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Frequent use of the hospital emergency department is indicative of high use of other health care services

ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 561-567页

作者： Hansagi, H Olsson, M Sjöberg, S Tomson, Y Göransson, S Karolinska Hosp Dept Clin Neurosci S-17176 Stockholm Sweden Huddinge Univ Hosp Dept Med Stockholm Sweden Huddinge Univ Hosp Emergency Dept Stockholm Sweden Huddinge Univ Hosp Dept Clin Sci Family Med Stockholm Sweden

Study objective: We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites. Methods: A computerized patient database covering ail ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period. Results: Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care far 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [Ct] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) far 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55;95% CI 1.26 to 1.90). Conclusion: High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category.

关键词：年龄分布门诊医疗/利用数据库事实型急诊室医院/利用卫生服务/利用卫生服务滥用/统计学和数值数据卫生服务研究健康状况医院公立/利用医院大学/利用医院市区/利用死亡率需求估价比值比病人入院/统计学和数值数据初级卫生保健/统计学和数值数据初级卫生保健/利用性别分布瑞典/流行病学青少年成年人老年人儿童儿童学龄前女(雌)性人类婴儿男(雄)性中年人

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Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders

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GENERAL HOSPITAL PSYCHIATRY 1999年第2期21卷 106-111页

作者： Steer, RA Cavalieri, TA Leonard, DM Beck, AT Univ Med & Dent New Jersey Sch Osteopath Med Dept Psychiat Stratford NJ 08084 USA Univ Med & Dent New Jersey Sch Osteopath Med Dept Med Stratford NJ 08084 USA Univ Penn Sch Med Dept Psychiat Philadelphia PA 19104 USA

To ascertain how effective the Beck Depression Inventory for Primary Care (BDI-PC) was in screening for DSM-IV major depression disorders (MDD) in outpatients who were scheduled for routine office visits with physicians specializing in internal medicine, the BDI-PC was administered to 60 male and 60 female outpatients. The internal consistency of the BDI-PC was high (alpha 0.85), and the Mood Module from the Primary Care Evaluation of Mental Disorders was used to diagnose MDD. The BDI-PC scores were not significantly correlated with sex, age, ethnicity, or total number of medical diagnoses. A BDI-PC cuttoff score of 4 and above yielded 98% maximum clinical efficiency with 97% (95% CI 82%-99%) sensitivity and 99% (95% CI 94%-99%) specificity rates, respectively,for identifying patients with and without MDD. The BDI-PC is discussed as an effective case-finding instrument for screening primary care patients for MDD. (C) 1999 Elsevier Science Inc.

关键词：贝叶斯定理置信区间抑郁症/诊断抑郁症/流行病学诊断试验常规/标准健康调查内科学/统计学和数值数据新泽西/流行病学初级卫生保健/方法初级卫生保健/统计学和数值数据精神病状态评定量表/标准心理测定学/标准 ROC曲线参考值样本大小抽样研究女(雌)性人类男(雄)性中年人

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Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care

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ANNALS OF THE RHEUMATIC DISEASES 2001年第2期60卷 91-97页

作者： Peat, G McCarney, R Croft, P Keele Univ Inst Med Postgrad Med Sch Primary Care Sci Res Ctr Stoke On Trent ST7 4NY Staffs England

Background-Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care. Aim-To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom. Design-Narrative review. Method-A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations, Findings from UK studies were summarised with reference to European and international studies. Results-During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled. Conclusion-Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.

关键词：日常生活活动年龄因素发病率骨关节炎膝/诊断骨关节炎膝/流行病学骨关节炎膝/治疗病人接受卫生保健的程度患病率初级卫生保健/统计学和数值数据疾病严重程度指数老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Clinical profile of hypertrophic cardiomyopathy identified de novo in rural communities

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第6期33卷 1590-1595页

作者： Maron, BJ Mathenge, R Casey, SA Poliac, LC Longe, TF Minneapolis Heart Inst Fdn Cardiovasc Res Div Minneapolis MN 55407 USA

OBJECTIVES The purpose of this study was to assess the extent to which hypertrophic cardiomyopathy (HCM) exists unsuspected and undetected in the general population. BACKGROUND Hypertrophic cardiomyopathy is a disease with diverse natural history for which the potential to produce adverse consequences has been emphasized. However, the possibility of this disease remaining clinically dormant for many years has not been as widely appreciated. Certainly, the clinical recognition of previously undiagnosed patients with HCM may be advantageous by permitting risk stratification for sudden cardiac death or for timely pharmacologic therapy when symptoms intervene. METHODS We prospectively conducted an echocardiographic survey in 64 primarily rural communities within Minnesota (populations <10,000) over a 33-month period. RESULTS A total of 15,137 echocardiograms were performed at the request of primary care physicians for the purpose of excluding cardiovascular abnormalities. Hypertrophic cardiomyopathy was identified in 44 patients during the survey (0.29%), and 29 of these patients (0.19% of the 15,137 echocardiograms) had not been previously identified as having cardiac disease or HCM. At diagnosis, ages were 16 to 87 years (mean 57);14 patients were greater than or equal to 60 years of age, and only two were <30 years, Twenty-four patients (83%) had either no or only mild or transient symptoms;5 (17%) evidenced severe functional limitation;in eight patients the Onset of symptoms had been deferred until greater than or equal to 70 years of age. Basal left ventricular outflow obstruction (gradients 20 to 82 mm Hg) was evident in 11 patients (38%). Relatively outflow phenotypic expression ofthe disease was substantiated by localized patterns of left ventricular wall thickening occurring more: commonly than diffusely distributed hypertrophy (48% vs. 7%, respectively), and electrocardiograms that were frequently normal (about 25%) and rarely showed evidence of left ventricul

关键词：心肌病肥厚性/诊断心肌病肥厚性/流行病学猝死心脏/流行病学猝死心脏/预防和控制超声心动描记术健康调查肥大左心室/诊断肥大左心室/流行病学明尼苏达/流行病学初级卫生保健/统计学和数值数据前瞻性研究危险性评估农村人口/统计学和数值数据青少年成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Diagnosis of depression by primary care physicians versus a structured diagnostic interview - Understanding discordance

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GENERAL HOSPITAL PSYCHIATRY 1999年第2期21卷 87-96页

作者： Tiemens, BG VonKorff, M Lin, EHB Univ Groningen Dept Psychiat NL-9700 RB Groningen Netherlands Grp Hlth Cooperat Puget Sound Ctr Hlth Studies Seattle WA 98101 USA

In this paper, false-negative and false-positive cases of depressive illness are examined, differentiating levels of disagreement between a primary care physician's diagnosis and a standardized research diagnosis. Two stratified random samples of primary cave patients in Seattle, USA (N = 373) and Groningen, The Netherlands (N = 340) were examined with the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC). Physician's severity ratings and diagnosis of psychological disorder were obtained. Three levels of disagreement between physician and CIDI diagnosis were distinguished: 1) complete disagreement about the presence of psychiatric symptoms (true false-negative and true false-positive patients);2) disagreement over severity of recognized psychological illness (underestimated or overestimated);and 3) disagreement over the specific psychiatric diagnosis among those given a diagnosis (misdiagnosed or given another CIDI diagnosis). All three levels of disagreement were common. Only 27% of the false-negative cases were due to complete disagreement (true false-negatives), and 55% of the false positives were due to complete disagreement (true false-positives). The true false-negative patients were younger, more often employed, rated their own health more favorably, visited their doctor for a somatic complaint and made fewer visits than the underestimated, misdiagnosed, and concordant positive patients. Complete disagreement in depressive diagnoses between the primary care physician and research interview is not as frequent as indicated by an undifferentiated false-negative/false-positive false-positive analysis. Differentiating levels of disagreement does move justice to diagnostic practice in primary care and provides guidance on how to improve the diagnostic accuracy of primary cave physicians. (C) 1999 Elsevier Science Inc.

关键词：卡方分布抑郁/诊断抑郁/流行病学诊断鉴别假阴性反应假阳性反应卫生保健调查门诊病人/统计学和数值数据患病率初级卫生保健/标准初级卫生保健/统计学和数值数据精神病学/标准危险因素抽样研究疾病严重程度指数单盲法成年人女(雌)性人类男(雄)性中年人

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The onset of common mental disorders in primary care attenders in Harare, Zimbabwe

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PSYCHOLOGICAL MEDICINE 1999年第1期29卷 97-104页

作者： Todd, C Patel, V Simunyu, E Gwanzura, F Acuda, W Winston, M Mann, A Univ Zimbabwe Sch Med Dept Psychiat Harare Zimbabwe Univ Zimbabwe Sch Med Dept Community Med Harare Zimbabwe Inst Psychiat Sect Epidemiol & Gen Practice London England

Background. This study aimed to investigate the onset and predictors of common mental disorders (CMD) in primary-care attenders in Harare, Zimbabwe. Method. Two (T1) and 12-month (T2) follow-up of a cohort of primary-care attenders without a common mental disorder (N = 197) as defined by the Shona Symposium Questionnaire (SSQ), recruited from primary health care clinics, traditional medical practitioner clinics and general practitioner surgeries. Outcome measure was caseness as determined by scores on the SSQ at followup. Results. Follow-up rate was 86 % at 2 months and 75 % at 12 months. Onset of CMD was recorded in 16 % at T1 and T2. Higher psychological morbidity scores at recruitment, death of a first-degree relative and disability predicted the presence of a CMD at both follow-up points. While female gender and economic difficulties predicted onset only in the short-term, belief in supernatural causation was strongly predictive of CMD at T2. Caseness at both follow-up points was associated with economic problems and disability at those follow-up points. Conclusions. Policy initiatives to reduce economic deprivation and targeting interventions to primary-care attenders who are subclinical cases and those who have been bereaved or who are disabled may reduce the onset of new cases of CMD. Closer collaboration between biomedical and traditional medical practitioners may provide avenues for developing methods of intervention for persons with supernatural illness models.

关键词：病例对照研究队列研究随访研究健康状况医学传统精神障碍/诊断精神障碍/流行病学精神障碍/心理学试验预期值初级卫生保健/统计学和数值数据社会经济因素津巴布韦/流行病学青少年成年人老年人女(雌)性人类男(雄)性中年人

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Low-intensity treatment of depression in primary care:: Is it problematic?

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GENERAL HOSPITAL PSYCHIATRY 2000年第2期22卷 78-83页

作者： Lin, EHB Katon, WJ Simon, GE Von Korff, M Bush, TM Walker, EA Unützer, J Ludman, EJ Grp Hlth Cooperat Puget Sound Ctr Hlth Studies Seattle WA 98101 USA Univ Washington Sch Med Dept Psychiat & Behav Sci Seattle WA 98195 USA Univ Calif Los Angeles Inst Neuropsychiat Ctr Hlth Serv Res Los Angeles CA 90024 USA

The aim of this study was to examine patterns of cave and outcomes of depressed patients tinder primary cave during acute phase treatment. A cohort of depressed patients was assessed 6-8 weeks after starting pharmacotherapy in four large primary care clinics in a health maintenance organization. These patients (n = 1671) were receiving antidepressant treatment for a new episode of depression. To calculate main outcome measures, Structured Clinical Interview for Depression evaluated prior history and current depression status. Visit and pharmacy refill data described use of health services and antidepressant medication. Six to eight weeks after starting antidepressant therapy, 33.2% of patients had 0-3 depressive symptoms and no prior history of depression, an additional 42.3% also reported 0-3 symptoms brit were at high risk of relapse, and 24.5% were persistently depressed with 4 or more depressive symptoms. In the initial 6 weeks of treatment, these three groups showed similar use of antidepressant medication and health services. About 50% in each group had no follow-up visit for depression and 32%-42% had not refilled their antidepressant prescription. In general, depressed patients under primary cave obtained low-intensity pharmacotherapy and inconsistent follow-up visits during initial acute phase treatment. Six weeks after starting antidepressant medicine, many were still symptomatic or recovered but had a high risk of depression relapse. Patients with unfavorable outcomes did not receive more intensive management than the one-third who had favorable outcomes. (C) 2000 Elsevier Science Inc.

关键词：急性病抗抑郁药/治疗应用队列研究抑郁症/诊断抑郁症/药物疗法抑郁症/流行病学疾病管理坚持准则健康维护组织/统计学和数值数据结果与过程评价(卫生保健) 病人依从诊疗准则(主题) 初级卫生保健/统计学和数值数据危险性评估二级预防华盛顿/流行病学青少年成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Impacting the use of the screening electrocardiogram

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AMERICAN HEART JOURNAL 2003年第6期145卷 936-937页

作者： Cuffe, MS Duke Clin Res Inst Durham NC 27715 USA

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Psychosocial and health belief variables associated with frequent attendance in primary care

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PSYCHOLOGICAL MEDICINE 1999年第6期29卷 1347-1357页

作者： Bellón, JA Delgado, A Luna, JD Lardelli, P Univ Granada Zaidin Sur Hlth Ctr Med Sch Family & Community Med Dept Prevent Med & Biostat E-18071 Granada Spain

Background. The reasons for high use of primary care, and in particular the role of psychosocial factors, remain unclear. Methods. We identified and interviewed 236 frequent attenders and 420 normal users, matched by age and sex, of a public Health Centre in Granada, Spain. Users were questioned about mental health (GHQ-28), social support (Duke-UNC-11), family dysfunction (family APGAR) and health beliefs (health belief model, locus of health control and medical care expectations). We also measured a set of individual, social and illness variables. Results. Multiple logistic regression analyses showed that mental health was the main factor associated with frequent attender status (odds ratio = 3.1;2.4-3.9). The association was stronger than that between frequent attender status and perceived illness, and between the former and reported chronic illness. Family dysfunction and perceived susceptibility to and severity of disease were also significantly but more weakly associated with frequent attender status. Affective support was more strongly associated with FA status than was confidant support, but both associations disappeared when mental health and family function were controlled for. Conclusions. Our findings document the association of psychosocial factors and primary health care use. We suggest that the effective management of mental health problems from a family-based approach may reduce primary health care high use.

关键词：慢性病/流行病学慢性病/心理学横断面研究家庭关系卫生服务滥用/统计学和数值数据体内外控制精神障碍/诊断精神障碍/心理学个性量表初级卫生保健/统计学和数值数据疾病角色社会支持西班牙青少年成年人老年人女(雌)性人类男(雄)性中年人

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Socioeconomic and geographical influences on primary dental care preferences in a population of young children

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BRITISH DENTAL JOURNAL 2000年第10期188卷 559-562页

作者： Tickle, M Moulding, G Milsom, K Blinkhorn, A Manchester Hlth Author Manchester M60 7LP Lancs England Univ Manchester Turner Sch Dent Manchester M13 9PL Lancs England

Objective To compare the socioeconomic profiles of children registered in the GDS, with those using the CDS services and unregistered children. Secondly to examine the effects of socioeconomic status on travelling to access primary dental care, and finally to map out the location of unregistered children in relation to primary dental care services. Setting The study was carried out in 1998 in Ellesmere Port in the North West of England. Subjects and materials The study population was all children younger than 6 years who used primary dental care services in, or were residents of, Ellesmere Port, The study population was categorised into those registered with a GDS dentist, those using CDS services and those unregistered by matching GDS and CDS data to the HA population register. Socioeconomic status was measured using the Super Profiles geodemographic classification The relationship between service preferences and travelling to access primary dental care with socioeconomic status were compared using cross-tabulations and chi square tests. Results There was a significant socioeconomic trend evident in the use of dental services. Two thirds of those using CDS services came from the most deprived area types. Of those who were unregistered half lived in the most deprived area types compared with one third of those registered with the GDS. Those who travelled into Ellesmere Port to access primary dental care were significantly more likely to live in an affluent area. Unregistered patients were homogeneously spread across the town. Conclusions The ability to match GDS and CDS data to the HA population register is essential to understand how dental services are used by the local population. Children from deprived areas are more likely to use the CDS and a service local to their homes, therefore primary dental care services for deprived communities have to be provided locally.

关键词：病例对照研究卡方分布队列研究社区牙科学儿童口腔保健/统计学和数值数据英格兰开业医生牙科卫生服务易得程度收入贫困初级卫生保健/统计学和数值数据登记社会阶级旅行儿童学龄前女(雌)性人类婴儿男(雄)性

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