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Song F, Wei R, Wang C, Zhang Y. Residents' willingness towards first-contact with primary health care under uncertainty in healthcare: a cross-sectional study in rural China. BMJ Open 2024; 14:e077618. [PMID: 38749685 PMCID: PMC11097851 DOI: 10.1136/bmjopen-2023-077618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 04/10/2024] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE To estimate Chinese rural residents' willingness degree of initially contacting primary healthcare (PHC) under uncertainty in healthcare and to explore its influencing factors. SETTING This study collected primary data from rural residents in Dangyang, Hubei Province in China. PARTICIPANTS The study investigated 782 residents and 701 finished the survey. The response rate was 89.64%. A further 27 residents failed the internal consistency test, so the effective sample size was 674. DESIGN In this cross-sectional study, residents' willingness was reflected by the threshold of disease severity for PHC (TDSP), the individual maximal disease scope for considering PHC based on residents' decision-making framework. TDSP was measured through scenario tests. Univariate analysis and unordered multiple logistic regression were used to explore the influencing factors of three-level TDSP: low, general, and high. RESULTS Only 28.2% of respondents had high TDSP and high willingness towards PHC. Compared with general TDSP, respondents who were younger than 40 (OR 7.344, 95% CI 2.463 to 21.894), rich (OR 1.913, 95% CI 1.083 to 3.379), highly risk-averse (OR 1.958, 95% CI 1.016 to 3.774), had substitute medical decision-maker (OR value of parent/child was 2.738, 95% CI 1.386 to 5.411) and had no visits to PHC in the last 6 months (OR 2.098, 95% CI 1.316 to 3.346) tended to have low TDSP and low willingness towards PHC. Compared with general TDSP, no factors were found to significantly influence respondents' high TDSP. CONCLUSIONS TDSP can be a good indicator of residents' willingness. TDSP results demonstrate rural residents' generally low willingness towards first-contact with PHC that some residents refuse to consider PHC even for mild diseases. This study provides practical significance for elaborating the underutilisation of PHC from resident decision-making and offers advice to policymakers and researchers for future modifications.
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Affiliation(s)
- Fei Song
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Ran Wei
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Chenzhou Wang
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Kim AM, Lee JS. Factors Affecting the Preference for Hospitals Over Clinics in Primary Care in Korea. J Korean Med Sci 2024; 39:e10. [PMID: 38225783 PMCID: PMC10789526 DOI: 10.3346/jkms.2024.39.e10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/24/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND While the effect of gatekeeping was extensively studied, few efforts have been made to explain why the measures to strengthen gatekeeping do not work well in some countries. This study examined the patient factors related to the choice of level of health care facilities for outpatient care in Korea. METHODS We examined a population-based sample representative of the population of Korea aged 15 and over in the healthcare experience survey of 2021. A logistic regression model examined the factors associated with choosing hospitals or clinics for outpatient care. RESULTS Easy accessibility, kindness of medical staff, and recommendations from acquaintances were considered more important for those who chose clinics over hospitals. While those who chose clinics were more likely to feel that physicians and nurses more readily communicated with patients, those who chose hospitals were more likely to feel that the facility was comfortable. Whereas those who chose hospitals were more likely to trust the current health care system in Korea, those who chose clinics were more likely to think that the health care system needed to be reformed. The tendency was similar when analyzed only among those with good perceived health conditions and without chronic diseases. CONCLUSION This study demonstrates that the preference for hospitals over clinics is mainly based on desire rather than medical need and is not likely to be affected by measures intended to induce a voluntary change of behavior.
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Affiliation(s)
- Agnus M Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Seok Lee
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea.
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Xie W, Liu J, Huang Y, Xi X. Capturing What Matters with Patients' Bypass Behavior? Evidence from a Cross-Sectional Study in China. Patient Prefer Adherence 2023; 17:591-604. [PMID: 36919186 PMCID: PMC10008354 DOI: 10.2147/ppa.s395928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/18/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND In China, bypassing is becoming increasingly prevalent. Such behavior, as going directly to upper-level health-care facilities without a primary care provider (PCP) referral when facing non-critical diseases, contrasts to "expanding the role of PCPs as the first-contact of care", may cause unneglectable damage to the healthcare system and people's physical health. OBJECTIVE To examine the relationship between patient experience in primary health-care clinics (PHCs) and their bypass behavior. METHODS A cross-sectional study was designed for data collection. From July 2021 to August 2021, we conducted a questionnaire survey nationally. Fifty-three investigators were dispatched to 212 pre-chosen PHCs, around which 1060 interviewees were selected to gather information, using a convenience sampling. The primary independent variable was scores measured by Chinese Primary Care Assessment Tool (PCAT-C) to quantify patients' experience at PHCs. The dependent variable was a binary variable measured by a self-developed instrument to identify whether participants actually practiced bypassing. Covariates were well-screened determinants of patients' bypass behavior including socio-demographic factors, policy factors, and health-care suppliers. Binary logistic regression analysis was employed to evaluate the association of patients' experience with their bypass behavior. FINDINGS A total of 928 qualified questionnaires were obtained. The first contact dimension (OR 0.961 [95% CI 0.934 to 0.988], P = 0.005) and continuity dimension (OR 1.034 [95% CI 1.000 to 1.068], P = 0.047) of patients' experience were significantly associated with patients' bypass behavior (P < 0.05). In addition, age (OR 1.072, [95% CI 1.015-1.132], P = 0.013) and gender (OR 2.044, [95% CI 1.139-3.670], P = 0.017) also made a statistically significant difference. CONCLUSION Enhancement in patient experience at PHCs may help reduce their bypass behavior. Specifically, efforts are needed to improve primary care accessibility and utilization. The positive correlation between bypassing rates and continuity scores may require more attention on strengthening PCPs' technical quality besides the quality of interpersonal interactions.
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Affiliation(s)
- Wenwen Xie
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Jiayuan Liu
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Yuankai Huang
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Xiaoyu Xi
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
- Correspondence: Xiaoyu Xi, Email
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Kaneko M, Okada T, Aoki T, Inoue M, Watanabe T, Kuroki M, Hayashi D, Matsushima M. Development and validation of a Japanese version of the person-centered primary care measure. BMC PRIMARY CARE 2022; 23:112. [PMID: 35538437 PMCID: PMC9088030 DOI: 10.1186/s12875-022-01726-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022]
Abstract
Background Although primary care (PC) is an indispensable part of the health system, measuring its quality is challenging. A recent measure of PC, Person-Centered Primary Care Measure (PCPCM), covers 11 important domains of PC and has been translated into 28 languages. This study aimed to develop a Japanese version of the PCPCM and assess its reliability and validity. Methods We employed a cross-sectional mail survey to examine the reliability and content, structure, criterion-related, and convergent validity of the Japanese version of the PCPCM. This study targeted 1000 potential participants aged 20–74 years, selected by simple random sampling in an urban area in Japan. We examined internal consistency, confirmatory factor analysis, correlation between the Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF), and the association between the PCPCM score and influenza vaccine uptake. Results A total of 417 individuals responded to the survey (response rate = 41.7%), and we used the data of 244 participants who had the usual source of care to assess the reliability and validity of the PCPCM. Confirmatory factor analysis demonstrated sufficient structural validity of the original one-factor structure. The overall Cronbach’s alpha was 0.94. The Spearman correlation coefficient between PCPCM and JPCAT-SF was 0.60. Influenza vaccine uptake was not significantly associated with total PCPCM score. Conclusions The study showed that the Japanese version of the PCPCM has sufficient internal consistency reliability and structural- and criterion-related validity. The measure can be used to compare the quality of primary care in Japan and other countries.
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Kaneko M, Shinoda S, Shimizu S, Kuroki M, Nakagami S, Chiba T, Goto A. Fragmentation of ambulatory care among older adults: an exhaustive database study in an ageing city in Japan. BMJ Open 2022; 12:e061921. [PMID: 35953252 PMCID: PMC9379480 DOI: 10.1136/bmjopen-2022-061921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Continuity of care is a core dimension of primary care, and better continuity is associated with better patient outcomes. Therefore, care fragmentation can be an indicator to assess the quality of primary care, especially in countries without formal gatekeeping system, such as Japan. Thus, this study aimed to describe care fragmentation among older adults in an ageing city in Japan. DESIGN Cross-sectional study. SETTING The most populated basic municipality in Japan. PARTICIPANTS Older adults aged 75 years and older. INTERVENTIONS This study used a health claims database, including older adults who visited medical facilities at least four times a year in an urban city in Japan. The Fragmentation of Care Index (FCI) was used as an indicator of fragmentation. The FCI was developed from the Continuity of Care Index and is based on the total number of visits, different institutions visited and proportion of visits to each institution. We employed Tobit regression analysis to examine the association between the FCI and age, sex, type of insurance and most frequently visited facility. RESULTS The total number of participants was 413 600. The median age of the study population was 81 years, and 41.6% were men. The study population visited an average of 3.42 clinics/hospitals, and the maximum number of visited institutions was 20. The proportion of patients with FCI >0 was 85.0%, with a mean of 0.583. Multivariable analysis showed that patients receiving public assistance had a lower FCI compared with patients not receiving public assistance, with a coefficient of 0.137. CONCLUSIONS To our knowledge, this is the first study to demonstrate care fragmentation in Japan. Over 80% of the participants visited two or more medical facilities, and their mean FCI was 0.583. The FCI could be a basic indicator for assessing the quality of primary care.
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Affiliation(s)
- Makoto Kaneko
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Satoru Shinoda
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Makoto Kuroki
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sachiko Nakagami
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Taiga Chiba
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Atsushi Goto
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
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Clarke-Deelder E, Afriyie DO, Nseluke M, Masiye F, Fink G. Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia. BMC Public Health 2022; 22:1205. [PMID: 35710372 PMCID: PMC9202228 DOI: 10.1186/s12889-022-13549-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13549-3.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Doris Osei Afriyie
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Mweene Nseluke
- Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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7
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Aoki T, Fujinuma Y, Matsushima M. Patient experience of residents with restricted primary care access during the COVID-19 pandemic. Fam Med Community Health 2022; 10:fmch-2022-001667. [PMID: 35688482 PMCID: PMC9189542 DOI: 10.1136/fmch-2022-001667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To evaluate primary care access for COVID-19 consultation among residents who have a usual source of care (USC) and to examine their associations with patient experience during the pandemic in Japan. DESIGN Nationwide cross-sectional study. SETTING Japanese general adult population. PARTICIPANTS 1004 adult residents who have a USC. MAIN OUTCOME MEASURES Patient experience assessed by the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF). RESULTS A total of 198 (19.7%) reported restricted primary care access for COVID-19 consultation despite having a USC. After adjustment for possible confounders, restricted primary care access for COVID-19 consultation was negatively associated with the JPCAT-SF total score (adjusted mean difference = -8.61, 95% CI -11.11 to -6.10). In addition, restricted primary care access was significantly associated with a decrease in all JPCAT-SF domain scores. CONCLUSIONS Approximately one-fifth of adult residents who had a USC reported restricted primary care access for COVID-19 consultation during the pandemic in Japan. Our study also found that restricted primary care access for COVID-19 consultation was negatively associated with a wide range of patient experience including first contact. Material, financial and educational support to primary care facilities, the spread of telemedicine and the application of a patient registration system might be necessary to improve access to primary care during a pandemic.
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Affiliation(s)
- Takuya Aoki
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan,Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuki Fujinuma
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Masato Matsushima
- Division of Clinical Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
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Şekercan A, Harting J, Peters RJG, Stronks K. Understanding transnational healthcare use in immigrant communities from a cultural systems perspective: a qualitative study of Dutch residents with a Turkish background. BMJ Open 2021; 11:e051903. [PMID: 34593502 PMCID: PMC8487186 DOI: 10.1136/bmjopen-2021-051903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Transnational utilisation of healthcare by people with an immigrant background carries risks, including medicalisation and adverse iatrogenic outcomes. We investigated the drivers behind such transnational healthcare use from a cultural perspective on health systems. DESIGN Qualitative interview study (2018). SETTING Two primary care practices in Amsterdam, the Netherlands. PARTICIPANTS Thirteen Dutch patients of Turkish background, who had obtained healthcare in Turkey, and who in general visited the primary care practice more than once a month. RESULTS In the respondents' stories, we observed how: (1) cross-border healthcare use was encouraged by cultural mismatches between expected and provided services and by differing explanatory models of illness upheld by patients and Dutch providers; (2) both transnationalism in patients and entitlements to insurance reimbursement facilitated the use of Turkish health services to bypass perceived barriers in the Dutch system; (3) cultural mismatches were reinforced during general practitioner consultations after the patients' return to the Netherlands, thereby inducing further service use abroad. CONCLUSIONS Although cultural system influences are difficult to bridge, measures to reduce the unwelcome consequences of transnational healthcare use may include (1) strengthening the provision of culturally sensitive care in the country of residence and (2) restricting the reimbursement of care in the country of origin while maintaining the option to obtain care abroad.
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Affiliation(s)
- Aydin Şekercan
- Public and Occupational Health, Amsterdam UMC, Location AMC, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Janneke Harting
- Public and Occupational Health, Amsterdam UMC, Location AMC, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Ron J G Peters
- Cardiology, Amsterdam UMC, Location AMC, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Karien Stronks
- Public and Occupational Health, Amsterdam UMC, Location AMC, Amsterdam Public Health research institute, Amsterdam, The Netherlands
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9
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Hu XJ, Wang HHX, Li YT, Wu XY, Wang Y, Chen JH, Wang JJ, Wong SYS, Mercer SW. Healthcare needs, experiences and treatment burden in primary care patients with multimorbidity: An evaluation of process of care from patients' perspectives. Health Expect 2021; 25:203-213. [PMID: 34585465 PMCID: PMC8849236 DOI: 10.1111/hex.13363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/15/2021] [Accepted: 09/06/2021] [Indexed: 01/06/2023] Open
Abstract
Background Patients with multimorbidity often experience treatment burden as a result of fragmented, specialist‐driven healthcare. The ‘family doctor team' is an emerging service model in China to address the increasing need for high‐quality routine primary care. Objective This study aimed to explore the extent to which treatment burden was associated with healthcare needs and patients' experiences. Methods Multisite surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer‐administered questionnaires were used to collect data from patients (N = 2160) who had ≥2 clinically diagnosed long‐term conditions (multimorbidity) and had ≥1 clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients' experiences and treatment burden were measured using a previously validated Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively. Results The mean age of the patients was 61.4 years, and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p < .001) and lower treatment burden scores (mean difference −6.4 points, p < .001) when compared to those who often bypassed primary care. Greater healthcare needs were significantly correlated with increased treatment burden (β‐coefficient 1.965, p < .001), whilst better patients' experiences were associated with lower treatment burden (β‐coefficient −0.252, p < .001) after adjusting for confounders. Conclusion The inverse association between patients' experiences and treatment burden supports the importance of primary care in managing patients with multimorbidity. Patient Contribution Primary care service users were involved in the instrument development and data collection.
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Affiliation(s)
- Xiu-Jing Hu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China.,JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Yu-Ting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Ya Wu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Yi Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Heng Chen
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Ji Wang
- Guangdong-provincial Primary Healthcare Association, Guangdong, China.,School of Public Health, Guangzhou Medical University, Guangzhou, China
| | - Samuel Y S Wong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Stewart W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Scotland, UK
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10
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Li C, Chen Z, Khan MM. Bypassing primary care facilities: health-seeking behavior of middle age and older adults in China. BMC Health Serv Res 2021; 21:895. [PMID: 34461884 PMCID: PMC8406824 DOI: 10.1186/s12913-021-06908-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With economic development, aging of the population, improved insurance coverage, and the absence of a formal referral system, bypassing primary healthcare facilities appear to have become more common. Chinese patients tend to visit the secondary or tertiary healthcare facilities directly leading to overcrowding at the higher-level facilities. This study attempts to analyze the factors associated with bypassing primary care facilities among patients of age 45 years or older in China. METHODS Random effects logistic models were used to examine bypassing of primary health facilities among rural-urban patients. Data from 2011 to 2015 waves of the China Health and Retirement Longitudinal Study were used. RESULTS Two in five older patients in China bypass primary health centers (PHC) to access care from higher-tier facilities. Urban patients were nearly twice as likely as rural patients to bypass PHC. Regardless of rural-urban residence, our analysis found that a longer travel time to primary facilities compared to higher-tier facilities increases the likelihood of bypassing. Patients with higher educational attainment were more likely to bypass PHCs. In rural areas, patients who reported their health as poor or those who experienced a recent hospitalization had a higher probability of bypassing PHC. In urban areas, older adults (age 65 years or older) were more likely to bypass PHC than the younger group. Patients with chronic conditions like diabetes also had a higher probability of bypassing. CONCLUSIONS The findings indicate the importance of strengthening the PHCs in China to improve the efficiency and effectiveness of the health system. Significantly lower out-of-pocket costs at the PHC compared to costs at the higher tiers had little or no impact on increasing the likelihood of utilizing the PHCs. Improving service quality, providing comprehensive person-centered care, focusing on family health care needs, and providing critical preventive services will help increase utilization of PHCs as well as the effectiveness and efficiency of the health system.
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Affiliation(s)
- Changle Li
- Department of Health Economics, School of Health Management, Inner Mongolia Medical University, Hohhot, China.,Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Rd, Wright Hall 116, Athens, GA, 30602, USA
| | - Zhuo Chen
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Rd, Wright Hall 116, Athens, GA, 30602, USA.,Centre for Health Economics, School of Economics, University of Nottingham Ningbo China, Ningbo, China
| | - M Mahmud Khan
- Department of Health Policy and Management, College of Public Health, University of Georgia, 100 Foster Rd, Wright Hall 116, Athens, GA, 30602, USA.
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11
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Detecting Undifferentiation of Tertiary and County Hospitals in China in Adoption of DRG Instrument. Healthcare (Basel) 2021; 9:healthcare9080922. [PMID: 34442059 PMCID: PMC8393376 DOI: 10.3390/healthcare9080922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Undifferentiated function for medical institutes in different levels had been a barrier to China’s healthcare reform. Thus, this study aimed to detect medical services that were capable offered both in tertiary and county hospitals in China and discuss the process of detection. (2) Method: Data of 2 tertiary hospitals that were city level and 12 county-level hospitals from one city in China were collected and grouped into diagnosis-related groups (DRGs). A strategy with four steps was devised by considering the aspects of service volume, in-hospital mortality rate, in-hospital adverse events rate, and inpatient cost. Additionally, a comparison of each indicator was made between city- versus county-level hospitals. (3) Results: There were no differences in service quality between the two levels of hospitals while county hospitals had lower average inpatient costs in 129 DRGs that covered 39.5% of all cases. About CNY 0.26 billion would be saved if certain cases were paid at county-level prices. (4) Conclusion: The study proposed a strategy with four steps that could help in locating the range of diseases in which patients’ admission suffered from the problem of undifferentiation between hospitals’ functions to reduce the irrational growth of healthcare expenditure.
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12
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Aoki T, Taguchi K, Hama E. Development and psychometric properties of the Japanese Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS). PLoS One 2021; 16:e0250843. [PMID: 33909708 PMCID: PMC8081233 DOI: 10.1371/journal.pone.0250843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/15/2021] [Indexed: 11/18/2022] Open
Abstract
The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) is one of the most widely studied and endorsed patient experience measures for ambulatory care. This study aimed to develop a Japanese CG-CAHPS and examine its psychometric properties. We evaluated the structural validity, criterion-related validity, internal consistency reliability, and site-level reliability of the scale. Data were analyzed for 674 outpatients aged 18 years or older in 11 internal medicine clinics. The confirmatory factor analysis supported the scale’s structural validity and the same composites (Access, Provider Communication, Care Coordination, and Office Staff) as that of the original CG-CAHPS. All site-level Pearson correlation coefficients between the Japanese CG-CAHPS composites and overall provider rating exceeded the criteria. Results of item-total correlations and Cronbach’s alpha indicated adequate internal consistency reliability. We developed the Japanese CG-CAHPS and examined its validity and reliability to measure the quality of ambulatory care based on patient experience. The results of the Japanese CG-CAHPS survey will provide useful information to providers, organizations, and policy makers for achieving a patient-centered healthcare system in Japan.
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Affiliation(s)
- Takuya Aoki
- Division of Clinical Epidemiology, The Jikei University School of Medicine, Tokyo, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Eiichi Hama
- Institute of Quality and Time of Healthcare, Tokyo, Japan
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Aoki T, Yamamoto Y, Nakata T. Translation, adaptation and validation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) for use in Japan: a multicentre cross-sectional study. BMJ Open 2020; 10:e040240. [PMID: 33331832 PMCID: PMC7678353 DOI: 10.1136/bmjopen-2020-040240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/01/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a well-established and internationally recognised scale for measuring patients' experience with hospital inpatient care. This study aimed to develop a Japanese version of the HCAHPS and to examine its structural validity, criterion-related validity and internal consistency reliability. DESIGN Multicentere cross-sectional study. SETTING A total of 48 hospitals in Japan. PARTICIPANTS 6522 patients aged ≥16 years who were discharged from the participating hospitals. RESULTS Confirmatory factor analysis showed excellent goodness of fit of the same factor structure as that of the original HCAHPS, with the following composites: communication with nurses, communication with doctors, responsiveness of hospital staff, hospital environment, communication about medicines and discharge information. All hospital-level Pearson correlation coefficients between the Japanese HCAHPS composites and overall hospital rating exceeded the criteria. Results of inter-item correlations indicated adequate internal consistency reliability. CONCLUSIONS The Japanese HCAHPS has acceptable psychometric properties for assessing patients' experience with hospital inpatient care. This scale could be used for quality improvement based on the assessment of patients' experience with hospital care and for health services research in Japan.
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Affiliation(s)
- Takuya Aoki
- Division of Clinical Epidemiology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
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Liang LL, Huang N, Shen YJ, Chen AYA, Chou YJ. Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan. BMC Health Serv Res 2020; 20:1050. [PMID: 33208148 PMCID: PMC7677770 DOI: 10.1186/s12913-020-05908-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 11/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system. Methods This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. Results The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. Conclusions Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05908-w.
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Affiliation(s)
- Li-Lin Liang
- Department of Business Management, National Sun Yat-sen University, No. 70, Lienhai Rd, Kaohsiung, 804, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, No.155, Section 2, Li-Nong Street, Taipei, 112, Taiwan
| | - Yi-Jung Shen
- Institute of Hospital and Health Care Administration, National Yang-Ming University, No.155, Section 2, Li-Nong Street, Taipei, 112, Taiwan
| | - Annie Yu-An Chen
- RAND Corporation, 1766 Main Street, Santa Monica, CA, USA.,Pardee RAND Graduate School, 1766 Main Street, Santa Monica, CA, USA
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, No.155, Sec. 2, Li-Nong St., Beitou Dist, Taipei, 112, Taiwan.
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Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165963. [PMID: 32824533 PMCID: PMC7460206 DOI: 10.3390/ijerph17165963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 11/26/2022]
Abstract
Excess healthcare utilization is rapidly rising in rural China. This study focused on excess outpatient demand (EOD) and aimed to measure its performance and sociodemographic determinants among China’s rural residents. A total of 1290 residents from four counties in central China were enrolled via multistage cluster random sampling. EOD is the condition in which the level of hospital a patient chooses is higher than the indicated level in the governmental guide. A multilevel logistic regression was used to examine the sociodemographic determinants of EOD. Residents with EOD accounted for 85.83%. The risk of EOD was 51.17% and value was 5.69. The value of EOD in diseases was higher than that in symptoms (t = −21.498, p < 0.001). Age (OR = 0.489), educational level (OR = 1.986) and hospital distance difference (OR = 0.259) were the main sociodemographic determinants of EOD. Excess outpatient demand was evident in rural China, but extreme conditions were rare. Results revealed that age, educational level and hospital distance were the main sociodemographic determinants of EOD. The capacity of primary healthcare institutions, universality of common disease judgement and understanding of institution’s scope of disease curing capabilities of residents should be improved to reduce EOD.
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Bell G, Macarayan EK, Ratcliffe H, Kim JH, Otupiri E, Lipsitz S, Hirschhorn L, Awoonor-Williams JK, Nimako BA, Ofosu A, Leslie H, Bitton A, Schwarz D. Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana. JAMA Netw Open 2020; 3:e2012552. [PMID: 32785634 PMCID: PMC7424402 DOI: 10.1001/jamanetworkopen.2020.12552] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient's homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care. OBJECTIVE To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice. DESIGN, SETTING, AND PARTICIPANTS This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019. EXPOSURES Bypass was defined as a woman's report that she sought care at a health facility other than the nearest facility. MAIN OUTCOMES AND MEASURES Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design. RESULTS A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (P = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility. CONCLUSIONS AND RELEVANCE The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.
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Affiliation(s)
- Griffith Bell
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Erlyn K. Macarayan
- Lancet Commission on High Quality Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Hannah Ratcliffe
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - June-Ho Kim
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine & Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Easmon Otupiri
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Stuart Lipsitz
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Anthony Ofosu
- Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana
| | - Hannah Leslie
- Lancet Commission on High Quality Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Asaf Bitton
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine & Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Dan Schwarz
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Aoki T, Fukuhara S, Yamamoto Y. Development and validation of a concise scale for assessing patient experience of primary care for adults in Japan. Fam Pract 2020; 37:137-142. [PMID: 31325300 DOI: 10.1093/fampra/cmz038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The existing scales to measure patient experience of primary care for adults tend to be with many items and difficult to use outside of the research setting. OBJECTIVE To develop a Japanese version of Primary Care Assessment Tool Short Form as a concise scale for assessing patient experience of primary care and to examine its validity and reliability. METHODS We conducted a cross-sectional survey in a primary care practice-based research network in Japan (25 primary care facilities). We evaluated the structural validity, criterion-related validity, convergent validity and the internal consistency reliability of the scale. RESULTS Data were analysed for 1725 primary care outpatients. A 13-item scale was constructed, and the confirmatory factor analysis showed excellent goodness of fit of the six-factor model (first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided) and community orientation). Pearson correlation coefficients between the total score and the overall rating of care and the original scale total score were 0.43 and 0.94, respectively. The total score was positively associated with influenza and pneumococcal vaccination (P < 0.001; P = 0.009 for trend). All of the multi-item scales achieved good internal consistency and the overall Cronbach's alpha was 0.77. CONCLUSIONS We developed a concise patient experience scale, which comprises six domains measuring primary care attributes and evaluated its validity and reliability. This scale can be used as a rapid assessment tool reducing the burden of respondents and provide effective information for further quality improvement and practice-based research in the Japanese primary care settings.
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Affiliation(s)
- Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima, Japan.,Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Aoki T, Yamamoto Y, Fukuhara S. Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan. Ann Fam Med 2020; 18:24-29. [PMID: 31937529 PMCID: PMC7227459 DOI: 10.1370/afm.2463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/09/2019] [Accepted: 05/05/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The quality of health care, including primary care, is influenced by the context in which care is delivered. We investigated the association between primary care practice location and patient experience with a focus on differences between hospital-based practices and community-based office practices. METHODS We conducted a cross-sectional study in a primary care practice-based research network in Japan among 25 participating facilities: 6 small and medium-sized hospitals and 19 community-based offices. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness with respect to services available, comprehensiveness with respect to services provided, and community orientation. RESULTS Analyses were based on 1,725 primary care patients. After adjustment for possible confounders and clustering within facilities, compared with community-based office practices, hospital-based practices were associated with poorer patient experience of community orientation (adjusted mean difference = -5.76; 95% CI, -10.35 to -1.17). In contrast, hospital-based practices were associated with comparatively better patient experience of first contact (adjusted mean difference = 15.43; 95% CI, 5.13 to 25.72). CONCLUSIONS Our study elucidates differences in the strengths and challenges of primary care between hospital-based practices and community-based office practices, with a focus on patient centeredness. Improving community orientation in hospital-based practices and improving accessibility, including out-of-hours care, in community-based office practices may enhance the quality of primary care and promote standardization of care across settings.
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Affiliation(s)
- Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Fukushima, Japan.,Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
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Kaneko M, Aoki T, Funato M, Yamashiro K, Kuroda K, Kuroda M, Saishoji Y, Sakai T, Yonaha S, Motomura K, Inoue M. Admissions for ambulatory care sensitive conditions on rural islands and their association with patient experience: a multicentred prospective cohort study. BMJ Open 2019; 9:e030101. [PMID: 31888923 PMCID: PMC6936984 DOI: 10.1136/bmjopen-2019-030101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The rate of admissions for ambulatory care sensitive conditions (ACSCs) is a key outcome indicator for primary care, and patient experience (PX) is a crucial process indicator. Studies have reported higher rates of admission for ACSCs in rural areas than in urban areas. Whether there is an association between admissions for ACSCs and PX in rural areas has not been examined. This study aimed to document admissions for ACSCs on Japanese rural islands, and assess whether there was an association between the rate of admissions for ACSCs and PX. DESIGN Multicentred, prospective, cohort study SETTING: This study was conducted on five rural islands in Okinawa, Japan. PARTICIPANTS The study participants were all island inhabitants aged 65 years or older. PRIMARY OUTCOME MEASURES This study examined the association between ACSCs and PX assessed by a questionnaire, the Japanese Version of Primary Care Assessment Tool. ACSCs were classified using the International Classification of Diseases, Tenth Revision, and the rate of admissions for ACSCs in 1 year. RESULTS Of 1258 residents, 740 completed the questionnaire. This study documented 38 admissions for ACSCs (29 patients, males/females: 15/14, median age 81.9) that included congestive heart failure (11), pneumonia (7) and influenza (5). After adjusting for covariates and geographical clustering, admissions for ACSCs had a significant positive association with each patient's PX scores (OR per 1 SD increase=1.62, 95% CI 1.02-2.61). CONCLUSIONS Physicians serving rural areas need to stress the importance of preventive interventions for heart failure, pneumonia and influenza to reduce the number of admissions for ACSCs. Contrary to previous studies, our findings might be explained by close patient-doctor relationships on the rural islands.
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Affiliation(s)
- Makoto Kaneko
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
- Shizuoka Family Medicine Program, Kikugawa, Japan
| | - Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masafumi Funato
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Shinjuku-ku, Japan
| | - Keita Yamashiro
- Department of Family Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | | | | | - Yusuke Saishoji
- Department of General Internal Medicine, National Hospital Organisation Nagasaki Medical Center, Omura, Japan
| | - Tatsuya Sakai
- Department of Family Medicine, Okinawa Prefectural Yaeyama Hospital, Ishigaki, Japan
| | - Syo Yonaha
- Department of Family Medicine, Okinawa Miyako Hospital, Miyakojima, Japan
| | - Kazuhisa Motomura
- Department of Family Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | - Machiko Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
- Shizuoka Family Medicine Program, Kikugawa, Japan
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Kato D, Ryu H, Matsumoto T, Abe K, Kaneko M, Ko M, Irving G, Ramsay R, Kondo M. Building primary care in Japan: Literature review. J Gen Fam Med 2019; 20:170-179. [PMID: 31516802 PMCID: PMC6732569 DOI: 10.1002/jgf2.252] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/17/2019] [Accepted: 04/21/2019] [Indexed: 11/06/2022] Open
Abstract
Japan's health system is well known for achieving one of the world's highest life expectancy with universal health coverage. However, the country now faces challenges of a rapidly aging population and changes in patterns and burden of disease. Primary care is an important component of a well-functioning health system. In Japan, primary care services are provided in both the community and hospital settings. The distinction between primary and secondary care may not always be clear. This review is based on the framework from the 2015 WHO publication on primary care systems in Europe. Our aim is to describe the journey of primary care in Japan, with its past, present, and future as a valuable addition to the academic English literature. We also hope that this article would inspire readers outside of Japan who might face similar issues in their respective countries.
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Affiliation(s)
- Daisuke Kato
- Department of Family MedicineMie University Graduate School of MedicineTsuJapan
| | - Hikohaku Ryu
- Department of General Medicine and Primary CareUniversity of Tsukuba HospitalTsukubaJapan
| | | | - Kazuhiro Abe
- Department of Public Health, Graduate School of MedicineThe University of TokyoHongoJapan
| | - Makoto Kaneko
- Department of Family and Community MedicineHamamatsu University School of MedicineHamamatsuJapan
| | - Mezhen Ko
- University Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
| | - Greg Irving
- Institute of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Robin Ramsay
- Usher Institute of Population health Sciences and InformaticsUniversity of EdinburghEdinburghUK
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Kaneko M, Motomura K, Mori H, Ohta R, Matsuzawa H, Shimabukuro A, Matsushima M. Gatekeeping function of primary care physicians under Japan's free-access system: a prospective open cohort study involving 14 isolated islands. Fam Pract 2019; 36:452-459. [PMID: 30202951 PMCID: PMC6669037 DOI: 10.1093/fampra/cmy084] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Gatekeeping is important for strong primary care and cost containment. Under Japan's free-access system, patients can access any medical institution without referral, which makes it difficult to evaluate the gatekeeping function of primary care physicians (PCPs). OBJECTIVES To examine the gatekeeping function of PCPs in Japan, we compared the frequencies of visits to primary care clinics, referrals to advanced care and hospitalizations between 14 remote islands and a nationwide survey. METHODS This study was a prospective, open cohort study involving 14 isolated islands (12 238 inhabitants) in Okinawa, Japan. Participants were all patients who visited the clinics on these islands in 1 year. Main outcome measures were the incidence of on-island clinic visits and referrals to off-island advanced care. RESULTS There were 54 741 visits to the islands' clinics with 2045 referrals to off-island medical facilities, including 549 visits to emergency departments and 705 hospitalizations. The age- and sex-standardized incidences of healthcare use per 1000 inhabitants per month were: 360.0 (95% confidence interval: 359.9 to 360.1) visits to primary care clinics, 11.6 (11.0 to 12.2) referrals to off-island hospital-based outpatient clinics, 3.3 (2.8 to 5.2) visits to emergency departments and 4.2 (3.1 to 5.2) hospitalizations. Comparison with the nationwide survey revealed a lower incidence of visits to hospital-based outpatient clinics in this study, while more patients had visited PCPs. CONCLUSIONS The lower incidence of visits to secondary care facilities in this study might suggest that introduction of a gatekeeping system to Japan would reduce the incidence of referral to advanced care.
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Affiliation(s)
- Makoto Kaneko
- Musashikoganei Clinic, Japanese Health and Welfare Co-operative Federation, Honcho, Koganei-shi, Tokyo, Japan
- Division of Clinical Epidemiology, Jikei University School of Medicine, Nishishimbashi, Minato-ku, Tokyo, Japan
| | | | - Hideki Mori
- National Hospital Organization Nagasaki Medical Center, Kubara, Omura-shi, Nagasaki, Japan
| | - Ryuichi Ohta
- Unnan City Hospital, Iida, Daito-cho, Unnan-shi, Shimane, Japan
| | - Hiroki Matsuzawa
- Teine Family Medicine Clinic, Maeda, Teine-ku, Sapporo-shi, Hokkaido, Japan
| | - Akira Shimabukuro
- Okinawa Miyako Hospital, Shimozato, Hirara, Miyakojima-shi, Okinawa, Japan
| | - Masato Matsushima
- Division of Clinical Epidemiology, Jikei University School of Medicine, Nishishimbashi, Minato-ku, Tokyo, Japan
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22
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Liang C, Mei J, Liang Y, Hu R, Li L, Kuang L. The effects of gatekeeping on the quality of primary care in Guangdong Province, China: a cross-sectional study using primary care assessment tool-adult edition. BMC FAMILY PRACTICE 2019; 20:93. [PMID: 31272392 PMCID: PMC6610915 DOI: 10.1186/s12875-019-0982-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 06/18/2019] [Indexed: 11/10/2022]
Abstract
Background Developed countries have widely implemented a gatekeeping system as a core policy of primary care, also known as the system of first visit in the community. As gatekeepers, general practitioners are responsible for the diagnosis and treatment of residents in the community health centres, and referring patients to specialists as appropriate. After several years of healthcare reform, gatekeeping policy has achieved remarkable success in China. Shenzhen and Dongguan were the first batch of pilot cities that implemented the policy of gatekeeping. This study aims to examine the effects of gatekeeping on the quality of primary care between the gatekeeping and non-gatekeeping groups in these two pilot cities. Methods A cross-sectional survey was conducted in five community health centres in Shenzhen and Dongguan cities, both located within Guangdong Province, China, using a validated Chinese version of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) and carrying out face-to-face interviews with patients 18 years and older. Analyses were grouped according to whether or not patients had gatekeepers. Propensity Score Matching was used to control for confounding factors. A chi-square test was used to compare the factors mentioned above and an independent t-test was performed to compare the eight domains of the core functions of primary care between the two groups of patients. Results In total, 765 valid questionnaires were collected for analysis, after matching the sample size were 238 pairs. All the confounding factors observed between the gatekeeping and non-gatekeeping groups were balanced. The PCAT-AE scores for first-contact utilisation (3.29 > 2.66, p < 0.001) and coordination (2.06 > 1.95, p < 0.05) were higher in the gatekeeping group after matching, but the domains of accessibility (1.59 < 1.67, p < 0.05) and continuity (2.26 < 2.40, p < 0.05) were lower. The PCAT-AE mean score was slightly higher in gatekeeping group (1.98 > 1.93, p > 0.05) but without statistical significance. Conclusion This study demonstrated that gatekeeping has helped to improve first-contact utilisation and coordination of primary care, but that other goals such as continuity and comprehensiveness have been harmed. To establish a sustainable gatekeeping system and to strengthen the core functions of the community comprehensively, the current gatekeeping system needs refinement.
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Affiliation(s)
- Cuiying Liang
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Jie Mei
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Yuan Liang
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Ruwei Hu
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Li Li
- Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, Ohio, 44106, USA.,Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Li Kuang
- Department of Health Administration, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China.
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23
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Kaneko M, Aoki T, Mori H, Ohta R, Matsuzawa H, Shimabukuro A, Motomura K, Inoue M. Associations of Patient Experience in Primary Care With Hospitalizations and Emergency Department Visits on Isolated Islands: A Prospective Cohort Study. J Rural Health 2018; 35:498-505. [PMID: 30550635 PMCID: PMC7380050 DOI: 10.1111/jrh.12342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE In rural areas, the management of hospitalizations and emergency department (ED) visits is an important issue, and it is compounded by factors such as the long distance to secondary care facilities, funding difficulties in many rural medical institutions, and shortage of medical staff. While better patient experience (PX) has been shown to reduce hospitalizations and ED visits, previous studies have not considered the differences between urban and rural areas. In addressing this gap, this study examines the association between PX and hospitalizations/ED visits on isolated islands. METHODS This prospective cohort study was conducted on 5 isolated islands in Okinawa, Japan. We assessed the PX of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was hospitalizations and ED visits in a year. We used a mixed effect model to adjust clustering within islands and individual covariates. FINDINGS Of 1,258 residents, 740 responded to a questionnaire for PX measurement. There were 73 hospitalizations and 62 ED visits. Adjusting for confounding and geographical clustering, hospitalizations had significant positive association with the PX score of each patient. ED visits were not associated with the total score of the JPCAT. CONCLUSION On the isolated islands, PX in primary care had positive correlation with hospitalizations. The contrast of our findings to those of previous studies may be due to the close patient-doctor relationship on isolated islands.
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Affiliation(s)
- Makoto Kaneko
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Shizuoka, Japan.,Shizuoka Family Medicine Program, Kikugawa, Shizuoka, Japan
| | - Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideki Mori
- National Hospital Organization, Nagasaki Medical Center, Omura-shi, Nagasaki, Japan
| | | | | | | | | | - Machiko Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Shizuoka, Japan.,Shizuoka Family Medicine Program, Kikugawa, Shizuoka, Japan
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24
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Aoki T, Yamamoto Y, Ikenoue T, Urushibara-Miyachi Y, Kise M, Fujinuma Y, Fukuhara S. Social Isolation and Patient Experience in Older Adults. Ann Fam Med 2018; 16:393-398. [PMID: 30201635 PMCID: PMC6130989 DOI: 10.1370/afm.2257] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/27/2018] [Accepted: 03/22/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Social isolation has been identified as a major health problem, particularly in the elderly. In the present study, we examine the association between social isolation and patient experience in elderly primary care patients. METHODS This cross-sectional study was conducted in a primary care practice-based research network (28 clinics) in Japan. We assessed social isolation using an abbreviated Lubben Social Network Scale and patient experience of primary care using a Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a linear mixed effects model to adjust clustering within clinics and individual covariates. RESULTS Data were analyzed for 465 elderly primary care patients aged ≥65 years. After adjustment for possible confounders and clustering within clinics, social isolation was negatively associated with the JPCAT total score, (mean difference = -3.67; 95% CI, -7.00 to -0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores. CONCLUSIONS Social isolation was associated with negative patient experience in elderly primary care patients. Raising awareness regarding patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.
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Affiliation(s)
- Takuya Aoki
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuyoshi Ikenoue
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Morito Kise
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Yasuki Fujinuma
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan .,Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan.,Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
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