Stacy Kramer
Article Review – Week 4
Factors predicting patient use of the emergency
department: a retrospective cohort study.
The purpose of this study was to determine possible factors predicting the use of emergency services in populations that have a primary care physician versus those who do not. Quebec was chosen because despite having relatively high numbers of family physicians per capita (compared with other provinces), residents of Quebec have the lowest rates of affiliation with a family physician and have one of the highest rates of seeing specialists. In addition, residents of Quebec have some of the highest rates of visits to emergency departments compared to other countries (McCusker et al., 2012).
The study design wasa retrospective, population-based cohort study that used information from healthcare administrative databases (McCusker et al., 2012). This type of study uses data collected over a period of time on an entire population or a representative sample of a population who have received a specific exposure. The incidence of a specific outcome of interest is tracked over time. The incidence in the exposed group is compared with the incidence in groups that are not exposed, have different levels of exposure, or have different types of exposures. This particular study followed residents of urban areas of Quebec because rural residents visited emergency rooms for primary care more often than residents of urban areas; most specialist care is provided in urban areas; and primary care services in rural areas are more likely to be provided by salaried physicians. The researchers sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients’ use of the emergency department (McCusker et al, 2012).
According to the study, results suggest that certain populations, particularly the elderly, the very sick and patients with chronic disease, derive the most benefit from being affiliated with a family physician as their primary physician. Any financial incentives for family physicians to register more patients would be best aimed at these vulnerable populations, such as has been done in Quebec since 2002. The benefits of a family physician are less clear for the younger, typically healthier populations. Therefore, future research should evaluate the effects of emerging models of primary care, financial incentives and other policies designed to increase affiliations with family physicians on use of emergency departments ((McCusker et al., 2012).
From what I think I know, an advantage of a retrospective, population based cohort study is that one can choose what to study and know there are results rather than having to wait for something to occur (i.e. the data is already available). Canadian healthcare is different from American healthcare in that it’s provided by the government so the “playing field” is more even. By conducting this study in Canada, I think there would be more relevant data available as ability for one to have a primary care physician is more equal (because care is based on need and not cost). With this study, they knew there was an issue with the use of emergency departments compared to use of primary care physicians so they were able to target their research on specific data such as physician specialty, continuity of care and comprehensiveness of care. The diagnostic criteria could be established prior to beginning the study. Also, because this study was retrospective, it is typically less expensive than doing a study prospectively and it’s less time consuming.
There are also some limitations associated with retrospective cohort studies. I think one of the biggest challenges may be in determining cause in a study like this since contact would have to be made with all participants. In a study this large (+300,000 people), not only would it be time consuming to contact everyone, it had to be difficult to find valid contact information for all participants. There is also a possibility of confounding variables accounting for differences in data. For example, selection bias may account for differences in the effect of affiliation with a specialist rather than a family physician or the effect of continuity of care with a specialist versus a family physician may skew data. It’s also likely that the data collected on the context of health care in Quebec and may not be generalizable to other countries.
As far as pertaining to current health issues, I think this study suggests that people don’t necessarily place value in having a “go to” physician as long as they know they have access to someone. Part of this seeming lack of value for a “go to” physician may be due to the access of medical information on the internet 24 hours a day. Another possibility may be due to the number of specialists available and the belief that they are better to see than a “family” doctor. Lastly, because of the availability of this information, I would assume there has been in increase in people who self-diagnose and end up in an emergency room because they didn’t treat the correct problem due to misdiagnosing themselves (but would be another study). This study is interesting in that it shows some benefit to having a family physician, however, I think it should/could be best used as a reason to study how the younger, healthier generation can be either promoted or incentivized to utilize a family/primary care physician. Who knows, this may reveal how to create a healthier society who seeks preventative care rather than a society who depends on treatment.
References
McCusker, J., Tousignant, P., Borgs Da Silva, R., Ciampi, A., Lvesque, J., Vadeboncoeur, A., and Sanche, S. (2012).Factors predicting patient use of the emergency department: a retrospective cohort study.CMAJ: Canadian Medical Association Journal,184(6), E307-E316. doi:10.1503/cmaj.111069