Abstract
BackgroundThe aim of this study was to assess the prevalence of common ear, nose or throat (ENT) conditions presenting to emergency departments that could be managed by a primary healthcare system Method Between January 2001 and January 2006 a total of 33 792 patients attended the ENT emergency department of one hospital. All cases were included in this retrospective study. The registry of ENT emergency department was analysed; age, sex and clinical diagnosis were tabulated. All patients were evaluated by a specialist. Classification of the cases was based on the main symptom seeking care. Results A total of 33 792 patients visited the otorhinolaryngology emergency department.Of these, 17 775 patients (52.6%) were men and 16 017 (47.4%) were women. Over 40% of the cases were classified in eight major groups of diagnosis. Acute tonsillitis (12.5%) and acute pharyngitis (11.4%) followed by acute otitis externa (5.9%) were the most common causes of all ENT emergency department visits. The admission rate was 1.2 % and only 0.6% (84) of patients were referred to other specialties. Conclusion Most common ENT disorders presenting to the emergency department in Greece could be managed at the level of primary health care. Incorporating ENT expertise into educational and training programmes of general practitioners may be successful in managing ENT problems in primary care in future.
Keywords
ENT disorders, general practitioners, primary care
Introduction
Improving quality, care and performance of health services is an important challenge for many governments in Europe.[1,2] The concept of primary health care has been articulated for well over a decade, but it has not yet routinely become part of the Greek health system. In Greece, primary care is not yet fully developed, especially in urban areas.[3] Due to lack of primary care settings in cities, people with a variety of disorders seek advice from hospitals or private specialists in order to seek a diagnosis and access treatment.[4] The burden of hospital care is high and the financial impact is considerable. Additionally, there is a lack of continuity of care since every hospital visit does not become a part of an individual’s medical record.
Over the past few years, attempts to improve and modernise national healthcare services in Greece have taken place. The Health Care Reform Act aimed to enhance quality improvement and co-ordination of outpatient and hospital services on a regional level through the enhancement of primary care.[3] Ear, nose or throat (ENT) symptoms are common causes for seeking care in the emergency department of Laiko University Hospital, which is one of the largest public hospital units and is on duty every four days.
The aim of this study was to assess the prevalence of common ENT conditions presenting to the emergency department, in order to help primary care providers to focus on them and plan essential reform of the healthcare system.
Method
All patients who attended the ENT emergency department (ENT ED) of Laiko University Hospital during the on-call days, between January 2001 and January 2006, were included retrospectively in this study. From the registry of the ENT ED, data on medical history, clinical examination and laboratory investigations were collected. AnENTspecialist evaluated all patients. Sex, age, region, common ENT disorders and their frequency were recorded. The clinical diagnosis, used for classification of the cases, was based on the main symptom or clinical sign of every patient seeking care.
Patients who visited theENT EDwere stratified into eight groups according to the infectious disease that they suffered: (a) stomatitis, (b) acute pharyngitis, (c) acute tonsillitis, (d) acute laryngitis, (e) sinusitis, (f) otitis externa, (g) rhinitis or (h) otitis media. Symptoms and treatment administered were examined, and hospitalisation rate was calculated.
The study conformed to the principles outlined in the Declaration of Helsinki; ethical approval was not deemed necessary as this was an evaluation.
Results
The total number of patients who visited the ENT ED during the study period was 33 792; 17 775 (52.6%) of these were men and 16 017 (47.4%) were women. Of these, 13 990 patients (41.4%) suffered from infectious diseases. The most common was acute tonsillitis observed in 1749 patients (12.5%), followed by acute pharyngitis (1595, 11.4%), otitis externa (825, 5.9%), otitis media (364, 2.6%), acute sinusitis (586, 4.2%), acute laryngitis (252, 1.8%), rhinitis (266, 1.9%) and stomatitis (154, 1.1%). It was felt that all these 13 990 (41.4%) patients could have been managed by a GP without the need for referral to a specialist.
Hospitalisation occurred in 1.2% (168). Consultations were performed with other specialties in the emergency department for only 0.6% (84). In 1707 patients (12.2%), a second-look (follow-up)examination was recommended. X-ray examination was performed in 1357 (9.7%) patients. Antibiotics were administered in 4099 (29.3%) patients. Interestingly, it was observed that 3889 (27.8%) patients were already taking antibiotics without prescription at the time of the visit to the ENT ED.
Acute pharyngitis, tonsillitis, laryngitis, otitis media and otitis externa were most commonly observed in younger patients aged 14–20 years, and were seen far less frequently in patients aged over 50 years. Stomatitis, rhinitis and sinusitis were mainly observed in older patients aged over 30 years.
Antibioticswere the most common treatment given to patients suffering from tonsillitis, pharyngitis and laryngitis. Patients being diagnosed with otitis media and externa were treated with antibiotics orally and topically. For stomatitis, oral cavity antiseptics were used and antibiotics combined with antihistamines were used for acute rhinitis. Finally, laryngitis was also treated with resting the voice.
Discussion
ENT problems were among the commonest reasons for attending Laiko University Hospital, and infections accounted for 41.4% of cases attending the ENT ED. Similar rates have been shown in previous studies.[5] Our findings demonstrate that general practitioners could provide a first appropriate contact care for patients with common ear, nose and throat disorders.
One of the limitations of this study is the fact that the data were drawn from only one hospital and it was not possible to assess community health needs without evidence from primary care settings or large community-based surveys.[6]
High consultation rates may sometimes have an underlying psychological cause.[7] Discrimination between streptococcal and non-streptococcal pharyngitis is important in assessing the requirement for antibiotics. Diagnosis of sinusitis may be difficult due to facial tenderness, postnasal drip or other features being unreliable.[8] Otoscopy skills are needed for diagnosis of ear infections, and false-negative observations are low.[9] More involvement with ear, nose and throat problems in vocational training, or attendance during continued education is suggested.
At the time of visit to the ENT ED, most patients were already on antibiotic treatment without a doctor’s prescription, which may be partly explained by the public perceptions that ENT inflammatory diseases are common health problems of minor importance, in combination with the trend towards overuse of antibiotics. Moreover, many patients may not be aware of the natural history of upper respiratory tract infections and that overuse of antibiotics causes bacterial resistance, side-effects and unnecessary healthcare costs.[10]
The hospitalisation rate was extremely low, reflecting the fact that few patients in the ENT ED were real emergencies and most needed access to primary care.[11] These data could be used to discriminate which conditions should be managed in a secondary care environment.
Our results support the need for better primary care access for ENT disorders.
Conclusion
Many common ENT disorders presenting to the hospital emergency department could be managed in primary care. General practitioners in Greece should be trained and have the skills to deal with the most frequently observed ENT problems. Incorporating ENT skills into the educational and training programmes of general practitioners might help to achieve this in future, which may decrease the burden on hospitals and improve quality of care.
Peer Review
Not commissioned, not externally Peer Reviewed.
Conflicts of Interest
None.
References
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Health Care Reform Through Practical Clinical Guidelines: Ear Nose Throat is a practical set of clinical guidelines for ENT doctors, arranged by symptom. It is the first book to attempt to define what good healthcare reform should be, in order to increase quality, decrease inefficiency, and build a financial model to achieve this.
The Editor and his team of expert contributing authors take into consideration the great variation among clinicians in diagnosing as well as treating a symptom. They bring to bear their many years experience in the treatment of patients without resorting to unnecessary tests and procedures, while still not overlooking a diagnosis. In so doing, they present a set of practical clinical guidelines that will change a very fragmented profession into a more cohesive one, with resultant cost-savings and increase in efficiency.
Currently, it takes the work of a committee of specialists, brought together by a medical society, working for around a year and costing some $100,000 in order to develop a set of evidence-based guidelines for one symptom. Simply, medical reform in otolaryngology cannot wait for the 30-plus years it could take to develop practical clinical guidelines for the more than 30 symptoms presented by patients to otolaryngologists. This book cuts to the chase and attempts to efficiently and appropriately bring consistency and cohesiveness into the current health care system.
This book covers the various symptoms presented in clinic; develops a list of differential diagnoses; explains how to systematically rule out each differential diagnosis, chooses the most cost-effective route; and presents the most cost-effective treatment for each.
Contributors include: Seilesh Babu, Eric Berg, Kevin Brown, Yvonne Chan, Edward Ermini, Marion Boyd Gillespie, Gregory Grillone, Ashutosh Kacker, David Karas, Howard Kotler, David Kutler, Steven Levine, Vincent Lin, Rodney Lusk, Robert McRae, Vikash Modi , David Nielsen, Krishna Patel, Gregory Randolph, Samuel Selesnick, Mark Shrime, Robyn Smith, MG Stewart, Elizabeth Toh, Robert Ward, Eiji Yanagisawa and Ken Yanagisawa.
"In the wake of the newly-minted comprehensive health reform bill, Dr. K.J. Lee and colleagues hit the ground running on the heart of health care reform: restoring the doctor-patient relationship to its rightful place at the center of health care. This book -- written by clinicians for clinicians -- offers practical clinical guidelines that address the cost and quality conundrum in a refreshing, common-sense way. Patients and health care professionals alike will appreciate the integrity and dedication to better patient care at lower cost encompassed in this book."
-Congresswoman Rosa L. DeLauro, CT-03
"For years K.J. Lee, MD, FACS has thought deeply and cared passionately about the health care dilemma in the United States. In this book, he concentrates on one segment: how physicians can continue to offer the best care while minimizing costs. He offers the notion of Practical Clinical Guidelines which will allow patients to be treated in the most economical way, with the best possible outcome.
-The Rev. Kendrick Norris, M.Div., S.T.M., D.Min., Ph.D.
"In this volume, Dr. Lee has responded to healthcare dilema by gathering together doctors in his field who are trusted for their clinical expertise, judgment and ethical standing to create stellar guidelines for practitioners today. A doctor, a pioneering reformer and a healer, K. J. Lees contributions to health care span generations and continue to be an ever-present balm to patients, colleagues and all those committed to the well-being of humanity."
-Rev. Susan J. Murtha
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/51219275
Civilized Medicine: Physicians and Health Care Reform
Article in Journal of Health Politics Policy and Law · June 2011
DOI: 10.1215/03616878-1271171 · Source: PubMed
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Civilized Medicine: Physicians and Health Care Reform
Miriam J. Laugesen
Columbia University
This is a true milestone in this process and the historical significance of the AMA’s support should not be underestimated. Quite honestly, it has been difficult to win the support of this organization going all the way back to the 1930s. That has been a great disappointment to many of us who have fought for quality, affordable health care for all, because we need the input of our fine doctors and healers.
— Representative John D. Dingell (2009)
Introduction
President Obama symbolically underscored the importance of support from physicians when he presented the health care reform proposal to the American Medical Association (AMA) in June 2009. The AMA later announced its support for health care reform, although it opposed the pub-lic option (AMA 2009). For the first time, the AMA was not fighting a major health care reform proposal. But its support had a price: that health reform’s supporters agree to “fix” Medicare physician payment policies in ways that would guarantee higher (and assured) payments for doctors and in turn increase the budget deficit.1 This essay explores the role of the
Support for this essay was provided by an RWJF Investigator Award in Health Policy Research from the Robert Wood Johnson Foundation, Princeton, NJ. The author is grateful for comments from Larry Brown; Eric Patashnik; Andy Sabl; and the editor, Colleen Grogan.
1. For details on Medicare politics and policy changes related to the Affordable Care Act (ACA), see Gitterman and Scott’s essay in this issue.
Journal of Health Politics, Policy and Law, Vol. 36, No. 3, June 2011
DOI 10.1215/03616878-1271171 © 2011 by Duke University Press
508 Journal of Health Politics, Policy and Law
AMA and the implications of payment reform for the politics of health care reform.
Past and Present Roles for
Organized Medicine
Doctors’ past opposition to universal coverage proposals was based on self-interest as well as on ideology. Physicians have usually supported means-tested insurance or subsidies, not universal programs, because they fear that a government-sponsored insurance market would decrease their income and reduce their autonomy.
This time around, the tone of the debate was different and decidedly pragmatic. Some county medical societies (Montgomery and Murray 2009) and some specialty societies opposed the reform.2 But for the most part, rather than ideological questions about whether health care reform would expand the welfare state, physician organizations focused on a few details. For example, the AMA opposed the public option and manda-tory physician participation in the public program (Pear 2009). It fought proposals to introduce payment cuts for physicians whose utilization was outside of the norm, as well as a tax on cosmetic surgery (AMA 2010), and primary care physicians will benefit from increased fees. The absence of significant criticism by the AMA (rather than its enthusiastic support) was noticeable. The AMA carefully avoided conflict and backed off from presenting doomsday scenarios.
To be sure, delivery reforms such as payment bundling (section 3023) were created as demonstration projects and only within Medicare, a move consistent with the emphasis on keeping private insurance. These dem-onstrations allow opt-in rather than compulsory participation, as noted above (Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 [2010]).
In 2009 the invective was recycled and used by two other actors. Tea Party activists revived the term “socialized medicine” while Republicans harshly characterized the AMA as a “cheap date” for giving away its sup-port (Wall Street Journal 2009) and accused the AMA of prostitution.3 However, the AMA position generally reflected what physicians, includ-
2. For an analysis of the role of all interest groups (not just the American Medical Associa-tion) in the passage of the ACA, see Quadagno’s essay in this issue.
3. As reported by Dana Milbank (2009), Senator Bob Corker (R-TN) stated, “We all know that the selling of one’s body is one of the oldest professions in the world. The AMA is engaged in basically selling the support of its body.”
Laugesen ■ Bundled Payments 509
ing AMA’s own members, wanted: a mixed public-private health care system with no public option (Keyhani and Federman 2010).
The absence of criticism by the AMA belies its key role in health care reform, however. A major reason the AMA agreed to support reform was that Congress promised to change the sustainable growth rate (SGR) used to calculate updates to fee-schedule payments in Medicare.4 The SGR or “doc fix,” as it is often called by journalists in Washington, DC, has been the subject of an almost decade-long campaign by physicians. Framing the issue as a problem to be fixed has deflected attention from the SGR’s original policy objective: to restrain volume (Laugesen 2009). Unwilling to enforce this objective at the cost of doctors’ support, Congress in past years has simply canceled the cuts. This is a poor solution by any ratio-nal standard; it adds incrementally each year to the massive disconnect between the updates issued through the regulatory process and the leg-islative updates passed by Congress (ibid.). However, explicitly changing the SGR raises even larger political problems, as it would officially and substantially increase the ten-year deficit — for which neither the president nor Congress wants to accept responsibility.
This promise to physicians has major fiscal implications. In the longer term, changing the SGR will require funding through either increased Medicare premiums or increased tax revenue. While current deficit pro-jections assume that cuts will go ahead, the Congressional Budget Office always cautions that these estimates are likely to be wrong, precisely because Congress has previously reversed those cuts. Neither the president nor Congress wants to raise the deficit.
Spillover Blame and Reforms at Risk
Because Medicare physician payments are so centrally related to overall projections of health care expenditures and to future deficit projections, payment reform is much more than a series of mundane technical deci-sions. Arguably, Medicare payment reform is pivotal to understanding the past and future course of health care reform. The major future implica-tion of raising Medicare payments is the issue of spillover blame and the potential risk to larger reform.
A glimpse at the debate prior to the passage of the Patient Protection
4. “AMA president J. James Rohack has said doctors would not be inclined to support reform if it does not address the steep cuts to their Medicare payments put in place by a 1997 law” (Bolton 2009).
510 Journal of Health Politics, Policy and Law
and Affordable Care Act (ACA) will give us a sense of the politics of Medicare payment and the political implications of spillover blame. In July 2009 H.R. 3200, the Affordable Care Act, was estimated to cost $245 billion over ten years, because it would increase Medicare payments and was estimated to increase the deficit by $239 billion between 2010 and 2019 (Elmendorf 2009). Meanwhile, the Senate bill was less costly, but only because it calculated Medicare payment increases for one year. Con-sequently, the House health care reform bill was framed politically as a so-called deficit-financed reform. Strategically, Republicans were unre-lenting in shaping their criticism of the bill around a notion of runaway costs, while remaining silent about Medicare payments. Politically, these criticisms proved effective because most voters already felt overwhelmed by the complexity of health care reform and few understood why the details of Medicare payment reform were so centrally related to health care reform.
Democrats responded by first realizing that bundling Medicare pay-ment with reform was a failing strategy. However, they could not simply drop Medicare payment reform, because they would lose the support of the AMA at a crucial time. Therefore, in October 2009, after the urging of the American Medical Association (Wolfensberger 2009), Senate Demo-crats removed the ten-year payment increase from the bill.
To meet the commitment made to the AMA, the fix was transferred into new legislation — the Medicare Physician Payment Reform Act (H.R. 3961). Not surprisingly, Republicans opposed this move. All but one House Republican voted against the SGR House bill, which canceled a 21 percent fee reduction. Eventually amended in the Senate, it passed and was implemented starting January 1, 2010. Republican analyses of the legislation said that H.R. 3961 was “an obvious attempt to hide the apparent cost of health ‘reform’ by introducing separate legislation to repeal the SGR mechanism” (House Republican Conference 2009). More important, Republicans used the opportunity to convince the public that Democrats were acting both shifty — that is, they were avoiding the true cost — and dishonest about the cost of the reform. Jon Kyl of Arizona, the second-ranking Senate Republican, said of congressional Democrats, “They thought they were getting a problem off the table, and instead they grabbed a rattlesnake by the tail and don’t know how to let go” (Milbank 2009). Other Republicans called the separate Medicare payment reform legislation proposed by Democrats “a shell game” (Ryan 2009) that “con-cealed . . . timing gimmicks, hidden spending and double-counting” to reduce the cost of the legislation (Ryan 2010). At the same time, Republi-
Laugesen ■ Bundled Payments 511
cans such as Representative Michael C. Burgess were also keen to drama-tize the issue and build sympathy for physicians living under a “sword of Damocles” every year (Congressional Quarterly Transcriptions 2009).
Reformers and policy experts have traditionally faulted organized medicine for its opposition to health care reform. In 2009 and 2010 that opposition was muted; strongly ideological opposition was restricted to Republican politicians and citizen groups. The AMA supported health care reform partly — but not only — because it wanted reform of the SGR. Nevertheless, the deal struck to link the two issues had, and will probably continue to have, spillover effects on the sustainability and implementa-tion of health care reform.
Linking these two issues together might have worked better had physi-cians and Congress (as well as the president) showcased their bargain. If this bargain was to be made, there was no point keeping it quiet. This was especially important since cuts were simultaneously being made to Medicare Advantage. Yet reformers in Congress most likely saw them-selves as expanding coverage for the uninsured, not reforming Medicare. To add insult to injury, the SGR is almost painfully complicated. Presi-dent Obama’s warm overtures, not to mention the SGR bill itself, could have been better promoted as a win for the elderly if stabilizing physician reimbursement policies within Medicare was planned all along.
If health care reform is going to last, the issue of the SGR — or Medi-care payment rates more generally — is likely to loom large over the options the federal government has for funding health care reform and the expansion of coverage. There is likely to be continual gamesmanship between Congress and physician groups, played along a tightrope of fiscal constraints. On this tightrope will balance fiscal conservatives, who will argue that we need to reduce the size of government while also claiming that seniors are in peril because of lowered reimbursement rates.
Physician opposition has been crucial in blocking reform in the past. An absence of enthusiasm from doctors for laws adopted could have a similar effect. Will physicians show their support for a more regulated insurance market? The chaos and complexity of the current health care system — with its multiple payers, plans, and coverage rules — are things that few physicians would rush to protect. If the implementation of reform makes physicians’ jobs easier and creates new payment mechanisms or processes that simplify their daily lives, they may be less likely to focus on Medicare rates. The risk is that the rare opportunity to change medicine in the United States through reforming our insurance system will be undone before it can be done.
512 Journal of Health Politics, Policy and Law
References
American Medical Association. 2009. AMA Supports H.R. 3200, “America’s Afford-able Health Choices Act of 2009.” News release, July 16. www.ama-assn.org/ama/ pub/news/news/ama-supports-hr-3200.shtml.
——— . 2010. House Passes Health System Reform Legislation. Health System Reform Bulletin, March 21. www.ama-assn.org/ama/pub/health-system-reform/resources/ bulletin/march-2010/21mar2010.shtml.
Bolton, A. 2009. Dem Thumbs Down to Reid Doctors Deal. The Hill, October 20.
thehill.com/homenews/senate/64019-dem-thumbs-down-to-reid-doctors-deal.
Congressional Quarterly Transcriptions. 2009. House Committee on Energy and Commerce. Rep. Henry A. Waxman Holds a Markup of H.R. 3200, the America’s Affordable Health Choices Act. CQ Transcriptions, July 30.
Dingell, J. D. 2009. Dingell on AMA Support of House Health Care Reform Bill. Press release, July 16. www.dingell.house.gov/news/press-releases/2009/07/090716AMA healthbill.shtml.
Elmendorf, D. W. 2009. Letter to the Honorable Charles B. Rangel. Preliminary analy-sis of H.R. 3200, America’s Affordable Health Choices Act of 2009, July 17. Wash-ington, DC: Congressional Budget Office. www.cbo.gov/ftpdocs/104xx/doc10464/ hr3200.pdf.
House Republican Conference. 2009. H.R. 3961 Medicare Physician Payment Reform Act. GOP.gov, Legislative Digest, November 19. www.gop.gov/bill/111/1/hr3961.
Keyhani, S., and A. Federman. 2010. Health Care Reform and the AMA. New England Journal of Medicine 362:2230 – 2232.
Laugesen, M. J. 2009. Siren Song: Physicians, Congress, and Medicare Fees. Journal of Health Politics, Policy and Law 34:157 – 179.
Milbank, D. 2009. The Democrats’ Fickle-and-Dime Health Strategy. Washington Post, October 21.
Montgomery, L., and S. Murray. 2009. Lawmakers Warned about Health Costs: CBO Chief Says Democrats’ Proposals Lack Necessary Controls on Spending. Washing-ton Post, July 17.
Pear, R. 2009. Doctors’ Group Opposes Public Insurance Plan. New York Times, June 11.
Ryan, P. D. 2009. The Majority’s $279 billion “Doc Fix” Shell Game. Republican Caucus, House Committee on the Budget. Statement, November 7. www.house.gov/ budget_republicans/press/2007/pr20091106health.pdf.
——— . 2010. Medicare. www.paulryan.house.gov/Issues/Issue/?IssueID=9969.
Wall Street Journal. 2009. The Doctor Fix Is In. October 21.
Wolfensberger, D. 2009. Will Congress Really Pay for Pending Health Care Plan? Roll Call, November 3. www.rollcall.com/issues/55_51/-40154-1.html.
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