Lee A, Lau F L, Hazlett C B, Kam C W, Wong P, Wong T W, Chow S
Department of Community and Family Medicine, The Chinese University of Hong Kong, Hong Kong.
Soc Sci Med. 2000 Oct;51(7):1075-85. doi: 10.1016/s0277-9536(00)00039-3.
Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs' inability to diagnose properly, and patients' wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients' wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors' inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.
急诊部门一直是初级医疗保健的一个热门来源，研究表明，高达三分之二前往急诊部门就诊的患者所患问题可由全科医生处理。尽管许多研究发现，社会经济地位较低且社会支持较少的患者急诊部门利用率较高，但最近一些研究得出了相反的证据。在本研究中，在不同时间从四个急诊部门随机选取了2410名患者。区分真正急诊病例和全科医生病例的金标准基于一组急诊医生独立进行的回顾性记录审查。两名急诊医生各自独立审查每个病例，若他们的独立评级一致，则以此作为金标准。被归类为全科医生病例的患者接受了电话访谈，并选取了一个样本，按照发病率与公共部门普通门诊诊所的病例进行匹配。未就诊于私人全科医生的原因包括诊所关闭、症状恶化、全科医生无法正确诊断以及患者希望在同一家医院继续治疗。非紧急患者未选择前往附近公共普通门诊诊所的原因包括费用问题、普通门诊诊所关闭、患者希望在同一家医院继续治疗、普通门诊诊所距离过远、就诊于普通门诊诊所医生后未见改善以及普通门诊诊所医生无法做出正确诊断。急诊部门服务利用率高的原因复杂，反映了全科医生服务提供方面的问题。迫切需要全科医生建立一个网络系统以提供非工作时间的服务，还需要在初级和二级医疗保健之间以及公共和私营部门之间实现更好的衔接，以便患者能够转回全科医生处。由执业护士或在急诊部门工作的全科医生为那些非紧急病例提供的临时临床服务也有助于将患者转至初级医疗保健机构。
