Family Practice Vol. 19, No. 2, 207-210
© Oxford University Press 2002
Original Paper |
The relevance of continuity of care: a solution for the chaos in the emergency services
a Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Rua Sarmento Leite 250, 90.035-002 Porto Alegre (RS),
b Conceição Community Health Service,
c Federal University of Rio Grande do Sul, Brazil and
d London School of Hygiene and Tropical Medicine, Keppel St, London, UK.
Stein AT, Harzheim E, Costa M, Busnello E and Rodrigues LC. The relevance of continuity of care: a solution for the chaos in the emergency services. Family Practice 2002; 19: 207–210.
Received 2 March 2001; Revised 26 July 2001; Accepted 1 November 2001.
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Abstract |
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Background. In Brazil, there continues to be an excessive use of emergency services by patients with elective medical problems. Those patients who report having a primary care physician are less likely to utilize the emergency department for non-urgent consultations.
Objective. The objective of this study was to compare patients who have a primary care physician with those who do not in relation to severity of their chief complaint at presentation in the emergency department.
Methods. The study was carried out as a cross-sectional interview-based survey at the Conceição Hospital Emergency Service in Porto Alegre (Brazil). The sample was 553 patients selected through a systematic random sampling, and the response rate was 88%. The data entry and analysis were performed using the software Epi-info, EGRET and SPSS. The analysis included simple statistics to determine the prevalence of the conditions being investigated and the effect of independent variables (regular doctor) in relation to the dependent variable (severity of disease) through logistic regression.
Results. The chief complaints were divided up as follows: 15% emergency cases, 46% urgent cases and 39% elective. The chief complaint was defined as urgent or emergency if it exhibited a significantly statistical association with the following independent variables, after being analysed by a logistic regression model: patients who reported having a primary care physician [odds ratio (OR) = 2.98, 95% confidence interval (CI) = 1.84–4.80] and patients who usually go to the emergency room by car (OR = 2.67, 95% CI = 1.75–4.05).
Conclusion. One strategy to reduce the number of non-urgent consultations at emergency rooms is to establish a close out-patient relationship between patients and physician. There is a need to optimize the health care of patients who have non-urgent problems but still seek the emergency department through strategies at the primary health care level—especially when continuous care is available—and where a comprehensive approach with an emphasis on prevention would stimulate better quality of care at a lower cost.
Keywords. Continuity of care, emergency, epidemiology, primary health care.
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Introduction |
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There is an excess demand on our emergency services to care for patients with elective medical problems. This demand, in turn, acts as a barrier to the access of patients who have real emergencies.
The emergency rooms in big cities of developing countries continue to be the only access to medical care for many patients who otherwise could not even receive primary care. However, there are many doctors who state that the care provided in these emergency departments could be delivered in a less acute setting. Studies of urgency in the emergency department have found 5%1 to 82%2 of visits to have been made for non-urgent problems. This large variation may be due in part to differences in the population being assessed or in the criteria used to define urgency.3 On the other hand, there are studies which found that longitudinal continuity was the patients' third priority after a doctor who listens and a doctor who sorts out problems.4,5 The objective of this study is to examine whether patients who report having a primary care physician utilize emergency services more appropriately compared with those who do not.
Figure 1
presents the theoretical model which shows the factors which determine the use of emergency services.
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Methods |
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The Emergency Service of the Conceição Hospital was the setting of the study. It is the busiest emergency service in Porto Alegre, with a catchment area of ~2 million inhabitants. The Community Health Service of Conceição Hospital has 13 health posts in the north area of Porto Alegre, which provide primary care for a population who live near the hospital, and is referred to here as the ‘community health service’;.
The subjects included were a systematic random sample of patients visiting the Hospital Conceição Emergency Service on 20 chosen days. This was a cross-sectional interview-based study. The sample size was calculated to test with a 95% confidence interval (CI) and 80% of statistical power the hypothesis that patients who consult at a primary care service had twice the chance of having a personal doctor; 438 patients were required.6 The methodology has been described in a previous article.7
The main exposure factor was whether or not the patient had a primary care physician. In order to assess this, we used the following question: "Do you usually see the same physician when you have a problem, and if yes, what is her/his name?" Patients who did not remember their physician's name were regarded as not having a personal doctor.
Two emergency physicians independently reviewed all the notes of the patients included in the sample and characterized each visit as either an emergency (need imminent care, otherwise he/she could die) or urgent (need a visit within 24 hours), according to the Federal Medical Council Resolution, and as elective (could define a visit in more than 24 hours) according to the dictionary definition.8 A comparison between two emergency physicians resulted as 88% of kappa.
The interviewers were blind to the hypothesis of the study. The variables collected were: perception of severity by the patient and by the referring physician; usual place of consultation; onset of symptoms; demographic factors; socio-economic characteristics; transportation method; and distance to the emergency department. Data entry and analysis were performed using the software Epi-info, EGRET and SPSS.9–11 The analysis included descriptive statistics, univariate analysis and logistic regression.12 Informed consent was obtained from subjects included in this study. The Ethical Committee of the Conceição Hospital approved the research project.
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Results |
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The population who used the emergency room of Conceição Hospital generally comprised young women who live in Porto Alegre. They usually went to the emergency room by bus, mostly with a relative, and decided to seek consultation of their own free will or on the advice of someone from their family. Men needed to be hospitalized more frequently than women. Primary health care services represented 23% of the usual care of those patients who went to the Conceição emergency room. The visits were divided into 15% emergency cases, 46% urgent cases and 39% elective cases. Thirty-one per cent of the patients stated that they had a primary care physician. The outcome of the visits showed that 73% of patients were discharged or referred to a specialist service, 10% stayed in the observation unit and only 5% were hospitalized. Patients who reported having a primary care physician were more likely to present to the emergency department appropriately compared with those who stated that they did not have a primary care physician (Table 1
).
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The visits defined as an emergency or an urgent case exhibited a significantly statistical association with the following independent variables, after being analysed by a logistic regression model: reported to have a primary care physician and patients who go to the emergency room by car (Table 2
).
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Discussion |
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These results lead to the conclusion that those patients who reported having a primary care physician are three times as likely to consult with an actual emergency problem at the emergency department compared with those who do not have a primary care physician.
There are several studies showing that patients who have a regular source of care use the emergency department more appropriately. The episodic nature of patient care at an emergency department makes it impossible to have a comprehensive view of the patient. In addition, the care of the patient may be more expensive, especially for elective consultations.13,14 The use of a primary care physician has been regarded as an important factor to provide access to health care, which is quite important to manage the health system.15,16
The continuity of the relationship between doctor and patient has the following assumption—the possibility of improving quality of care. One of the reasons why continuity of care leads to enhanced health benefits is due to the fact that the physician has multiple exposures to patients over the years. These physicians can act as a safety net for patients' problems that arise during the life of the patient—biological, social or psychological problems. The primary care physician can become a specialist on that particular patient and could provide easy access to health care.
Even though the direct cost of a consultation is reasonable, it can lead to enormous expenditures, if one considers the unnecessary ordering of tests, prescriptions and referrals often generated. When the patient has an elective problem in the emergency room, the only way to achieve a better resolution for the health system is to develop an interface between the secondary and primary level of care. The absence of a relationship with a regular doctor was correlated with use of the emergency department for non-urgent conditions. Our study suggests that maintaining a relationship with a regular physician may reduce non-urgent use of the emergency department regardless of other variables.
There are several factors which are involved in the decision by the patient to go to the emergency department. When patients decide to visit, they probably have defined the problem as an emergency. The perception of illness by patients is more severe than the perception by physicians, which is an important aspect in development of health education schemes designed to improve communication between doctors and patients. People will use the health resources according to their perceived needs and not the expectations from the managers of the system. There is a need to develop strategies to stimulate physicians and patients to solve elective problems at the primary health care level.
There is a need to optimize the health care of patients who have non-urgent problems but still seek the emergency room by using strategies at the primary health care level, especially when continuous care is available, and where a comprehensive approach with an emphasis on prevention would stimulate better quality of care at a lower cost.
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Acknowledgments |
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We would like to express our gratitude to Karyn Baum who provided valuable input.
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References |
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4
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6 Kramer HC, Thiemann S. How Many Subjects? Statistical Power Analysis in Research. Beverly Hills: Sage, 1987: 15–117.
7
Stein AT, Costa M, Busnello ED, Rodrigues LC. Who in Brazil has a personal doctor? Fam Pract 1999; 16:596–599.
8 Brazilian Medical Federal Council. Resolution 1451, 1995.
9 Dean AG, Dean JA, Coulombier D et al. Epi Info, Version 6: A Word Processing, Database, and Statistics Program for Epidemiology on Microcomputers. Atlanta (GA): Center for Disease Control and Prevention, 1994.
10 EGRET: Statistics and Epidemiology. Research Corporation and Cytel Sofware Corporation, 1991.
11 Norusis M. Statistical Package for Social Science–SPSS. Chicago, 1986.
12 Altman DG. Practical Statistics for Medical Research. London: Chapman and Hall, 1991.
13
Kelman HR, Lane SD. Use of hospital emergency room in relation to use of private physician. Am J Publ Health 1976; 66:891.
14 Billings J, Hasselblad V. Use of Small Area Analysis to Assess the Performance of the Outpatient Delivery System in New York City. New York: New York Health Systems Agency, 1989.
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