4. CousiNs MJ, MAZZE RI: Methoxyflurane nephrotoxicity: a study of dose response in man. JAMA 225: 1611, 1973 5. FsAscrnO JA, VANAMEE P, ROSEN PP: Renal oxalosis and azotemia after methoxyflurane anesthesia. N Engi J Med 283: 676, 1970
6. HOLLENBERG NK, MCDONALD FD, COTRAN R,
et al: Irreversible acute oliguric renal failure. A complication of methoxyflurane anesthesia. N Engi J Med 286: 877, 1972
7. BERMAN ML, Lowa HJ, BOCHANTIN J, et al:
Uptake and elimination of methoxyflurane as influenced by enzyme induction in the rat. Anesthesiology 38: 352, 1973 8. MAZZE RI, Hrrr BA, COUSINS MJ: Effect of enzyme induction with phenobarbital on the in vivo and in vitro defluorination of isoflurane and methoxyflurane. J Pharmacol Exp Ther 190: 523, 1974 9. CousiNs MJ, MAZZE RI, KOSEK JC, et al: The etiology of methoxyflurane nephrotoxicity. Ibid, p 530
10. VARELA F, MENES C, Lowa HJ, et al: Correlation between methoxyflurane dose, serum inorganic fluoride and renal function (abstr),
in Proceedings of the annual meeting of the American Society of Anesthesiologists, Chicago, Oct 2-4, 1972, p 47 11. CHURCHILL D, YAcous JM, GAULT MH: Interaction between methoxyflurane and secobarbital. Clin Res 21: 725A, 1974 12. COUSINS MJ, MAZZE RI: A rapid directinjection method for measuring volatile anesthetics in whole blood. Anesthesiology 36: 293, 1972
13. BARNES FW, RUNCIE J: Potentiometric method for the determination of inorganic fluoride in biological material. J Clin Pathol 21: 668, 1968 14. FRASER J, CAMPBELL DJ: Indirect measure of oxalic acid in urine by atomic absorption spectrophotometry. Clin Biochem 5: 99, 1972 15. VAN DYKE RA, CHENOWETH MB: Metabolism of volatile anesthetics. II. In vitro metabolism of methoxyflurane and halothane in rat liver slices and cell fractions. Biochem Pharmacol 14: 603, 1965 16. MAZZE RI, TRUDELL JR, CousINs MJ: Methoxyflurane metabolism and renal dysfunction. Anesthesiology 35: 247, 1971 17. HaTRIcI. WD, WoLs'soN G, GAncIA DA, et al: Renal responses to "light" methoxyflurane anesthesia. Anesthesiology 38: 30, 1973 18. Tosav RE, CLUBB RJ: Renal function after methoxyflurane and halothane anesthesia. JAMA 223: 649, 1973 19. VALERINO DM, VESSEL ES, AuRORI KC, et al: Effects of various barbiturates on hepatic microsomal enzymes. A comparative study. Drug Metab Dispos 2: 448, 1974 20. RoBINsON DS, SYLWESTER D: Interaction of commonly prescribed drugs and warfarin. Ann intern Med 72: 853, 1970 21. HUNNINOHAKE DB, AZARNOFF DL: Drug in-
teractions with warfarin. Arch Intern Med 121: 349, 1968
22. SoN SL, COLELLA JJ JR, BROWN BR .ia: The
effect of phenobarbitone on the metabolism
of methoxyflurane to oxalic acid in the rat. Br I Anaesth 44: 1224, 1972 23. FISEROVA-BERGEROVA V: Changes of fluoride content in bone: an index of drug defluorination in vivo. Anesthesiology 38: 345, 1973 24. VAN Dyj.a RA, Wooo CL: Metabolism of methoxyflurane: release of inorganic fluoride in human and rat hepatic microsomes. Anesthesiology 39: 613, 1973 25. New Zealand Rheumatism Association Study: Aspirin and the kidney. Br Med 1 1: 593, 1974 26. MAcKLON AF, CRAFT AW, THOMPSON M,
et al: Aspirin and analgesic nephropathy. Ibid, p 597 27. ALEXANDERSON B, SsocvssT F: Individual differences in the pharmacokinetics of monomethylated tricyclic anti-depressants. Role of genetic and environmental factors and clinical importance. Ann NY Acad Sd 179: 739, 1971 28. Aspirin and the kidney (E). Can Med Assoc 1 111: 629, 1974 29. Kuzucu EY: Methoxyflurane, tetracycline and renal failure. JAMA 211: 1162, 1970 30. BARR GA, MAZZE RI, CousNs MJ, et al: An animal model for combined methoxyflurane and gentamicin nephrotoxicity. Br I
Anaesth 45: 306, 1973 31. MAzza RI, CousINs MJ: Combined nephrotoxicity of gentamicin and methoxyflurane anesthesia in man. Ibid, p 394
Primary care for nontraumatic illness at the emergency department and the family physician's office R.E.M. LEES,* MD; R. STEELE,t MD; R.A. SPASOFF4 MD
A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days' care and were less likely to receive more than 31 days' care; those without a family physician more From the department of community health and epidemiology, Queen's University, Kingston *As.ciate professor tProfessor and head .Assistant professor Reprint requests to: Dr. R. Steele, Department of community health and epidemiology, Queen's University, Kingston, ON K7L 2N6
often received additional care (were referred, admitted or asked to return).
de 5 jours de soins et moms susceptibles den recevoir plus de 31 jours; los patients n'ayant pas de medecin de famille re9urent plus souvent des soins additionnels (us furent diriges vers un consultant ou hospitalis6s, ou on leur demanda de se pr6senter A une date ulterleure).
On a etudie un total de 1117 consultations faites au cours de deux periodes de 2 semaines, dans les services d'urgence de deux h6pitaux et dans les cabinets prives de 15 medecins de famille, pour des affections The public's use of the hospital emernontraumatiques. Les patients gency department for primary medical s'adressant aux deux milleux se sont care is increasing in both Canada and repartis en deux sousgroupes bien the United States.1 Several studies have distincts, et le choix du milieu semble described the demographic characterisavoir ete influenc6 par l'acuite et Ia tics of persons seeking such care from duree de leurs malaises. Plusieurs this source and the role of the hospital differences tres significatives ont et6 in meeting this demand;2. but, although observ6es entre les deux groupes: the results help us understand the patceux qui se sont adresses & un service tern of such use, they provide little d'urgence present&rent des malaises de insight into the management of the paplus courte duree, subirent plus de tients or their illnesses after admission tests (qul donnerent plus souvent des to the hospital. We have investigated resultats anormaux), furent plus the economics of primary care in the susceptibles d'&tre examines pour des hospital setting as part of a major study sympt8mes psychiatriques, eurent of primary care services in hospital plus de consultations, re.urent moms emergency departments.3 de recommandations et de medicaments However, concern cannot rest with (mais de plus frequentes injections patient characteristics and economics intramusculaires), furent hospitalis6s when there may be differences in manplus souvent, se presenterent moms agement and quality of care between souvent pour obtenir des soins the emergency department and the supplementaires pour les m&mes more traditional locus of such care, the malaises, se conform&rent moms family physician's office. Teglas6 in souvent aux instructions reques, furent 1969 analysed presenting problems and plus susceptibles de recevoir moms the disposition of patients seeking treatCMA JOURNAL/FEBRUARY 21, 1976/VOL 114 333
ment in the emergency
department of Toronto hospital, and Bain and John¬ son4 in 1971 noted that 60% of pa¬ tients attending the emergency depart¬ ment of another Toronto hospital did so for complaints resulting from a
trauma.
A pilot study at the two general hos¬ pitals in Kingston showed that, when traumatic conditions were excluded, 87% of complaints at the emergency departments were included in 1 of 10 symptom/sign complexes, for each of which the patient could have gone to a family physician. We therefore under¬ took a study of the patients presenting for treatment of these symptom/sign complexes, during the same periods, at the hospital emergency departments and 15 family physicians' offices, as well as the patterns of care, patient management and patient disposition in the two settings. Methods
The emergency
departments of the hospitals are staffed by full-time physicians. The participating family physicians were selected principally from the preceptors in the Queen's University family medicine program, who are community physicians in pri¬ vate practice. During two 2-week periods in May/ June and January (selected to reduce the influence of seasonal illnesses), the charts of all patients presenting with any of the 10 symptom/sign complexes were tagged for identification after con¬ sent was obtained for each patient's inclusion in the study. The 10 com¬ plexes were the following: pain (of any body system); upper respiratory tract infection; mental symptoms (largely anxiety or depression, or both); nausea, vomiting or diarrhea; earache; dyspnea; fever; abnormal vaginal bleeding; uri¬ nary tract symptoms; and urethral or vaginal discharge. The presenting com¬ plaint had to be for an episode of a new illness or one for which the pa¬ tient had not previously sought medical two
care.
Information
ceptionists,
was nurses
obtained by the reand physicians at
each location and entered on a stand¬ ard data collection sheet, each patient being identified only by a code number allocated from a central register at the first visit. One trained, experienced research assistant supervised the col¬ lection of data. Recorded for each pa¬ tient were demographic characteristics, whether he had a family physician,
sultations and with whom, treatment, arrangements for follow-up and dispo¬ sition. Each patient was followed up for 1 month (by his family physician, the emergency department physician or the physician to whom he had been referred), and further visits to physi¬ cians, investigations, treatment and re¬ ferrals were recorded, together with changes in diagnosis and disposition. The results of all investigations and the delay in obtaining them were recorded. Finally, the outcome of treatment and the status of the illness at the end of 1 month were obtained. The duration of care for the illness episode was cal¬ culated and compliance or noncompliance with disposal instructions was de¬ termined for each patient. The data were centrally processed and coded, and computer analysis was carried out using the Statistical Package for the Social Sciences (SPSS). Because we were dealing with groups of people rather than individuals and comparing general approaches to pa¬ tient management, many of the vari¬ ables of investigation, diagnosis, treat¬
ment and outcome were expressed within broad categories. Management, including drug therapy, for specific ill¬
disease
categories and drug treatment groups and would have made reading the report a chore. No two physicians will react identically to any given clin¬ ical problem, but it is believed that some measure of uniformity of ap¬ proach to problems exists among phy¬ sicians.
Results and discussion Numbers of patients There were no great differences in the daily numbers of patients visiting the emergency departments and, sur¬ prisingly, the very low rate of visits to family physicians at weekends (only 1.4% of all contacts with family phy¬ sicians were made on Saturday or
Sunday)
accompanied by
was not
a
compensatory loading in the emergency departments. However, heavy, probably compensatory, loading of patients was
noted in the physicians' offices on Mondays and Tuesdays; more than 50% of weekly visits for the studied
symptom/sign complexes on these 2 days.
made
were
Sex distribution
There was an almost equal distribu¬ compared directly. tion of the two sexes in individuals considered sufficient to visiting the emergency departments, but Thus, discuss the management of, for ex¬ of individuals visiting the family physi¬ ample, cardiovascular disease or gyne- cians' offices 70.5% were female cologic illness or mental disease as a (Table I); such a preponderance has whole, and to classify the therapeutic been observed frequently. agents used into such broad headings Family physician as anti-infective drugs or drugs acting on the gastrointestinal system. While Most patients (70.9%) seeking care these may be points for criticism, an at the hospitals claimed to have a fam¬ attempt to be specific would have re¬ ily physician (Table II); Vayda, Gent sulted in small numbers within many and Paisley7 reported a figure of 90% nesses
was it was
not
Table I.Percent distribution of 1117 patient visits, by
sex
Emergency departments Time Unknown 12 pmto 7:59 am 8 amto 3:59 pm 4 pmto 11:59 pm Total % of visits Total no. of visits
Male
(%)
0.3 14.0 48.4 37.2 46.6
285
Family physicians' offices
Female
(%)
(%)
Male
Female
0.9 6.7 52.9 39.4 53.4 327
17.4
21.9
58.4 24.2 29.5
62.6 15.4 70.5 356
149
(%)
Table II.Percent distribution of time of 1114* patient visits, by whether the patient had a family physician
Emergency departments Patients with
Patients without
family physician family physician
Time Unknown 0.2 12 pmto 7:59 am 10.4 9.6 8 amto 3:59 pm 51.6 presenting complaint, provisional diag¬ 4 49.7 11:59 37.7 pm 40.7 nosis, investigations performed (in¬ pmto cluding laboratory tests, radiography, Total % of visits 70.9 29.1 432 177 electrocardiography, electroencephalo¬ Total no. of visits graphy, ete), whether there were con- ?Whether the patient had a family physician was not known in three instances. 334 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
Family physicians'
offices
20.6 61.4 18.0 100.0 505
from their recent study in Hamilton. Visits of these patients to the hospitals were evenly distributed throughout the week.
Presenting complaint Duration of complaint was plotted against frequency of visits for each of the two settings (Fig. 1). Despite the large area of overlap, the highly signi¬ ficant differences between the two curves at the shortest and longest durations suggest that the two populations were different. In general, patients with complaints of recent onset tended to seek care at an emergency department, whereas those with complaints of long¬ er duration were more likely to go to a family physician. This trend was most pronounced for mental symptoms, dyspnea, pain and urinary tract symp¬ toms. This indicates that patients may assess the urgency of their complaints
8
30
M
io
Hours
Days
and
on
this basis decide where to seek
care.
The frequency of each type of com¬ plaint was similar in the two settings (Table III). Pain was the most frequent complaint, accounting for about half the visits to each setting. The least fre¬ quent were urethral and vaginal dis¬ charges (1.5% of hospital complaints) and nausea, vomiting and diarrhea (2.2% of office complaints). Provisional diagnosis In both settings respiratory illnesses accounted for most provisional diag¬ noses (21.6% of all hospital diagnoses and 25.0% of all office diagnoses); gastrointestinal illnesses were second in the emergency departments (15.0% of diagnoses) and psychiatric illnesses were second in the physicians' offices (13.5% of diagnoses). The least fre¬ quent diagnoses were endocrine and
metabolic diseases in each setting).
(0.6% of diagnoses
Investigations General physical conducted
assessments were
often in the family physicians' offices but the difference was not significant at the 0.05 level. While there were differences between the two settings in the proportion of patients on whom investigations were carried out and in the mean number of investigations per patient, these were not significant (Table IV). Only for pa¬ tients with mental symptoms were a more
significantly higher (P < 0.001) propor¬ tion investigated in the emergency de¬ partments. For patients on whom investigations were performed there was a significant difference (P < 0.01) in the mean number of investigations per pa¬ tient between the emergency depart¬ ments and the family physicians' of¬ fices (2.1 v. 1.5) and in the frequency with which positive test results were obtained (21.0% v. 17.6%). In the emergency departments 33.3% of these patients had one or more abnormal test results, compared with 22.1% of patients in the family physicians' of¬ fices. While these findings suggest that the emergency department physicians were more selective in ordering inves¬ tigations, it is difficult to draw any definite conclusions because investiga¬ tions are conducted as often in the hope that negative results will exclude a possible diagnosis as in the hope that positive results will confirm a provi¬ sional diagnosis. In both settings patients seen after 4 pm were less likely to have investiga¬
tions carried out than were those seen between 8 am and 4 pm. However, the highest frequency of investigations was in the emergency departments be¬ tween midnight and 8 am, when 53.2% of patients seen had a mean of 1.5 investigations. This may reflect greater urgency or severity of illnesses dealt
patient visits to family physicians' offices and hospital departments by duration of complaint. Table IV.Percentage of patients undergoing initial investigations and Table lll.Frequency of presenting of investigations per patient complaints FIG. 1.Distribution of
emergency
mean
number
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 335
night. In both settings microbiologic services were used frequently and in apparently similar patterns. Overall, hematologic and biochemical services were sought almost twice as often by the emergency departments, and electrocardiography with
during
radiologic
four times
the
and
as
often.
Consultations Consultations were held significantly often (P < 0.01) for patients seen in the emergency departments (28.8% of all patients seen) than for those seen in the family physicians' offices (11.5%); this was true for all com¬ plaints. This may indicate greater seve¬ rity or complexity of illness among patients who go to the emergency de¬ partment, or it may only reflect the availability of specialist services in the hospital. Consultation rates for indi¬ vidual complaints varied in the emer¬ gency departments from a high of 66.7% for vaginal bleeding to a low of 11.1% for urethral and vaginal dis¬ charges, and in the family physicians' offices from 17.6% for dyspnea to 0% for fever. The effects of higher consultation rates may be apparent if outcomes for specific complaints are examined in more detail. For example, consultation rates for vaginal bleeding differed greatly, at 67% for patients seen in the hospitals, compared with 15% for those seen in the offices, but more of the former group had been discharged from care at the end of 1 month. One is, of course, left with the problem of whether the underlying morbid condi¬ tions were qualitatively alike. There were notable differences in the categories of specialists with whom consultations were sought. Emer¬ gency room physicians most com¬ monly sought opinions from internists (25.5%), pediatricians (21%) and sur¬ geons (21%), whereas family physi¬ cians sought them from practitioners of the minor specialties (39%), surgeons (20.3%) and gynecologists (15.5%). This could reflect the greater frequency with which patients with urgent med¬ ical or surgical problems go to the emergency department. more
sicians' offices); these differences were significant at P < 0.01. Few technical procedures were performed in the fam¬ ily physicians' offices. Most complaints were treated by drug therapy. For all complaints a significantly greater proportion (P < 0.01) of patients were given drugs at the first office visit than at the first emergency department visit. However, among those who were given drugs, more drugs were given per patient at the hospital (mean, 1.38 drugs) than at the office (mean, 1.25 drugs). For none of the individual symptom/sign complexes were the differences in pre¬ scribing patterns between the emer¬ gency departments and the family phy¬ sicians' offices significantly different. As has been noted in other studies of primary care services8'9 anti-infective agents accounted for the greatest pro¬ portion of drugs prescribed in both set¬
tings. The distribution of drug therapy was similar in the two settings, except for cardiovascular disease, for which drug therapy was given less frequently in the emergency departments; 60% of patients with this diagnosis were ad¬ mitted to hospital and few were given drug therapy before admission. In con¬ trast, only 23% of patients for whom this diagnosis was made at a family physician's office were admitted to hos¬ Table V.Frequency of
use
pital; the others received drug therapy. Overall, the diagnosis of cardiovascular disease was made less often in the fam¬ ily physicians' offices. Follow-up There were significantly more (P < 0.01) return visits (30% v. 19%) to the family physicians' offices than to the emergency departments for the same complaint. Additional drugs were prescribed in 32% of return visits to the hospitals, compared with 17% of return visits to the offices. Family phy¬ sicians apparently have patients return for follow-up more often after treat¬ ment of acute conditions when no fur¬ ther medication is required, whereas return to hospital is more frequently associated with a need for further drug therapy. Disposition The only significant difference in disposition between the two settings was in the rate of admission to hospital, which was significantly higher (P < 0.01) in the emergency departments (Table VI). After the first visit to a family physician more patients were discharged and more were told to re¬ turn for a follow-up visit, compared with patients visiting an emergency de-
of specific therapeutic procedures
Treatment The frequency of use of specific therapeutic procedures differed in the two settings, though not greatly in most instances (Table V). However, in the family physicians' offices counselling accounted for
39.0% of all initial pro¬ cedures (v. 1.1% in the emergency de¬ partments), whereas in the emergency departments intramuscular injections of drugs accounted for 40.6% of all initial ?Compliance rates in parenthesis. procedures {v. 3.7% in the family phy¬ t Difference between the two settings significant at P < 0.01, 336 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
partment, but the difference in the proportions told to return was slight if those told to return to the emergency department and those told to visit their family physician after a first visit to the emergency department are considered together. Of the patients who visited the emergency departments a larger proportion of those without a family physician were discharged, asked to return for follow-up, or referred for consultation, compared with patients who had a family physician. However, if the proportions of patients who were referred, admitted or asked to return are added, it is apparent that a significantly smaller proportion (P < 0.001) of patients without a family physician received additional care, compared with those who had a family physician (62.1% v. 78.1%). This may indicate that poorer care is dispensed to those who have no family physician. The large proportion (43.3%) of patients advised to see their family physician after a visit to an emergency department may have represented, in many instances, courtesy referral, when a follow-up visit was not necessary; the low compliance rate suggests this was so. The higher referral rate for those without a family physician suggests that reasonable care is being dispensed to this group. The high admission rate for those with a family physician suggests that this group of patients bypasses the family physician when care is urgently needed. Patients visiting their family physician complied with disposal instructions significantly more often (P < 0.01) than those visiting an emergency department (76.5% v. 27.1%) (Table VI). This could indicate that emergency department visits tend to be for acute, rapidly resolving illnesses, whereas office visits tend to be for more chronic conditions. On the other hand, it might reflect a difference in the two groups of patients, those visiting their family physician being more inclined to accede to his instructions. This area is worth more detailed study. In no diagnostic group did rates of admission of patients from the physicians' offices exceed those from the emergency departments, and the frequency of admission from the emergency departments was much higher for some categories of illness - namely, gastrointestinal (23.9% v. 4.8%), genitourinary (21.9% v. 4.8%), psychiatric (19.6% v. 1.5%) and gynecologic (32.5% v. 0%). Accuracy of patients in assessing the severity of their complaints before selecting the setting from which they sought care could explain these differences. Whether investigations were carried out at the first visit appeared to influence little the disposal decision. In-
deed, all of the family physicians' admissions and 74% of those from the emergency departments were made without investigations. The duration of care for an illness depends on several factors, such as severity and duration of the presenting complaint, quality of care and management, and quality of follow-up. Less than 50% of patients seen in family physicians' offices received fewer than 5 days' care, compared with 72.7% of those seen in the emergency departments - a significant difference (P K 0.01). Significantly more (P
6. HOLLENBERG NK, MCDONALD FD, COTRAN R,
et al: Irreversible acute oliguric renal failure. A complication of methoxyflurane anesthesia. N Engi J Med 286: 877, 1972
7. BERMAN ML, Lowa HJ, BOCHANTIN J, et al:
Uptake and elimination of methoxyflurane as influenced by enzyme induction in the rat. Anesthesiology 38: 352, 1973 8. MAZZE RI, Hrrr BA, COUSINS MJ: Effect of enzyme induction with phenobarbital on the in vivo and in vitro defluorination of isoflurane and methoxyflurane. J Pharmacol Exp Ther 190: 523, 1974 9. CousiNs MJ, MAZZE RI, KOSEK JC, et al: The etiology of methoxyflurane nephrotoxicity. Ibid, p 530
10. VARELA F, MENES C, Lowa HJ, et al: Correlation between methoxyflurane dose, serum inorganic fluoride and renal function (abstr),
in Proceedings of the annual meeting of the American Society of Anesthesiologists, Chicago, Oct 2-4, 1972, p 47 11. CHURCHILL D, YAcous JM, GAULT MH: Interaction between methoxyflurane and secobarbital. Clin Res 21: 725A, 1974 12. COUSINS MJ, MAZZE RI: A rapid directinjection method for measuring volatile anesthetics in whole blood. Anesthesiology 36: 293, 1972
13. BARNES FW, RUNCIE J: Potentiometric method for the determination of inorganic fluoride in biological material. J Clin Pathol 21: 668, 1968 14. FRASER J, CAMPBELL DJ: Indirect measure of oxalic acid in urine by atomic absorption spectrophotometry. Clin Biochem 5: 99, 1972 15. VAN DYKE RA, CHENOWETH MB: Metabolism of volatile anesthetics. II. In vitro metabolism of methoxyflurane and halothane in rat liver slices and cell fractions. Biochem Pharmacol 14: 603, 1965 16. MAZZE RI, TRUDELL JR, CousINs MJ: Methoxyflurane metabolism and renal dysfunction. Anesthesiology 35: 247, 1971 17. HaTRIcI. WD, WoLs'soN G, GAncIA DA, et al: Renal responses to "light" methoxyflurane anesthesia. Anesthesiology 38: 30, 1973 18. Tosav RE, CLUBB RJ: Renal function after methoxyflurane and halothane anesthesia. JAMA 223: 649, 1973 19. VALERINO DM, VESSEL ES, AuRORI KC, et al: Effects of various barbiturates on hepatic microsomal enzymes. A comparative study. Drug Metab Dispos 2: 448, 1974 20. RoBINsON DS, SYLWESTER D: Interaction of commonly prescribed drugs and warfarin. Ann intern Med 72: 853, 1970 21. HUNNINOHAKE DB, AZARNOFF DL: Drug in-
teractions with warfarin. Arch Intern Med 121: 349, 1968
22. SoN SL, COLELLA JJ JR, BROWN BR .ia: The
effect of phenobarbitone on the metabolism
of methoxyflurane to oxalic acid in the rat. Br I Anaesth 44: 1224, 1972 23. FISEROVA-BERGEROVA V: Changes of fluoride content in bone: an index of drug defluorination in vivo. Anesthesiology 38: 345, 1973 24. VAN Dyj.a RA, Wooo CL: Metabolism of methoxyflurane: release of inorganic fluoride in human and rat hepatic microsomes. Anesthesiology 39: 613, 1973 25. New Zealand Rheumatism Association Study: Aspirin and the kidney. Br Med 1 1: 593, 1974 26. MAcKLON AF, CRAFT AW, THOMPSON M,
et al: Aspirin and analgesic nephropathy. Ibid, p 597 27. ALEXANDERSON B, SsocvssT F: Individual differences in the pharmacokinetics of monomethylated tricyclic anti-depressants. Role of genetic and environmental factors and clinical importance. Ann NY Acad Sd 179: 739, 1971 28. Aspirin and the kidney (E). Can Med Assoc 1 111: 629, 1974 29. Kuzucu EY: Methoxyflurane, tetracycline and renal failure. JAMA 211: 1162, 1970 30. BARR GA, MAZZE RI, CousNs MJ, et al: An animal model for combined methoxyflurane and gentamicin nephrotoxicity. Br I
Anaesth 45: 306, 1973 31. MAzza RI, CousINs MJ: Combined nephrotoxicity of gentamicin and methoxyflurane anesthesia in man. Ibid, p 394
Primary care for nontraumatic illness at the emergency department and the family physician's office R.E.M. LEES,* MD; R. STEELE,t MD; R.A. SPASOFF4 MD
A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days' care and were less likely to receive more than 31 days' care; those without a family physician more From the department of community health and epidemiology, Queen's University, Kingston *As.ciate professor tProfessor and head .Assistant professor Reprint requests to: Dr. R. Steele, Department of community health and epidemiology, Queen's University, Kingston, ON K7L 2N6
often received additional care (were referred, admitted or asked to return).
de 5 jours de soins et moms susceptibles den recevoir plus de 31 jours; los patients n'ayant pas de medecin de famille re9urent plus souvent des soins additionnels (us furent diriges vers un consultant ou hospitalis6s, ou on leur demanda de se pr6senter A une date ulterleure).
On a etudie un total de 1117 consultations faites au cours de deux periodes de 2 semaines, dans les services d'urgence de deux h6pitaux et dans les cabinets prives de 15 medecins de famille, pour des affections The public's use of the hospital emernontraumatiques. Les patients gency department for primary medical s'adressant aux deux milleux se sont care is increasing in both Canada and repartis en deux sousgroupes bien the United States.1 Several studies have distincts, et le choix du milieu semble described the demographic characterisavoir ete influenc6 par l'acuite et Ia tics of persons seeking such care from duree de leurs malaises. Plusieurs this source and the role of the hospital differences tres significatives ont et6 in meeting this demand;2. but, although observ6es entre les deux groupes: the results help us understand the patceux qui se sont adresses & un service tern of such use, they provide little d'urgence present&rent des malaises de insight into the management of the paplus courte duree, subirent plus de tients or their illnesses after admission tests (qul donnerent plus souvent des to the hospital. We have investigated resultats anormaux), furent plus the economics of primary care in the susceptibles d'&tre examines pour des hospital setting as part of a major study sympt8mes psychiatriques, eurent of primary care services in hospital plus de consultations, re.urent moms emergency departments.3 de recommandations et de medicaments However, concern cannot rest with (mais de plus frequentes injections patient characteristics and economics intramusculaires), furent hospitalis6s when there may be differences in manplus souvent, se presenterent moms agement and quality of care between souvent pour obtenir des soins the emergency department and the supplementaires pour les m&mes more traditional locus of such care, the malaises, se conform&rent moms family physician's office. Teglas6 in souvent aux instructions reques, furent 1969 analysed presenting problems and plus susceptibles de recevoir moms the disposition of patients seeking treatCMA JOURNAL/FEBRUARY 21, 1976/VOL 114 333
ment in the emergency
department of Toronto hospital, and Bain and John¬ son4 in 1971 noted that 60% of pa¬ tients attending the emergency depart¬ ment of another Toronto hospital did so for complaints resulting from a
trauma.
A pilot study at the two general hos¬ pitals in Kingston showed that, when traumatic conditions were excluded, 87% of complaints at the emergency departments were included in 1 of 10 symptom/sign complexes, for each of which the patient could have gone to a family physician. We therefore under¬ took a study of the patients presenting for treatment of these symptom/sign complexes, during the same periods, at the hospital emergency departments and 15 family physicians' offices, as well as the patterns of care, patient management and patient disposition in the two settings. Methods
The emergency
departments of the hospitals are staffed by full-time physicians. The participating family physicians were selected principally from the preceptors in the Queen's University family medicine program, who are community physicians in pri¬ vate practice. During two 2-week periods in May/ June and January (selected to reduce the influence of seasonal illnesses), the charts of all patients presenting with any of the 10 symptom/sign complexes were tagged for identification after con¬ sent was obtained for each patient's inclusion in the study. The 10 com¬ plexes were the following: pain (of any body system); upper respiratory tract infection; mental symptoms (largely anxiety or depression, or both); nausea, vomiting or diarrhea; earache; dyspnea; fever; abnormal vaginal bleeding; uri¬ nary tract symptoms; and urethral or vaginal discharge. The presenting com¬ plaint had to be for an episode of a new illness or one for which the pa¬ tient had not previously sought medical two
care.
Information
ceptionists,
was nurses
obtained by the reand physicians at
each location and entered on a stand¬ ard data collection sheet, each patient being identified only by a code number allocated from a central register at the first visit. One trained, experienced research assistant supervised the col¬ lection of data. Recorded for each pa¬ tient were demographic characteristics, whether he had a family physician,
sultations and with whom, treatment, arrangements for follow-up and dispo¬ sition. Each patient was followed up for 1 month (by his family physician, the emergency department physician or the physician to whom he had been referred), and further visits to physi¬ cians, investigations, treatment and re¬ ferrals were recorded, together with changes in diagnosis and disposition. The results of all investigations and the delay in obtaining them were recorded. Finally, the outcome of treatment and the status of the illness at the end of 1 month were obtained. The duration of care for the illness episode was cal¬ culated and compliance or noncompliance with disposal instructions was de¬ termined for each patient. The data were centrally processed and coded, and computer analysis was carried out using the Statistical Package for the Social Sciences (SPSS). Because we were dealing with groups of people rather than individuals and comparing general approaches to pa¬ tient management, many of the vari¬ ables of investigation, diagnosis, treat¬
ment and outcome were expressed within broad categories. Management, including drug therapy, for specific ill¬
disease
categories and drug treatment groups and would have made reading the report a chore. No two physicians will react identically to any given clin¬ ical problem, but it is believed that some measure of uniformity of ap¬ proach to problems exists among phy¬ sicians.
Results and discussion Numbers of patients There were no great differences in the daily numbers of patients visiting the emergency departments and, sur¬ prisingly, the very low rate of visits to family physicians at weekends (only 1.4% of all contacts with family phy¬ sicians were made on Saturday or
Sunday)
accompanied by
was not
a
compensatory loading in the emergency departments. However, heavy, probably compensatory, loading of patients was
noted in the physicians' offices on Mondays and Tuesdays; more than 50% of weekly visits for the studied
symptom/sign complexes on these 2 days.
made
were
Sex distribution
There was an almost equal distribu¬ compared directly. tion of the two sexes in individuals considered sufficient to visiting the emergency departments, but Thus, discuss the management of, for ex¬ of individuals visiting the family physi¬ ample, cardiovascular disease or gyne- cians' offices 70.5% were female cologic illness or mental disease as a (Table I); such a preponderance has whole, and to classify the therapeutic been observed frequently. agents used into such broad headings Family physician as anti-infective drugs or drugs acting on the gastrointestinal system. While Most patients (70.9%) seeking care these may be points for criticism, an at the hospitals claimed to have a fam¬ attempt to be specific would have re¬ ily physician (Table II); Vayda, Gent sulted in small numbers within many and Paisley7 reported a figure of 90% nesses
was it was
not
Table I.Percent distribution of 1117 patient visits, by
sex
Emergency departments Time Unknown 12 pmto 7:59 am 8 amto 3:59 pm 4 pmto 11:59 pm Total % of visits Total no. of visits
Male
(%)
0.3 14.0 48.4 37.2 46.6
285
Family physicians' offices
Female
(%)
(%)
Male
Female
0.9 6.7 52.9 39.4 53.4 327
17.4
21.9
58.4 24.2 29.5
62.6 15.4 70.5 356
149
(%)
Table II.Percent distribution of time of 1114* patient visits, by whether the patient had a family physician
Emergency departments Patients with
Patients without
family physician family physician
Time Unknown 0.2 12 pmto 7:59 am 10.4 9.6 8 amto 3:59 pm 51.6 presenting complaint, provisional diag¬ 4 49.7 11:59 37.7 pm 40.7 nosis, investigations performed (in¬ pmto cluding laboratory tests, radiography, Total % of visits 70.9 29.1 432 177 electrocardiography, electroencephalo¬ Total no. of visits graphy, ete), whether there were con- ?Whether the patient had a family physician was not known in three instances. 334 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
Family physicians'
offices
20.6 61.4 18.0 100.0 505
from their recent study in Hamilton. Visits of these patients to the hospitals were evenly distributed throughout the week.
Presenting complaint Duration of complaint was plotted against frequency of visits for each of the two settings (Fig. 1). Despite the large area of overlap, the highly signi¬ ficant differences between the two curves at the shortest and longest durations suggest that the two populations were different. In general, patients with complaints of recent onset tended to seek care at an emergency department, whereas those with complaints of long¬ er duration were more likely to go to a family physician. This trend was most pronounced for mental symptoms, dyspnea, pain and urinary tract symp¬ toms. This indicates that patients may assess the urgency of their complaints
8
30
M
io
Hours
Days
and
on
this basis decide where to seek
care.
The frequency of each type of com¬ plaint was similar in the two settings (Table III). Pain was the most frequent complaint, accounting for about half the visits to each setting. The least fre¬ quent were urethral and vaginal dis¬ charges (1.5% of hospital complaints) and nausea, vomiting and diarrhea (2.2% of office complaints). Provisional diagnosis In both settings respiratory illnesses accounted for most provisional diag¬ noses (21.6% of all hospital diagnoses and 25.0% of all office diagnoses); gastrointestinal illnesses were second in the emergency departments (15.0% of diagnoses) and psychiatric illnesses were second in the physicians' offices (13.5% of diagnoses). The least fre¬ quent diagnoses were endocrine and
metabolic diseases in each setting).
(0.6% of diagnoses
Investigations General physical conducted
assessments were
often in the family physicians' offices but the difference was not significant at the 0.05 level. While there were differences between the two settings in the proportion of patients on whom investigations were carried out and in the mean number of investigations per patient, these were not significant (Table IV). Only for pa¬ tients with mental symptoms were a more
significantly higher (P < 0.001) propor¬ tion investigated in the emergency de¬ partments. For patients on whom investigations were performed there was a significant difference (P < 0.01) in the mean number of investigations per pa¬ tient between the emergency depart¬ ments and the family physicians' of¬ fices (2.1 v. 1.5) and in the frequency with which positive test results were obtained (21.0% v. 17.6%). In the emergency departments 33.3% of these patients had one or more abnormal test results, compared with 22.1% of patients in the family physicians' of¬ fices. While these findings suggest that the emergency department physicians were more selective in ordering inves¬ tigations, it is difficult to draw any definite conclusions because investiga¬ tions are conducted as often in the hope that negative results will exclude a possible diagnosis as in the hope that positive results will confirm a provi¬ sional diagnosis. In both settings patients seen after 4 pm were less likely to have investiga¬
tions carried out than were those seen between 8 am and 4 pm. However, the highest frequency of investigations was in the emergency departments be¬ tween midnight and 8 am, when 53.2% of patients seen had a mean of 1.5 investigations. This may reflect greater urgency or severity of illnesses dealt
patient visits to family physicians' offices and hospital departments by duration of complaint. Table IV.Percentage of patients undergoing initial investigations and Table lll.Frequency of presenting of investigations per patient complaints FIG. 1.Distribution of
emergency
mean
number
CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 335
night. In both settings microbiologic services were used frequently and in apparently similar patterns. Overall, hematologic and biochemical services were sought almost twice as often by the emergency departments, and electrocardiography with
during
radiologic
four times
the
and
as
often.
Consultations Consultations were held significantly often (P < 0.01) for patients seen in the emergency departments (28.8% of all patients seen) than for those seen in the family physicians' offices (11.5%); this was true for all com¬ plaints. This may indicate greater seve¬ rity or complexity of illness among patients who go to the emergency de¬ partment, or it may only reflect the availability of specialist services in the hospital. Consultation rates for indi¬ vidual complaints varied in the emer¬ gency departments from a high of 66.7% for vaginal bleeding to a low of 11.1% for urethral and vaginal dis¬ charges, and in the family physicians' offices from 17.6% for dyspnea to 0% for fever. The effects of higher consultation rates may be apparent if outcomes for specific complaints are examined in more detail. For example, consultation rates for vaginal bleeding differed greatly, at 67% for patients seen in the hospitals, compared with 15% for those seen in the offices, but more of the former group had been discharged from care at the end of 1 month. One is, of course, left with the problem of whether the underlying morbid condi¬ tions were qualitatively alike. There were notable differences in the categories of specialists with whom consultations were sought. Emer¬ gency room physicians most com¬ monly sought opinions from internists (25.5%), pediatricians (21%) and sur¬ geons (21%), whereas family physi¬ cians sought them from practitioners of the minor specialties (39%), surgeons (20.3%) and gynecologists (15.5%). This could reflect the greater frequency with which patients with urgent med¬ ical or surgical problems go to the emergency department. more
sicians' offices); these differences were significant at P < 0.01. Few technical procedures were performed in the fam¬ ily physicians' offices. Most complaints were treated by drug therapy. For all complaints a significantly greater proportion (P < 0.01) of patients were given drugs at the first office visit than at the first emergency department visit. However, among those who were given drugs, more drugs were given per patient at the hospital (mean, 1.38 drugs) than at the office (mean, 1.25 drugs). For none of the individual symptom/sign complexes were the differences in pre¬ scribing patterns between the emer¬ gency departments and the family phy¬ sicians' offices significantly different. As has been noted in other studies of primary care services8'9 anti-infective agents accounted for the greatest pro¬ portion of drugs prescribed in both set¬
tings. The distribution of drug therapy was similar in the two settings, except for cardiovascular disease, for which drug therapy was given less frequently in the emergency departments; 60% of patients with this diagnosis were ad¬ mitted to hospital and few were given drug therapy before admission. In con¬ trast, only 23% of patients for whom this diagnosis was made at a family physician's office were admitted to hos¬ Table V.Frequency of
use
pital; the others received drug therapy. Overall, the diagnosis of cardiovascular disease was made less often in the fam¬ ily physicians' offices. Follow-up There were significantly more (P < 0.01) return visits (30% v. 19%) to the family physicians' offices than to the emergency departments for the same complaint. Additional drugs were prescribed in 32% of return visits to the hospitals, compared with 17% of return visits to the offices. Family phy¬ sicians apparently have patients return for follow-up more often after treat¬ ment of acute conditions when no fur¬ ther medication is required, whereas return to hospital is more frequently associated with a need for further drug therapy. Disposition The only significant difference in disposition between the two settings was in the rate of admission to hospital, which was significantly higher (P < 0.01) in the emergency departments (Table VI). After the first visit to a family physician more patients were discharged and more were told to re¬ turn for a follow-up visit, compared with patients visiting an emergency de-
of specific therapeutic procedures
Treatment The frequency of use of specific therapeutic procedures differed in the two settings, though not greatly in most instances (Table V). However, in the family physicians' offices counselling accounted for
39.0% of all initial pro¬ cedures (v. 1.1% in the emergency de¬ partments), whereas in the emergency departments intramuscular injections of drugs accounted for 40.6% of all initial ?Compliance rates in parenthesis. procedures {v. 3.7% in the family phy¬ t Difference between the two settings significant at P < 0.01, 336 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114
partment, but the difference in the proportions told to return was slight if those told to return to the emergency department and those told to visit their family physician after a first visit to the emergency department are considered together. Of the patients who visited the emergency departments a larger proportion of those without a family physician were discharged, asked to return for follow-up, or referred for consultation, compared with patients who had a family physician. However, if the proportions of patients who were referred, admitted or asked to return are added, it is apparent that a significantly smaller proportion (P < 0.001) of patients without a family physician received additional care, compared with those who had a family physician (62.1% v. 78.1%). This may indicate that poorer care is dispensed to those who have no family physician. The large proportion (43.3%) of patients advised to see their family physician after a visit to an emergency department may have represented, in many instances, courtesy referral, when a follow-up visit was not necessary; the low compliance rate suggests this was so. The higher referral rate for those without a family physician suggests that reasonable care is being dispensed to this group. The high admission rate for those with a family physician suggests that this group of patients bypasses the family physician when care is urgently needed. Patients visiting their family physician complied with disposal instructions significantly more often (P < 0.01) than those visiting an emergency department (76.5% v. 27.1%) (Table VI). This could indicate that emergency department visits tend to be for acute, rapidly resolving illnesses, whereas office visits tend to be for more chronic conditions. On the other hand, it might reflect a difference in the two groups of patients, those visiting their family physician being more inclined to accede to his instructions. This area is worth more detailed study. In no diagnostic group did rates of admission of patients from the physicians' offices exceed those from the emergency departments, and the frequency of admission from the emergency departments was much higher for some categories of illness - namely, gastrointestinal (23.9% v. 4.8%), genitourinary (21.9% v. 4.8%), psychiatric (19.6% v. 1.5%) and gynecologic (32.5% v. 0%). Accuracy of patients in assessing the severity of their complaints before selecting the setting from which they sought care could explain these differences. Whether investigations were carried out at the first visit appeared to influence little the disposal decision. In-
deed, all of the family physicians' admissions and 74% of those from the emergency departments were made without investigations. The duration of care for an illness depends on several factors, such as severity and duration of the presenting complaint, quality of care and management, and quality of follow-up. Less than 50% of patients seen in family physicians' offices received fewer than 5 days' care, compared with 72.7% of those seen in the emergency departments - a significant difference (P K 0.01). Significantly more (P
