Healthcare policy = Politiques de santé
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On June 1, 2009 the town of McAllen, Texas rose to brief prominence on the American political stage. With the highest (bar Miami) per-beneficiary costs in the entire US Medicare program, it was featured in an essay in The New Yorker by Atul Gawande, then seized upon by President Obama: "This is what we have to fix." Behind the headlines were decades of documentation of clinical practice and analysis of regional variations by John Wennberg, Elliott Fisher and their colleagues, and by Leslie and Noralou Roos and theirs. The implications for health systems were grasped over 30 years ago and have been confirmed by more recent work. Efforts to understand these variations within standard economic theory have, however, had limited success.
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This study explored whether organizational characteristics of primary care services provided by area of residence in two Quebec regions are related to outcomes of an emergency department (ED) visit among seniors discharged home. Provincial administrative databases on a sample of seniors who made an ED visit and their 30-day outcomes were linked by area of residence to data from a survey of key informants from primary care clinics. ⋯ In multivariate analyses, adjusting for patient characteristics, patients living in areas in the lowest quartile for the global score had higher rates of return ED visits without hospitalization. Emerging primary care organizational models along the lines currently being pursued in Quebec may help to reduce the growing burden of ED care of seniors.
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Little is known about inter-facility patient transfers in populations. In 2003, detailed information about inter-facility patient transfers began to be systematically collected in Ontario. ⋯ Patients in Ontario are often transferred between healthcare facilities. Most transfers are for routine, non-life-threatening reasons, using the Emergency Medical Services (EMS) system. This practice diverts resources from more emergent requests. Although patient transportation is a necessary part of any healthcare system, the results of this study highlight the current demands on a system that was not intended for the volume of inter-facility patient transfers it is supporting. These results call into question the use of sophisticated, highly trained, expensive patient transfer resources to provide routine medical services in Ontario.
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A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban-rural differences in accessibility-related organizational features that predicted ER use. ⋯ Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies.