Quality of after-hours care

In today’s world, Canadian families are seeking accessible health care in a timely manner. In addition, primary paediatric health services are becoming less available, the public’s expectations for immediate care are increasing, and the work habits of Canadians are rapidly changing, making evening medical visits more convenient. In light of this, other options for access to care have been introduced. Additional options (eg, after-hours clinics) focus on improving access to immediate care, particularly outside of regular office hours. As a result, parents seeking after-hours care for their acutely ill child now have a variety of options. For example, they can seek medical advice over the phone (eg, Edmonton Region Capital Health Authority’s Health Link program), through the Internet, at an emergency department, or through their local pharmacist.

Among this plethora of care options is the potential for each to provide a different quality of care for the same medical problem. However, the question of which option provides the highest quality of care for the same health issue remains unanswered. As a result, there is a need to determine which health care options provide the highest quality of care and how they compare with each other. This information will offer insight into many important issues such as where consumers should seek medical advice, where policy makers should allocate resources and where to enhance education.

Hutchison and colleagues (1) attempt to answer these questions for walk-in clinics, family practices and emergency departments. They found that satisfaction and waiting time were of highest concern among family practice patients. In addition, both family practices and walk-in clinics were perceived more positively than emergency departments. However, there were higher quality of care scores for walk-in clinics and emergency departments than for family practices. The authors assessed quality by identifying if the care provided fulfilled a set of modified quality of care criteria developed by the College of Family Physicians of Canada. These criteria focus on the processes of care, especially performance of appropriate actions and avoidance of inappropriate clinical actions.

There are several other factors in addition to processes of care that contribute to quality of care. Subsequently, there are various different indicators of quality that can be measured, including clinical performance, health outcomes, efficiency, patient satisfaction and accessibility (2). Where possible, the quality indicator that is measured should be based on scientific evidence such as rigorously conducted empirical studies and reviews (2). The application of evidence in practice is a key indicator of the quality of care and, as such, several investigators have studied it (3–5).

In this issue of Paediatrics & Child Health, Maguire et al (pages 427–431) assess and compare the application of evidence-based medicine across three different paediatric after-hours settings in Toronto. To assess the application of evidence, the authors retrospectively investigated whether providers adhered to the guideline recommendations made by the Canadian Paediatric Society in Ottawa and the Centres for Disease Control and Prevention in Atlanta for the treatment of otitis media. These guidelines suggest prescribing amoxicillin for ten days as the first line therapy for otitis media. They found that providers in all three settings followed the guidelines, prescribing amoxicillin more often than other antibiotics.

Although adherence to guidelines constitutes one form of practicing evidence-based medicine, nonadherence does not imply that evidence was not used. There are various shortcomings to using guidelines, both when assessing whether evidence-based medicine was applied and in day-to-day clinical practice. The guidelines may be outdated or may not reflect the ‘best’ evidence. To illustrate, the otitis media guidelines do not take into account the evidence that no treatment (ie, waiting and watching) (6) or treatment for less than 10 days (7) are also effective treatment options. It can be suggested that when Maguire et al found that the physician did not adhere to the guidelines, the physician may have been adhering to other high quality evidence (eg, systematic review). This illustrates the importance of considering all potential sources of evidence when assessing whether an organization practices evidence-based medicine.

In addition to assessing whether providers applied evidence-based medicine, Maguire et al compared the level of adherence across three different after-hours settings: a nonacademic paediatric after-hours clinic, a university-affiliated paediatric emergency department, and a general hospital emergency department. They found that adherence to the guidelines was significantly higher in the paediatric after-hours clinic and the paediatric emergency department when compared with the general emergency department. Therefore, Maguire et al concluded that the paediatric after-hours clinic may be an excellent venue for after-hours treatment. However, the authors do not address the potential reasons for why this venue differs from the general emergency department. Factors such as specialization of care, patient volume, education level or setting (academic versus nonacademic) may contribute to the use of evidence-in-practice. Identifying the characteristics of the health care organization that may contribute to whether or not evidence is applied is a crucial component to improving the quality of care and therefore needs to be included in any assessment of evidence-based medicine.

Many issues around which venues provide the best care for acutely ill and/or injured children remain. Maguire et al’s study provides insight into whether evidence-based medicine is applied in a paediatric after-hours clinic and how the application of evidence in this clinic compares with two other after-hours settings. However, the authors only investigated one of each setting type, thereby limiting the generalizablity of their results. It is therefore critical for health services researchers to determine which venues provide the highest quality of care, how different venues compare to each other, and if quality varies by type of illness. Answers to these questions will provide the necessary information to ensure that all children and families receive quality health care.