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How Primary Care Can Help Reduce Avoidable ED Visits

How Primary Care Can Help Reduce Avoidable ED Visits

Throughout the United States, patients are using the ED for the treatment of acute but minor episodic conditions. According to Truven Health Analytics, 42% of ED visits are for urgencies that could be treated in the primary care office setting. Even as more urgent care centers are being opened, this problem persists. In some cases, ED care is sought because a patient’s primary care physician (PCP) office operates mostly within normal daytime business hours. Other times, it may be because of difficulty in obtaining same day appointments. There are simple changes PCPs can make to help patients avoid ending up in the ED for these types of conditions. The Greater Detroit Area Health Council (GDAHC) ED Utilization Team leads the effort in Detroit. In my work as chair of the GDAHC team—which includes representation from EDs, PCPs, purchasers, health plans and consumers—we piloted an initiative with 11 PCPs at five practice sites to give patients better options when faced with acute, unscheduled medical needs. Sites were chosen because they had a worsening trend of their HMO members using the ED for conditions likely treatable in the PCP office. Collectively, these PCPs reduced these types of ED visits from 49.2 to 7.3 visits per 1,000 members. Here are some of the key lessons from our program: Collaborate The goal is to get everyone in the PCP office working together in the same direction. The first step is to establish an access-to-care policy. Everyone from receptionists to nurses to physicians needs to understand what access to care means and define it together. This includes how to handle clinical advice for patients...
Managing Skin Abscesses in the MRSA Era

Managing Skin Abscesses in the MRSA Era

Abscesses are one of the most common skin conditions encountered by general practitioners and emergency physicians, and the incidence of these infections has increased in recent years. In addition, MRSA infections have become one of the most common causes of skin abscesses. “Community-associated MRSA (CA-MRSA) has also been shown to cause severe infections in non-immuno-compromised hosts,” explains David A. Talan, MD, FACEP, FIDSA. “We’re still unsure as to why CA-MRSA appears to be more virulent than other healthcare–associated strains and methicillin-susceptible Staphylo-coccus aureus. Unfortunately, the management of skin abscesses is highly variable throughout the country.” In a review article published in the New England Journal of Medicine, Dr. Talan and Adam J. Singer, MD, described helpful approaches to managing common skin abscesses that generally involve the extremities and trunk. “When possible, our recommendations were based on randomized trials,” Dr. Talan says. “However, many recommendations are based on small observational studies or expert opinion. While there may be some disagreement, the approaches we advise have been both workable and useful in our practice.” Diagnosis Skin abscesses typically appear as a swollen, red, tender, and fluctuant mass, often with surrounding cellulitis. The diagnosis of skin abscesses based on physical exams is often straightforward and proven correct by incision and drainage. Ultrasonography may be helpful for cases in which the abscess is deep, complex, or obscured by extensive cellulitis. It may also be helpful for patients treated for cellulitis in which initial antibiotic treatment fails and to ensure the adequacy of drainage. Needle aspiration is an alternative approach to diagnosing and treating abscesses. Treatments “Standard incision and drainage is the mainstay of...
The Increasing Burden of Atrial Fibrillation

The Increasing Burden of Atrial Fibrillation

Research suggests that atrial fibrillation (AF) is the most common heart rhythm disorder, but the global burden of AF has not been estimated until recently. The World Health Organization (WHO) assesses the global burden of many public health concerns every 20 years through its Global Burden of Disease Project, but AF was not included in 1990 when the project was last conducted. To establish the global and regional prevalence of AF—in addition to its associated incidence and mortality rates—Sumeet S. Chugh, MD, FACC, FHRS, FAHA, and colleagues systematically reviewed nearly 200 population-based studies of AF. Worldwide Findings “The most important metric that WHO established for understanding the burden that a disease imposes on society is disability-adjusted life-years (DALYs),” explains Dr. Chugh. He and his colleagues found that the burden associated with AF, measured in DALYs, increased by nearly 19% in both men and women between 1990 and 2010 (Figure 1). An estimated 33.5 million men and women had AF across the globe in 2010. The estimated age-adjusted, global prevalence rates per 100,000 population increased from 569.5 in 1990 to 596.2 in 2010 for men and from 359.9 in 1990 to 373.1 in 2010 for women. In addition, the overall incidence (Figure 2) and associated mortality rates (Figure 3) increased significantly for both genders during the study period. “AF is not a condition that directly leads to death,” notes Dr. Chugh. “However, it keeps company with many heart conditions that do.” On the Local Level It is well understood that patients are getting older, not only because of the baby boomer generation but also because survival rates among patients who...
Clinical Questions at the Point of Care

Clinical Questions at the Point of Care

Since the 1980s, studies have shown that clinicians frequently raise questions during patient encounters in all healthcare settings. These studies have suggested that although questions arise frequently, they often go unanswered. “Unanswered questions should be seen as an opportunity to improve outcomes by filling gaps in medical knowledge,” says Guilherme Del Fiol, MD, PhD. He adds that understanding clinicians’ questions is essential to guiding the design of interventions that aim to provide the right information at the right time. According to Dr. Del Fiol, there are challenges associated with maintaining current knowledge in medicine. “Several factors can come into play,” he says. “Science is continuing to expand medical knowledge, but this can make it increasingly complex to appropriately deliver healthcare. In addition, the aging population continues to grow, a phenomenon that further complicates how easily clinicians can address more difficult questions at the point of care.” No systematic reviews have been available on the clinical questions raised by clinicians in the context of patient care and decision making. A Systematic Review on Clinical Questions Dr. Del Fiol and colleagues recently conducted a systematic review of the literature on clinicians’ questions. Published in JAMA Internal Medicine, the research focused on the need for general medical knowledge that could be obtained from books, journals, specialists, and online resources. The systematic review took into account the frequency by which clinicians raised clinical questions, how often these questions were pursued and how often answers were successfully found, and the types of questions that were typically asked. They also sought to determine overriding themes and the potential effects of information seeking on clinicians’ decision...
Recognizing & Treating Caregiver Burden

Recognizing & Treating Caregiver Burden

Research has shown that unpaid family or informal caregivers provide as much as 90% of the in-home long-term care that is needed by adults. A 2009 study estimated that 65.7 million people in the United States served as unpaid family caregivers to an adult or child, two-thirds of whom provided care for an adult aged 50 or older. “The burden of caring for others is increasing because of our aging population, an increase in the number of people living with chronic disease, and a lack of formal support for caregivers,” says Ronald D. Adelman, MD. In addition to providing assistance with basic and instrumental activities of daily living and medical support, caregivers also provide emotional support and comfort. The economic burden of informal caregiving is substantial, with a recent study estimating that the cost of informal dementia caregiving was $56,290 annually per patient. Furthermore, many caregivers have little choice in taking on a caregiving role, and many report feeling ill prepared to take on these responsibilities. “Many caregivers are unaware of the toll that caregiving takes on them, making them more vulnerable to other serious health problems,” Dr. Adelman says. “In addition, caregivers often receive inadequate support from health professionals and frequently feel abandoned and unrecognized by the healthcare system.” Diagnosis & Assessment of Caregiver Burden In a recent issue of JAMA, Dr. Adelman and colleagues reviewed cohort studies and other analyses to provide strategies to diagnose, assess, and intervene for caregiver burden. Several risk factors for caregiver burden were identified, including female sex, low educational attainment, and residing with care recipients. Depression, social isolation, financial stress, a higher...
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