Hours worked by general practitioners and waiting times for primary care

Grace Under Pressure: a mixed methods impact assessment of a verbatim theatre intervention to improve healthcare workplace culture

BACKGROUND

Healthcare workplace mistreatment has been documented globally. Poor workplace behaviour, ranging from incivility to bullying and harassment, is common in healthcare, and contributes significantly to adverse events in healthcare, poor mental health among healthcare workers, and to attrition in the healthcare workforce, particularly in junior years. Poor workplace behaviour is often normalised, and is difficult to address. Verbatim theatre, a form of research informed theatre in which plays are created from informants' exact words only, is particularly suited to facilitating workplace culture change by raising awareness about issues that are difficult to discuss. The objective of this study was to assess the impact of the verbatim theatre play 'Grace Under Pressure' on workplace culture in NSW hospitals.

METHODS

The intervention was conducted in 13 hospitals from 8 Local Health Districts (LHDs) in NSW, Australia, in October and November 2019, with aggregated impact across all sites measured by a bespoke survey ('Pam McLean Centre (PMC) survey') at the conclusion of the intervention. This study was conducted in 3 Local Health Districts (one urban, one regional, one remote), with data collection conducted in November-December 2019 and December 2020. The study design was a mixed methods assessment of the play's impact using (1) validated baseline measures of psychosocial risk, analysed descriptively, (2) overall findings from the PMC survey above, analysed descriptively, (3) interviews conducted within a month of the intervention, analysed thematically and (4) interviews conducted one year later, analysed thematically.

RESULTS

Half (51.5%) of the respondents (n = 149) to the baseline survey had scores indicating high risk of job strain and depressive symptoms. Of 478 respondents to the PMC survey (response rate 57%), 93% found the play important, 92% recommended others see the play, 89% considered that it stimulated thinking about workplace behaviour, and 85% that it made discussing these issues easier. Thematic analysis of interviews within one month (n = 21) showed that the play raised awareness about poor workplace behaviour and motivated behaviour change. Interviews conducted one year later (n = 6) attributed improved workplace culture to the intervention due to improved awareness, discussion and capacity to respond to challenging issues.

CONCLUSIONS

Verbatim theatre is effective in raising awareness about difficult workplace behaviour in ways that motivate behaviour change, and hence can be effective in catalysing real improvements in healthcare workplace culture. Creative approaches are recommended for addressing similarly complex challenges in healthcare workforce retention.

Impact of primary care physicians working part-time on patient care: A scoping review

BACKGROUND

Increasing numbers of primary care physicians (PCPs) are reducing their working hours. This decline may affect the workforce and the care provided to patients.

OBJECTIVES

This scoping review aims to determine the impact of PCPs working part-time on quality of patient care.

METHODS

A systematic search was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. Peer-reviewed, original articles with either quantitative, qualitative or mixed methods designs, published after 2000 and written in any language were considered. The search strings combined the two concepts: part-time work and primary care. Studies were included if they examined any effect of PCPs working part-time on quality of patient care.

RESULTS

The initial search resulted in 2,323 unique studies. Abstracts were screened, and information from full texts on the study design, part-time and quality of patient care was extracted. The final dataset included 14 studies utilising data from 1996 onward. The studies suggest that PCPs working part-time may negatively affect patient care, particularly the access and continuity of care domains. Clinical outcomes and patient satisfaction seem mostly unaffected or even improved.

CONCLUSION

There is evidence of both negative and positive effects of PCPs working part-time on quality of patient care. Approaches that mitigate negative effects of part-time work while maintaining positive effects should be implemented.

Impact of Socio-demographic Characteristics on Time in Outpatient Cardiology Clinics: A Retrospective Analysis

Inequitable access to health services influences health outcomes. Some studies have found patients of lower socio-economic status (SES) wait longer for surgery, but little data exist on access to outpatient services. This study analyzed patient-level data from outpatient public cardiology clinics and assessed whether low SES patients spend longer accessing ambulatory services. Retrospective analysis of cardiology clinic encounters across 3 public hospitals between 2014 and 2019 was undertaken. Data were linked to age, gender, Indigenous status, country of birth, language spoken at home, number of comorbidities, and postcode. A cox proportional hazards model was applied adjusting for visit type (new/follow up), clinic, and referral source. Higher hazard ratio (HR) indicates shorter clinic time. Overall, 22 367 patients were included (mean [SD] age 61.4 [15.2], 14 925 (66.7%) male). Only 7823 (35.0%) were born in Australia and 8452 (37.8%) were in the lowest SES quintile. Median total clinic time was 84 min (IQR 58-130). Visit type, clinic, and referral source were associated with clinic time (R² = 0.23, 0.35, 0.20). After adjusting for these variables, older patients spent longer in clinic (HR 0.94 [0.90-0.97]), though there was no difference according to SES (HR 1.02 [0.99-1.06]) or other variables of interest. Time spent attending an outpatient clinic is substantial, amplifying an already significant time burden faced by patients with chronic health conditions. SES was not associated with longer clinic time in our analysis. Time spent in clinics could be used more productively to optimize care, improve health outcomes and patient experience.

Nationally Informed Recommendations on Approaching the Detection, Assessment, and Management of Mild Cognitive Impairment

Prior to the usual clinical symptoms of dementia, there can be subtle changes in cognitive function that differ from the normal age-related cognitive decline, which has been termed mild cognitive impairment (MCI). The increase in the numbers of individuals with possible MCI presenting to health care professionals, notably, General Practitioners (GPs), is going to rise dramatically in the coming years. With ever increasing demands on GPs, it is therefore timely to provide information that can be accessed by health care professionals to assist them in making appropriate diagnoses and to provide the most relevant, evidence-based treatment options. We have provided a comprehensive list of recommendations that aim to address key aspects of MCI in primary care. Specifically, these relate to detection and diagnosis; sharing the diagnosis, monitoring, and follow up; practical interventions to potentially delay progression; and personalizing care—planning, engagement, and patient motivation for the long term.

Provider supply and access to primary care

Resource-constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018.

Dually-enrolled patients choose providers with lower wait times: Budgetary implications for the VHA

OBJECTIVE

To estimate the effect of wait times on patients' choice of provider and simulate changes in choice of provider due to compliance with VA MISSION Act wait time targets.

DATA SOURCES

We use nationwide administrative data (2014-2017) on Veterans who are enrolled in Medicare and the Veterans Health Administration (VHA), the Survey of VHA Enrollees, Area Health Resource Files, and other data provided by the Centers for Medicare & Medicaid Services.

STUDY DESIGN

We use an instrumental variables approach to identify the effect of VHA wait times on the proportion of total (Medicare and VHA) services that are paid for by the VHA ("reliance"). We exploit shocks to VHA provider supply to isolate supply-driven changes in wait times and estimate the effect on VHA reliance. We control for market and time fixed effects and local demand factors.

DATA COLLECTION/EXTRACTION METHODS

We use monthly aggregated data on 140 markets (groups of counties). VHA reliance is computed among patients aged 65 years or older who are dually enrolled in VHA and Medicare. VHA wait times and reliance are calculated for multiple specialties: cardiology, gastroenterology, orthopedics, urology, dermatology, and ophthalmology/optometry.

PRINCIPAL FINDINGS

A 10% increase in the mean wait time (+2.8 days) reduces VHA reliance by 2.3 percentage points (95% CI: 2.3, 2.7), or 7.9% of the sample mean. This implies that meeting the MISSION Act wait time targets may have multi-billion-dollar budgetary impacts. Effects vary across specialties. For example, a 10% increase in the mean wait time for cardiology services (+2.0 days) reduces reliance by 1.8 percentage points (95% CI: 1.6, 2.1), or 6.3% of the sample mean for cardiology services.

CONCLUSIONS

Meeting statutory wait time targets may have substantial unforeseen impacts on federal health care spending as patients sort to providers who have lower wait times.

Impact of rural workforce incentives on access to GP services in underserved areas: Evidence from a natural experiment

Financial incentives are often used to improve recruitment and retention of physicians in rural and remote areas. In 2010, the General Practice Rural Incentive Program (GPRIP) was introduced in Australia, causing an exogenous change in the eligibility for rural incentives for some geographical areas. This study investigates the effect of this policy reform on waiting times for a non-urgent GP appointment using panel data (2008-2014) on 2058 GPs. Using difference-in-difference methodology, results show that the number of GPs in practices in newly eligible areas increased. However, no evidence is found that this reduces waiting times for existing patients, and only weak evidence is found that waiting times for new patients fell, by around 16%. Our results suggest that financial incentives may only play a limited role in improving access to primary care and should not be the only solution to address medical workforce shortages in underserved areas.

Evolution of the determinants of unmet health care needs in a universal health care system: Canada, 2001-2014

While ensuring adequate access to care is a central concern in countries with universal health care coverage, unmet health care needs remain prevalent. However, subjective unmet health care needs (SUN) can arise from features of a health care system (system reasons) or from health care users' choices or constraints (personal reasons). Furthermore, investigating the evolution of SUN within a health care system has rarely been carried out. We investigate whether health needs, predisposing factors and enabling factors differentially affect SUN for system reasons and SUN for personal reasons, and whether these influences are stable over time, using representative data from the Canadian Community Health Surveys from 2001 to 2014. While SUN slightly decreased overall during our period of observation, the share of SUN for system reasons increased. Some key determinants appear to consistently increase SUN reporting over all our observation periods, in particular being a woman, younger, in poorer health or not having a regular doctor. The distinction between personal and system reasons is important to better understand individual experiences. Notably, women report more SUN for system reasons and less for personal reasons, and reporting system reasons increases with age. Given this stability over time, our results may inform health policymakers on which subpopulations to target to ensure access to health care is universal.

Patient chosen gap payments in primary care: Predictions of patient acceptability, uptake and willingness to pay from a discrete choice experiment

Compulsory co-payments limit access and may compromise quality in primary care. Patient Chosen Gap Payments (PCGPs) allow patients to specify a (voluntary) out-of-pocket contribution, creating an incentive for patient-centred care without the need for complex outcomes-based funding formulae. It is not yet known if widespread use of PCGP services is consistent with consumer preferences. We conducted a discrete choice experiment (DCE) in a sample of the adult Australian general population (n = 1457) during April 2019 to simulate patient choice between alternative primary care services and describe preferences for PCGP services. Participants also completed a supplementary valuation task in which participants reported their intended PCGP contribution for PCGP services. Finally, we conducted policy-simulations to predict market shares when PCGP clinics operate alongside the two existing models of primary care funding in Australia. Results suggest that patients prefer shorter wait time, longer consults, lower compulsory copayments, services with higher patient satisfaction ratings, choice of doctor and $0 suggested voluntary contribution for PCGP services. Policy-simulations suggest that high-quality PCGP services could obtain market share of up to 39% and voluntary contributions of up to $25.36 per service (95%CI: $10.24, $40.47), potentially adding $1.48 billion AUD in revenues and funding for primary care at no cost to government. Low-quality PCGP services are unlikely to capture significant market share and PCGP contributions were lowest for low-quality PCGP services ($12.12, 95%CI: $2.09, $26.34). Further field testing is recommended where (i) patients make consequential choices (e.g. real payments for simulated services), and (ii) dynamic effects on quality of care and utilisation can be observed; particularly in vulnerable populations. We conclude that PCGP services aligned with patient preferences could capture significant market share and substantially increase revenue to general practice.

Doctors' response to queues: Evidence from a Portuguese emergency department

We evaluate how doctors in an emergency department react to the number of patients waiting for treatment. Our outcomes reflect the time spent with the patient, the intensity of treatment, and discharge destination. Using visit-level data in a Lisbon-area hospital, we use a fixed effects model to exploit variation in the queue size while addressing endogeneity using the number of arrivals to the hospital in the previous 60 min as an instrumental variable. Furthermore, we estimate doctors' reactions separately for patients with different degrees of urgency, as measured by the Manchester triage system. Results show that doctors discharge patients more rapidly as queues become longer, and this effect is stronger for patients that do not have life-threatening conditions. We also find that the intensity of diagnosis/treatment procedures decreases when patients face longer queues, driven by the extensive margin. Finally, doctors are less likely to admit patients to inpatient care. We interpret the results in the light of the doctors' incentives literature, explaining how these agents behave in the context of a National Health Service, with no financial incentives.

Waiting Time as an Indicator for Health Services Under Strain: A Narrative Review

As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.

What matters to people with chronic conditions when accessing care in Australian general practice? A qualitative study of patient, carer, and provider perspectives

BACKGROUND

Research underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia.

METHODS

Using a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher's reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions.

RESULTS

A total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers' decisions to waive or reduce costs for some patients and not others.

CONCLUSIONS

People managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients' experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.