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Primary Care and Emergency Department Decision Making
Jennifer E. McNulty, MD;
Louis C. Hampers, MD;
Steven E. Krug, MD
Arch Pediatr Adolesc Med. 2001;155:1266-1270.
Objective To determine the effect of primary care status on decision making in
the pediatric emergency department (ED).
Setting Urban tertiary care children's hospital.
Design Examining physicians prospectively completed questionnaires describing
the presence of and their familiarity with patients' primary care providers
(PCPs), as well as several relevant clinical factors.
Patients We prospectively surveyed care for patients with triage temperature
of 38.5°C or higher or symptoms of gastroenteritis between August 1, 1999,
and February 15, 2000.
Outcome Measures Intravenous fluid use, hospital admission status, rates of diagnostic
testing and interventions, mean total costs, and length of ED stay.
Results Among 1166 nonreferred patients, no PCP was identified for 164 patients
and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted
vital signs, triage category, initial appearance, patient care setting (main
ED or urgent care clinic), time of day, day of week, certainty of diagnosis,
or perceived importance of follow-up. Mean unadjusted direct hospital costs
for diagnostic testing were significantly higher for the group without PCPs,
$23 vs $16. In regression models controlling for age, ethnicity, insurance
status, patient care setting, ED attending physician, temperature, and initial
appearance, the absence of a PCP was associated with an increased likelihood
of diagnostic testing. Compared with a subset of the cohort with PCPs who
were familiar to the treating physicians, the group without PCPs also had
a significantly higher rate of intravenous fluid administration.
Conclusion In this patient population, ED physicians may vary their assessment
and management decisions based on primary care status.
From the Division of Pediatric Emergency Medicine, Department of Pediatrics,
Children's Memorial Hospital, Chicago, Ill (Drs McNulty and Krug); and the
Section of Pediatric Emergency Medicine, Department of Pediatrics, The Children's
Hospital, Denver, Colo (Dr Hampers).
Corresponding author: Jennifer E. McNulty, MD, Division of Pediatric
Emergency Medicine, Department of Pediatrics, Children's Memorial Hospital,
Campus Box 62, 2300 Children's Plaza, Chicago, IL 60614 (e-mail: jenemcnulty{at}yahoo.com).
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