% three years later. Three years after the change, there were more than twice as many telephone consultations as before the change, and there were only a third as many home visits. After three years, the GPs' fees were reduced by 20%. There was a significant decrease in patient satisfaction, although the overall level remained high. This decrease was lower three years after the change than immediately after the new system was introduced. CONCLUSION: The new service had a major cost-effectiveness benefit, but there was a price to pay in patient satisfaction.  (+info)

Delay in presentation of patients with acute stroke to hospital in Oxford. (2/2311)

We identified prospectively all patients (181 patients, 183 episodes) admitted to hospital in Oxford with acute stroke from 1 January to 30 June 1997. Data were inadequate in 30, leaving 153 episodes in 151 patients (63 men, 90 women). Structured interviews were used to investigate the timing of events preceding admission. Most strokes (91%) occurred at home, and 36% of patients were alone. After a median delay of 15 min, 56% called a GP (median 30 min response), 41% an ambulance (median 48 min to admission), and 3% went directly to A&E. Median time from hospital admission to doctor assessment was 69 min. Factors reducing delay were: initially calling an ambulance rather than a GP (p < 0.0001); onset not at home (p < 0.001); symptoms improving between onset and admission (p < 0.002); and altered consciousness (p < 0.002). The stroke was not recognized by 44% of patients, but no significant delay resulted. Overall, 31% were admitted within 3 h of onset, 46% within 6 h. Initial contact with the GP is a major determinant of delay. If acute therapies for stroke become available, GPs should be the primary targets for an educational initiative.  (+info)

Rider injury rates and emergency medical services at equestrian events. (3/2311)

BACKGROUND: Horse riding is a hazardous pastime, with a number of studies documenting high rates of injury and death among horse riders in general. This study focuses on the injury experience of cross country event riders, a high risk subset of horse riders. METHOD: Injury data were collected at a series of 35 equestrian events in South Australia from 1990 to 1998. RESULTS: Injury rates were found to be especially high among event riders, with frequent falls, injuries, and even deaths. The highest injury rates were among the riders competing at the highest levels. CONCLUSION: There is a need for skilled emergency medical services at equestrian events.  (+info)

Where do people go for treatment of sexually transmitted diseases? (4/2311)

CONTEXT: Major public health resources are devoted to the prevention of sexually transmitted diseases (STDs) through public STD clinics. However, little is known about where people actually receive treatment for STDs. METHODS: As part of the National Health and Social Life Survey, household interviews were performed from February to September 1992 with 3,432 persons aged 18-59. Weighted population estimates and multinomial response methods were used to describe the prevalence of self-reported STDs and patterns of treatment utilization by persons who ever had a bacterial or viral STD. RESULTS: An estimated two million STDs were self-reported in the previous year, and 22 million 18-59-year-olds self-reported lifetime STDs. Bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) were more common than viral STDs (genital herpes, genital warts, hepatitis and HIV). Genital warts were the most commonly reported STD in the past year, while gonorrhea was the most common ever-reported STD. Almost half of all respondents who had ever had an STD had gone to a private practice for treatment (49%); in comparison, only 5% of respondents had sought treatment at an STD clinic. Respondents with a bacterial STD were seven times more likely to report going to an STD clinic than were respondents with a viral STD--except for chlamydia, which was more likely to be treated at family planning clinics. Men were significantly more likely than women to go to an STD clinic. Young, poor or black respondents were all more likely to use a family planning clinic for STD treatment than older, relatively wealthy or white respondents. Age, sexual history and geographic location did not predict particular types of treatment-seeking. CONCLUSIONS: The health care utilization patterns for STD treatment in the United States are complex. Specific disease diagnosis, gender, race and income status all affect where people will seek treatment. These factors need to be taken into account when STD prevention strategies are being developed.  (+info)

Time course of respiratory decompensation in chronic obstructive pulmonary disease: a prospective, double-blind study of peak flow changes prior to emergency department visits. (5/2311)

The aim of this study was to look at changes in peak expiratory flow rates (PEFR) prior to emergency department visits for decompensated chronic obstructive pulmonary disease (COPD). It was designed as a prospective, double-blind study at the Albuquerque Veterans Affairs Medical Center. Twelve patients with an irreversible component of airflow obstruction on pulmonary function tests were assessed. At entry, all subjects were instructed in the use of a mini-Wright peak flow meter with electronic data storage. They then entered a 6-month monitoring phase in which they recorded PEFR twice daily, before and after bronchodilators. The meter displays were disabled so that the patients and their physicians were blinded to all values. Medical care was provided in the customary manner. Patients were considered to have respiratory decompensation if they required treatment for airflow obstruction in the Emergency Department (ED) and no other causes of dyspnea could be identified. Simple linear regression was used to model changes in PEFR over time. The 12 subjects had 22 episodes of respiratory decompensation during 1741 patient-days of observation. Two episodes could not be analysed because of missing values. Ten episodes in seven subjects were characterized by a significant linear decline in at least one peak flow parameter prior to presentation. The mean rates of change for the four daily parameters varied from 0.22% to 0.27% predicted per day (or 1.19 to 1.44 1 min-1 day-1). The average decrement in these parameters ranged from 30.0 to 33.8 1 min-1 (or 18.6%-25.9% of their baseline values). No temporal trends were found for the 10 episodes occurring in the other five subjects. We concluded that respiratory decompensation is characterized by a gradual decline in PEFR in about half of cases. Future studies should be done to elucidate the mechanisms of respiratory distress in the other cases.  (+info)

Older people's use of ambulance services: a population based analysis. (6/2311)

OBJECTIVE: To investigate the use of emergency and non-urgent ambulance transport services by people aged 65 years and over. SETTING: The study was undertaken in Queensland where the Queensland Ambulance Services (QAS) is the sole provider of emergency pre-hospital and non-urgent ambulance services for the entire state. METHODS: The age and sex of 351,000 emergency and non-urgent cases treated and transported by the QAS from July 1995 to June 1996 were analysed. RESULTS: People aged 65 years and over who comprise 12% of the population utilise approximately one third of the emergency and two thirds of the non-urgent ambulance resources provided in Queensland. While the absolute number of occasions of service for females for emergency services is higher than for males, when the data are stratified for age and sex, males have higher rates of emergency ambulance service utilisation than females across every age group, and particularly in older age groups. Gender differences are also found for non-urgent ambulance usage. The absolute number of occasions of service for older females aged 65 and over using non-urgent ambulance transport is high, but utilisation patterns on stratified data reveal similar gender usage patterns across most age groupings, except at the older age groupings where male usage greatly exceeds female usage. CONCLUSIONS: As the aged are disproportionately high users of ambulance services, it will become increasingly important for ambulance services to plan for the projected increase in the aged population. Emergency pre-hospital care is one of the few health services along the continuum of care where male usage patterns are higher than those of females. More information needs to be obtained on the age and presenting characteristics of those people who are multiple users of the ambulance service. Such information will assist service planners.  (+info)

Delphi study into planning for care of children in major incidents. (7/2311)

This paper describes a Delphi study used to identify and improve areas of concern in the planning of care for children in major incidents. The Delphi was conducted over three rounds and used a multidisciplinary panel of 22 experts. Experts were selected to include major incident, immediate care, emergency medicine, and paediatric specialists. This paper presents a series of consensus statements that represent the Delphi group's opinion on the management of children in major incidents. The statements cover all phases of major incident planning and response. Paediatric services may play a vital role in the preparation and response to a major incident involving children. This paper represents a consensus view on how best to plan and respond to major incidents involving children. An accompanying paper describes the practical implementation of this guidance.  (+info)

Planning for major incidents involving children by implementing a Delphi study. (8/2311)

This paper provides a practical approach to the difficult problem of planning for a major incident involving children. It offers guidance on how general principles resulting from an expert Delphi study can be implemented regionally and locally. All phases of the response are covered including preparation, management of the incident, delivery of medical support during the incident, and recovery and support. A check list for regional planners is provided. Supplementary equipment is discussed and action cards for key roles in the paediatric hospital response are shown. Particular emphasis is placed on management of the secondary-tertiary interface including the special roles of paediatric assessment teams and paediatric transfer teams. A paediatric primary triage algorithm is provided. The important role of local interpretation of guidance is emphasised.  (+info)