***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To study the morbidity patterns of non-urgent patients utilising accident and emergency services  and compare these patients with ' true ' accident and emergency cases . To analyse the morbidity pattern of non-urgent cases over different time periods , and across different age groups . DESIGN A cross-sectional study completed over a 1-year period . SETTING Four accident and emergency departments in Hong Kong . PATIENTS Two thous and , four hundred and ten patients r and omly selected from four accident and emergency departments . MAIN OUTCOME MEASURES The morbidity patterns by body system , according to the International Classification of Primary Care , were tabulated and analysed for ' true ' accident and emergency cases versus non-urgent cases . The ten most frequent diagnoses for the ' true ' accident and emergency and non-urgent cases were also compared . Further analysis of accident and emergency service utilisation was conducted comparing different age groups , and also different time periods . RESULTS Significantly more cases presenting to the accident and emergency service with respiratory and digestive problems were found to be non-urgent , rather than appropriate accident and emergency cases . In contrast , significantly more cases presenting with circulatory and neurological problems were appropriate cases for accident and emergency department management . The morbidity pattern for the ten most frequent diagnoses seen in non-urgent cases was noted to be similar to the Hong Kong general practice morbidity pattern for self-limiting conditions . Utilisation of accident and emergency services for acute self-limiting conditions was more marked in the late evening , and also among children and the younger population in general . CONCLUSION The utilisation of accident and emergency services by patients requiring a general practice service only , reflects problems in the primary health care delivery system . These may be solved by appropriate interfacing between general practitioners and other service providers , with the aim of providing seamless health care . Without revision of primary health care services , accident and emergency departments will continue to be used inappropriately by patients as an alternative to general practice care CONTEXT Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination . A primary care group visit ( i.e. , several patients meeting together with the provider at the same time ) may reduce fragmentation of care and subsequent emergency department utilization . OBJECTIVE To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults . DESIGN R and omized trial conducted over a 2-year period . SETTING Group-model HMO in Denver , Colorado . PATIENTS 295 older adults ( > or = 60 years of age ) with frequent utilization of outpatient services and one or more chronic illnesses . INTERVENTION Monthly group visits ( generally 8 to 12 patients ) with a primary care physician , nurse , and pharmacist held in 19 physician practice s. Visits emphasized self-management of chronic illness , peer support , and regular contact with the primary care team . MEASURES Emergency department visits , hospitalizations , and primary care visits . RESULTS On average , patients in the intervention group attended 10.6 group visits during the 2-year study period . These patients averaged fewer emergency department visits ( 0.65 vs. 1.08 visits ; P = 0.005 ) and were less likely to have any emergency department visits ( 34.9 % vs. 52.4 % ; P = 0.003 ) than controls . These differences remained statistically significant after controlling for demographic factors , comorbid conditions , functional status , and prior utilization . Adjusted mean difference in visits was -0.42 visits ( 95 % CI , -0.13 to -0.72 ) , and adjusted RR for any emergency department visit was 0.64 ( CI , 0.44 to 0.86 ) . CONCLUSION Monthly group visits reduce emergency department utilization for chronically ill older adults Accident and Emergency Departments ( A&E ) have been a popular source of primary care , and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners ( GPs ) . Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E , some recent studies have revealed contrary evidence . In this study 2410 patients were r and omly selected from four A&E at different times . The gold st and ard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians . Two emergency physicians review ed each case independently , and if their independent ratings were in agreement , this became the gold st and ard . Patients classified as GP cases were given a telephone interview , and a sample was selected and matched with cases from  general out patient clinics ( GOPC ) in the public sector by morbidity . Reasons for not attending a private GP included closure of clinic , deterioration of symptoms , GPs ' inability to diagnose properly , and patients ' wish to continue medical treatment in the same hospital . Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability , closure of the GOPC , patients ' wish to continue treatment at the same hospital , GOPC too far away , no improvement shown after visits to GOPC doctors , and GOPC doctors ' inability to make proper diagnoses . The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services . There is an urgent need for GPs to set up a network system to provide out of hours services , and also for a better interfacing between primary and secondary care , and between public and private sectors , so that patients can be referred back to GPs . Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities STUDY OBJECTIVE To assess agreement among health professionals with regard to the need for urgent care among emergency department patients . METHODS We conducted a chart review of 266 ED patients in an urban teaching hospital . Eight health professionals ( four emergency nurses , two emergency physicians , two family physicians ) used identical criteria to retrospectively rate urgency . Agreement was measured for all review ers , as well as among health professionals of the same specialty . Agreement was also measured between one ED nurse 's retrospective assessment and the prospect i ve assessment s of the triage nurses who had seen the patients on presentation . RESULTS The percentage of patients rated as needing urgent care by the retrospective review ers ranged from 11 % to 63 % . Agreement among the retrospective review ers was fair ( kappa = .38 ; 95 % confidence interval , .30 to .46 ) and was no better among review ers of the same specialty . We found only slight agreement between the nurse review er 's retrospective assessment and the triage nurses ' prospect i ve assessment s ( kappa = 19 ; 95 % confidence interval , .07 to .31 ) . CONCLUSION Even when using the same criteria , health professionals frequently disagree about the urgency of care in ED patients . When retrospective review ers disagree with a prospect i ve assessment of urgency , the potential exists for denial of payment or even lawsuits . Because the subjectivity of urgency definitions may increase disagreement , the development of more objective and uniform definitions may help improve agreement BACKGROUND We evaluate the appropriateness of  medical visits to the accident and emergency department ( A&ED ) of a university hospital using an instrument based on explicit and objective criteria , analyze the association between inappropriate visits and certain factors , and identify reasons for inappropriate use . METHODS This concurrent review of a r and om sample of 2,980 adult medical patients ' visits to the A&ED of the hospital of Elche uses the Hospital Urgencies Appropriateness Protocol , an instrument based on explicit criteria . We analyze the association between inappropriate use and specific factors , and provide a descriptive analysis of reasons for inappropriate use assigned by A&ED staff . RESULTS Of the total number , 882 ( 29.6 % ) of the visits were evaluated as inappropriate . Inappropriate use was associated with younger patients , use of own means of transportation , referral by the hospital , certain months of the year , and certain diagnostic groups of lesser severity . The most frequent reasons for inappropriate use were the patients ' greater trust in the hospital than primary care ( 451 [ 51.1 % ] ) , inappropriate use of services by patients ( 160 [ 18.1 % ] ) , and inappropriate referrals by primary care physicians ( 142 [ 16.1 % ] ) . CONCLUSION Inappropriate use represents an important percentage of use of the A&ED . Many reasons contribute to it , although foremost among them is patient preference ( and the convenience and accessibility ) of these services compared with primary care OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity Abstract Objectives : To compare outcome and costs of general practitioners , senior house officers , and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type . Design : Prospect i ve intervention study which was later costed . Setting : Inner city accident and emergency department in south east London . Subjects : 4641 patients presenting with primary care problems : 1702 were seen by general practitioners , 2382 by senior house officers , and 557 by registrars . Main outcome measures : Satisfaction and outcome assessed in sub sample of 565 patients 7 - 10 days after hospital attendance and aggregate costs of hospital care provided . Results : Most patients expressed high levels of satisfaction with clinical assessment ( 430/562 ( 77 % ) ) , treatment ( 418/557 ( 75 % ) ) , and consulting doctor 's manner ( 434/492 ( 88 % ) ) . Patients ' reported outcome and use of general practice in 7 - 10 days after attendance were similar : 206/241 ( 85 % ) , 224/263 ( 85 % ) , and 52/59 ( 88 % ) of those seen by general practitioners , senior house officers , and registrars respectively were fully recovered or improving ( χ2=0.35 , P=0.840 ) , while 48/240 ( 20 % ) , 48/268 ( 18 % ) , and 12/57 ( 21 % ) respectively consulted a general practitioner or practice nurse ( χ2=0.51 , P=0.774 ) . Excluding costs of admissions , the average costs per case were £ 19.30 , £ 17.97 , and £ 11.70 for senior house officers , registrars , and general practitioners respectively . With cost of admissions included , these costs were £ 58.25 , £ 44.68 , and £ 32.30 respectively . Conclusion : Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome . These results support new role for general practitioners . Key messages We compared the costs and outcomes of general practitioners and hospital doctors treating patients with primary care problems who attended an accident and emergency department There were no significant differences between the types of doctor in terms of patients ' satisfaction and clinical outcome General practitioners provided care more cheaply than did the hospital doctors , reflecting their less frequent requests for investigations and referrals Employing general practitioners in accident and emergency departments offers a potential means of reducing the costs of treating patients with primary care BACKGROUND In Brazil , there continues to be an excessive use of emergency services by patients with elective medical problems . Those patients who report having a primary care physician are less likely to utilize the emergency department for non-urgent consultations . OBJECTIVE The objective of this study was to compare patients who have a primary care physician with those who do not in relation to severity of their chief complaint at presentation in the emergency department . METHODS The study was carried out as a cross-sectional interview-based survey at the Conceição Hospital Emergency Service in Porto Alegre 
    Output:
    
Difficulties in accessing primary health care ( difficulties in setting appointments , longer waiting periods , and short business hours at the primary health care service ) were also associated with inappropriate ED use .