Is general practitioner decision making associated with patient socio-economic status?

Individual, interpersonal, and organisational factors associated with discrimination in medical decisions affecting people with a migration background with mental health problems: the case of general practice

OBJECTIVES

Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB.

DESIGN

An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables.

RESULTS

Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress.

CONCLUSION

This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients.

Primary care physicians' perceptions of social determinants of health recommendations: a qualitative study

BACKGROUND

Several organisations have called for primary care professionals to address social determinants of health (SDoH) in clinical settings. For primary care physicians to fulfill their community health responsibilities, the implications of the SDoH recommendations need to be clarified.

AIM

To describe primary care physicians' views about being asked to address SDoH in clinical settings, from both positive and negative perspectives.

DESIGN & SETTING

A qualitative study in Japan. Twenty-one physicians were purposively recruited.

METHOD

'Love and breakup letter' methodology was used to collect qualitative data that contained both positive and negative feelings. Participants wrote love and breakup letters about being asked to address SDoH in a clinical setting, then undertook an in-depth online interview. Data were analysed via thematic analysis using the framework approach.

RESULTS

The following themes were identified: (i) primary care physicians take pride in being expected to address SDoH; (ii) primary care physicians rely on the recommendations as a partner, even in difficult situations; (iii) primary care physicians consider the recommendations to be bothersome, with unreasonable demands and challenges, especially when supportive surroundings are lacking; and (iv) primary care physicians reconstruct the recommendations on the basis of their experience.

CONCLUSION

Primary care physicians felt both sympathy and antipathy towards recommendations asking them to address SDoH in their clinical practice. The recommendations were not followed literally, instead contributing to physicians' clinical mindlines. Professional organisations that plan to develop and publish recommendations about SDoH should consider how their recommendations might be perceived by their target audience.

Dental antibiotics and referrals in general medical practice: Wales 1974-2017

OBJECTIVES

This study aimed to explore trends and predictors for antibiotic prescriptions and referrals for patients seeking dental care at General Medical Practitioners (GMPs) over a 44-year period in Wales, UK.

METHODS

This retrospective observational study analysed data from the nationwide Secure Anonymised Information Linkage Databank of visits to GMPs. Read codes associated with dental diagnoses were extracted from 1974-2017. Data were analysed using descriptive statistics, univariate and multivariable logistic regression.

RESULTS

Over the 44-year period, there were a total of 160,952 antibiotic prescriptions and 2,947 referrals associated with a dental attendance. Antibiotic prescriptions were associated with living in the most deprived (OR 0.91, 95% CI 0.89-0.93) or rural (OR 0.83, 95% CI 0.82-0.84) areas, whereas referrals were associated with living in an urban area (OR 2.16, 95% CI 1.99-2.35) or rural and less deprived area (OR 1.71, 95% CI 1.26-2.33). The number of antibiotic prescriptions decreased over time whereas the number of referrals increased.

CONCLUSIONS

These changes coincide with dental attendance rates at GMPs over the same period and indicate that appointment outcome and repeat patient attendance are linked. Rurality and deprivation may also influence care provided.

CLINICAL SIGNIFICANCE

General medical practices are not the most appropriate place for patients seeking dental care to attend, and efforts should be made to change current practice and policy to support patients to seek care from dental practices. When patients do seek dental care from GMPs they should be encouraged to refer the patient to a dentist rather than prescribe antibiotics as an important element of national antimicrobial stewardship efforts, as well as to discourage repeat attendance.

Using Australian panel data to account for unobserved factors in measuring inequities for different channels of healthcare utilization

Inequity in healthcare utilization is typically measured as the unequal distribution of services by observable non-need indicators, such as income, after controlling for observable need indicators. However, important sources of unequal healthcare utilization are often unobserved. The unobserved element may reflect need factors, such as imperfectly measured severity of illness, that would predict greater utilization across different healthcare channels, but also based on choice, such as patient preferences to use a particular healthcare channel over an alternative one, which may differ in its effect between channels. Accounting for unobserved sources of utilization may, therefore, help to understand contradictory inequalities between different healthcare channels, such as pro-poor inequalities for general practitioner use and pro-rich inequalities for specialist visits. This paper uses survey data from the Household Income and Labour Dynamics in Australia and panel data methods to investigate if seemingly contradictory inequalities between different healthcare channels are explained by latent individual-level heterogeneity. Results show that unobserved individual-level heterogeneity affects inequities across different healthcare channels, providing indications that the unobserved element may primarily represent unobserved need.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

BACKGROUND

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

METHOD

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

RESULTS

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

CONCLUSION

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Giardiasis notifications are associated with socioeconomic status in Sydney, Australia: a spatial analysis

OBJECTIVE

In developed countries prolonged symptoms due to, or following, Giardia intestinalis infection can have a significant impact on the quality of life. In this research, we investigate the presence of a socioeconomic status (SES) gradient in the reporting of giardiasis in South West Sydney Local Health District (SWSLHD), New South Wales (NSW), Australia, across geographic scales.

METHODS

We used a large database, spatial-cluster analysis and a linear model.

RESULTS

Firstly, we found one spatial cluster of giardiasis in one of the most advantaged neighbourhoods of SWSLHD. Secondly, rates of giardiasis notifications were significantly and consistently lower in SWSLHD compared to an unnamed advantaged Local Health District and NSW over multiple years. Finally, we found an overall significant positive dose-response relationship between counts of giardiasis and area-level SES.

CONCLUSIONS

Lower reporting in disadvantaged areas may represent true differences in incidence across SES groups or may result from differential use of health services and reporting. Implications for public health: If the disparities result from differential use of health services, research should be directed toward identifying barriers and facilitators of use. If disparities result from a true difference in incidence, then the behavioural mediators between SES and giardiasis should be identified and addressed.

Psychosocial information use for clinical decisions in diabetes care

OBJECTIVE

There are increasing efforts to capture psychosocial information in outpatient care in order to enhance health equity. To advance clinical decision support systems (CDSS), this study investigated which psychosocial information clinicians value, who values it, and when and how clinicians use this information for clinical decision-making in outpatient type 2 diabetes care.

MATERIALS AND METHODS

This mixed methods study involved physician interviews (n = 17) and a survey of physicians, nurse practitioners (NPs), and diabetes educators (n = 198). We used the grounded theory approach to analyze interview data and descriptive statistics and tests of difference by clinician type for survey data.

RESULTS

Participants viewed financial strain, mental health status, and life stressors as most important. NPs and diabetes educators perceived psychosocial information to be more important, and used it significantly more often for 1 decision, than did physicians. While some clinicians always used psychosocial information, others did so when patients were not doing well. Physicians used psychosocial information to judge patient capabilities, understanding, and needs; this informed assessment of the risks and the feasibility of options and patient needs. These assessments influenced 4 key clinical decisions.

DISCUSSION

Triggers for psychosocially informed CDSS should include psychosocial screening results, new or newly diagnosed patients, and changes in patient status. CDSS should support cost-sensitive medication prescribing, and psychosocially based assessment of hypoglycemia risk. Electronic health records should capture rationales for care that do not conform to guidelines for panel management. NPs and diabetes educators are key stakeholders in psychosocially informed CDSS.

CONCLUSION

Findings highlight opportunities for psychosocially informed CDSS-a vital next step for improving health equity.

Exploring the differences in general practitioner and health care specialist utilization according to education, occupation, income and social networks across Europe: findings from the European social survey (2014) special module on the social determinants of health

Background

Low socioeconomic position (SEP) tends to be linked to higher use of general practitioners (GPs), while the use of health care specialists is more common in higher SEPs. Despite extensive literature in this area, previous studies have, however, only studied health care use by income or education. The aim of this study is, therefore, to examine inequalities in GP and health care specialist use by four social markers that may be linked to health care utilization (educational level, occupational status, level of financial strain and size and frequency of social networks) across 20 European countries and Israel.

Methods

Logistic regression models were employed using data from the seventh round of the European Social Survey; this study focused upon people aged 25–75 years, across 21 countries. Health care utilization was measured according to self-reported use of GP or specialist care within 12 months. Analyses tested four social markers: income (financial strain), occupational status, education and social networks.

Results

We observed a cross-national tendency that countries with higher or equal probability of GP utilization by lower SEP groups had a more consistent probability of specialist use among high SEP groups. Moreover, countries with inequalities in GP use in favour of high SEP groups had comparable levels of inequalities in specialist care utilization. This was the case for three social markers (education, occupational class and social networks), while the pattern was less pronounced for income (financial strain).

Conclusion

There are significant inequalities associated with GP and specialist health care use across Europe—with higher SEP groups more likely to use health care specialists, compared with lower SEP groups. In the context of health care specialist use, education and occupation appear to be particularly important factors.

Patterns of analgesic use to relieve tooth pain among residents in British Columbia, Canada

The use of prescription opioids has increased dramatically in Canada in recent decades. This rise in opioid prescriptions has been accompanied by increasing rates of opioid-related abuse and addiction, creating serious public health challenges in British Columbia (BC), one of Canada's most populated provinces. Our study explores the relationship between dental pain and prescription opioid use among residents in BC. We used data from the 2003 Canadian Community Health Survey (CCHS), which asked respondents about their use of specific analgesic medications, including opioids, and their history of tooth pain in the past month. We used logistic regression, controlling for potential confounding variables, to identify the predictive value of socioeconomic factors, oral health-related variables, and dental care utilization indicators. The Relative Index of Inequality (RII) was calculated to assess the magnitude of socioeconomic inequalities in the use of particular analgesics by incorporating income-derived ridit values into a binary logistic regression model. Our results showed that conventional non-opioid based analgesics (such as aspirin or Tylenol) and opioids were more likely to be used by those who had experienced a toothache in the past month than those who did not report experiencing a toothache. The use of non-opioid painkillers to relieve tooth pain was associated with more recent and more frequent dental visits, better self-reported oral health, and a greater income. Conversely, a lower household income was associated with a preference for opioid use to relieve tooth pain. The RII for recent opioid use and conventional painkiller use were 2.06 (95% CI: 1.75-2.37) and 0.62 (95% CI: 0.35-0.91), respectively, among those who experienced recent tooth pain, suggesting that adverse socioeconomic conditions may influence the need for opioid analgesics to relieve dental pain. We conclude that programs and policies targeted at improving the dental health of the poor may help to reduce the use of prescription opioids, thereby narrowing health inequalities within the broader society.

Impact of service redesign on the socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction: a natural experiment and electronic record-linked cohort study

AIM

To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI).

DESIGN

Natural experiment and retrospective cohort study using linked data sets in the Secure Anonymised Information Linkage databank.

NON-RANDOMISED INTERVENTION

An increase in the capacity of revascularisation procedures and service redesign in the provision of revascularisation in late 2011 to early 2012.

SETTING

South Wales cardiac network, Census 2011 population 1 359 051 aged 35 years and over.

PARTICIPANTS

9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up.

MAIN OUTCOME MEASURE

Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural-urban classification and revascularisation facilities of admitting hospital.

RESULTS

In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001).

CONCLUSIONS

Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas.

Socio-economic Health Differentials

A large and expanding literature demonstrates the existence and persistence of socio-economic differences in health. This literature is extensive, but very little of it examines the individual's experience of health. This article argues the need for research into socio-economic differentials in health from a qualitative perspective, and draws on research from this perspective to present and discuss several issues of relevance to health differentials. These include talking about health, contact with health professionals, views on modem medicine, the meaning of health, control and fatalism, smoking and health, diet and food, exercise and fitness and the healthy body. Findings illustrate considerable differences in the ways people from upper and lower socio-economic positions understand and experience health and illness, and also demonstrate how their health-related concerns are embedded in the fabric of everyday lives. Further research from this perspective has potential for improving our understanding of socio-economic differentials in health. In closing, the article offers some directions for future research, and identifies three issues: the type of qualitative approach adopted; the nature of linguistic accounts; and the need for a theoretical framework, to which future research should attend.

Frequency and pattern of radiological and laboratory investigations in patients with mental illnesses: A study from North Rajasthan

BACKGROUND

There are widespread perceptions that excessive and unnecessary investigations are done in many patients with mental illnesses. There are no studies from India looking into this issue.

AIMS

(i) To study the frequency and pattern of various investigations such as electroencephalography (EEG), computerized tomography (CT) scan of head, magnetic resolution imaging (MRI) scan of brain, and blood investigations carried out by the previous doctors on patients seeking treatment in three different settings. (ii) To study the socio-demographic and clinical correlates of investigations carried out on these patients.

STUDY DESIGN AND SETTINGS

A cross-sectional study in a community outreach clinic, a district level psychiatric hospital, and psychiatry outpatient clinic of a medical college.

MATERIALS AND METHODS

160 newly registered patients seeking treatment at these settings were assessed using a semi-structured pro forma regarding various investigations that they had undergone before seeking the current consultation. Frequency of investigations was analyzed.

RESULTS

About 47.5% of patients had at least one of the three brain investigations done. EEG, CT head, and MRI brain had been done in 37.5%, 20.0%, and 8.8% of the patients, respectively. Only 1.8% of the patients had blood tests done before current consultation.

CONCLUSION

This study results raise question whether certain investigations such as EEG and CT head were carried out excessively and blood investigations were done infrequently. Further studies on larger samples with prospective study design to evaluate the appropriateness of current practices of carrying out investigations in patients presenting with psychiatric symptoms are required.

General practice and residential aged care: A qualitative study of barriers to access to care and the role of remuneration

BACKGROUND

More than 169,000 people live in residential aged care facilities (RACFs). As people age they use health services, particularly general practitioner (GP) services, more frequently but many GPs do not attend patients in RACFs.

AIMS

To examine GPs' perceptions of barriers to providing care to patients in RACFs.

METHODS

This study was conducted in June 2014 in the Bayside Medicare Local (BML) region in Victoria, Australia; all participants were drawn from this region. Two focus groups (FGs) were conducted. One was for GPs (n=5) that have a specific interest in practicing in RACFs, the other with RACF staff (n=8) representing public, private, and not-for-profit aged care providers. Results were presented to the Royal Australian College of General Practitioners (RACGP) National Standing Committee for General Practice Advocacy and Support for feedback and validation of the findings against national perspectives of the effect of remuneration on the provision of GP services in RACFs.

RESULTS

Remuneration problems are a barrier to the provision of GP services to patients in RACFs. These problems can be grouped into: direct remuneration, opportunity cost, additional administrative burden, and unremunerated work. GPs' perceptions of the effects of these problems on willingness to practice in RACFs are described.

CONCLUSION

Innovative models of remuneration for GPs attending RACFs are needed to ameliorate the problems identified. Such models need to capture and pay for activities that are time consuming but often unremunerated.

Recommended drug use after acute myocardial infarction by migration status and education level

PURPOSE

The purpose of this study is to investigate the association between migration status and education level and the use of recommended drugs after first acute myocardial infarction (MI).

METHODS

A nationwide cohort study performed in Sweden from January 1, 2006 to August 1, 2008. The cohort consisted of 49,037 incident cases of first acute MI. In total, 37,570 individuals survived 180 days after MI, of whom 4782 (12.7%) were foreign-born. We used logistic regression to estimate the odds ratio (OR) with 95% confidence interval (CI) of the association between migration status and education level and prescribed drugs after MI.

RESULTS

One third of the patients who were not on any recommended cardiovascular drugs before MI continued to be without recommended cardiovascular drugs after MI. Among those with no cardiovascular drugs before MI, we found no difference in recommended drug use after MI by migration status (OR 1.00, 95% CI 0.89-1.12). Among those with some but not all recommended cardiovascular drugs before MI, foreign-born cases had a slightly non-significant lower use of recommended drugs (OR 0.92, 95% CI 0.83-1.03). Foreign-born patients with low education had a slightly lower use of recommended drug compared to Sweden-born. Women with low education had a lower use of drugs after MI (Sweden born, OR 0.85; 95% CI 0.74-0.96 and foreign born OR 0.51; 95% CI 0.34-0.77).

CONCLUSION

There is no apparent difference between foreign-born and Sweden-born in recommended drug use after MI. However, our study reveals an inequity in secondary prevention therapy after myocardial infarction by education level.

Mode of birth and social inequalities in health: the effect of maternal education and access to hospital care on cesarean delivery

Access to health care is an important factor in explaining health inequalities. This study focuses on the issue of access to health care as a driving force behind the social discrepancies in cesarean delivery using data from 707 newborn children in the 2006-2011 birth cohorts of the German Socio-Economic Panel Study (SOEP). Data on individual birth outcomes are linked to hospital data using extracts of the quality assessment reports of nearly all German hospitals. Geographic Information Systems (GIS) are used to assess hospital service clusters within a 20-km radius buffer around mother׳s homes. Logistic regression models adjusting for maternal characteristics indicate that the likelihood to deliver by a cesarean section increases for the least educated women when they face constraints with regard to access to hospital care. No differences between the education groups are observed when access to obstetric care is high, thus a high access to hospital care seems to balance out health inequalities that are related to differences in education. The results emphasize the importance of focusing on unequal access to hospital care in explaining differences in birth outcomes.

Social inequalities in patient experiences with general practice and in access to specialists: the population-based HUNT Study

BACKGROUND

In countries with gatekeeping and equitable access to general practitioners (GPs), social inequalities in GP-patient interaction could be an important mechanism by which inequalities in access to medical specialists arise. The aim of this study was to investigate whether socioeconomic inequalities in experiences with general practice are associated with socioeconomic inequalities in access to specialist services.

METHODS

The study included 6,067 participants in the third survey of the Nord-Trøndelag Health Study (HUNT3, 2006-08) who were asked to evaluate their experiences with primary care and their regular general practitioner in Norway. Self-reported data on health status and number of visits to GP and specialist services in the last 12 months were included in the study. Socioeconomic status was measured by education and household income and rescaled to relative index of inequality (RII). Relative risks were calculated using Poisson regression.

RESULTS

We found that a majority of patients reported positive experiences with general practice. Low socioeconomic status (SES) and male gender were associated with negative experiences. Patient experiences both directly and indirectly related to referrals were associated with the probability and quantity of specialist utilization: perception of low subjective influence on decisions about choice of medical care was associated with lower probability and quantity of specialist utilization, whereas desire to change the regular GP or to use GPs other than the regular GP and critical evaluations of the GP were associated with higher specialist consultation frequency. However, the level of education-related inequity in access to specialists was not sensitive to adjustment by survey responses.

CONCLUSION

Patient experiences with general practice were associated with the patients' level of utilization of specialist services. There are socioeconomic inequalities in patient experiences with general practice, however the aspects measured in this study do not explain the observed socioeconomic inequity in access to specialists.

Socio-economic inequalities in Norwegian health care utilization over 3 decades: the HUNT Study

BACKGROUND

The aim of this study was to investigate socio-economic inequalities in health care utilization from the 1980s and through the last 3 decades in a Norwegian county population.

METHODS

Altogether, 166 758 observations of 97 251 individuals during surveys in 1984-86 (83% eligible responses), 1995-97 (51% eligible responses) and 2006-08 (50% eligible responses) of the total population of adults (≥ 20 years) from Nord-Trøndelag county in Norway were included. Health care utilization was measured as at least one visit to general practitioner (GP), hospital outpatient services and inpatient care in the past year. Socio-economy was measured by both education and income and rescaled to measure relative indexes of inequality (RII). Relative and absolute inequalities were estimated from multilevel logistic regression. Estimates were adjusted for age, sex, municipality size and self-reported health.

RESULTS

GP utilization was higher among individuals with higher education in 1984-86. Among men the RII was 0.54 (CI: 0.48-0.62), and among women RII was 0.67 (CI: 0.58-0.77). In 2006-08, the corresponding RII was 1.31 (CI: 1.13-1.52) for men and 1.00 (CI: 0.85-1.18) for women, indicating higher or equal GP utilization among those with lower education, respectively. The corresponding RIIs for outpatient consultations were 0.58 (CI: 0.49-0.68) for men and 0.40 (CI: 0.34-0.46) for women in 1984-86, and 0.53 (CI: 0.46-0.62) for men and 0.47 (CI: 0.41-0.53) for women in 2006-08.

CONCLUSION

Through the last 3 decades, the previous socio-economic differences in GP utilization have diminished. Despite this, highly educated people were more prone to utilize hospital outpatient consultations throughout the period 1984-2008.

The effect of socioeconomic status on access to primary care: an audit study

BACKGROUND

Health care office staff and providers may discriminate against people of low socioeconomic status, even in the absence of economic incentives to do so. We sought to determine whether socioeconomic status affects the response a patient receives when seeking a primary care appointment.

METHODS

In a single unannounced telephone call to a random sample of family physicians and general practices (n = 375) in Toronto, Ontario, a male and a female researcher each played the role of a patient seeking a primary care physician. Callers followed a script suggesting either high (i.e., bank employee transferred to the city) or low (i.e., recipient of social assistance) socioeconomic status, and either the presence or absence of chronic health conditions (diabetes and low back pain). We randomized the characteristics of the caller for each office. Our primary outcome was whether the caller was offered an appointment.

RESULTS

The proportion of calls resulting in an appointment being offered was significantly higher when the callers presented themselves as having high socioeconomic status than when they presented as having low socioeconomic status (22.6% v.14.3%, p = 0.04) and when the callers stated the presence of chronic health conditions than when they did not (23.5% v. 12.8%, p = 0.008). In a model adjusted for all independent variables significant at a p value of 0.10 or less (presence of chronic health conditions, time since graduation from medical school and membership in the College of Family Physicians of Canada), high socioeconomic status was associated with an odds ratio of 1.78 (95% confidence interval 1.02-3.08) for the offer of an appointment. Socioeconomic status and chronic health conditions had independent effects on the likelihood of obtaining an appointment.

INTERPRETATION

Within a universal health insurance system in which physician reimbursement is unaffected by patients' socioeconomic status, people presenting themselves as having high socioeconomic status received preferential access to primary care over those presenting themselves as having low socioeconomic status.

Equal cancer treatment regardless of education level and family support? A qualitative study of oncologists' decision-making

OBJECTIVE

Treatment gradients by socioeconomic status have been observed within cancer care in several countries. The objective of this study was to explore whether patients' educational level and social network influence oncologists' clinical decision-making.

DESIGN

Semi-structured interviews on factors considered when deciding on treatment for cancer patients. Interviews were transcribed and analysed using inductive qualitative content analysis.

SETTING

Oncologists in Swedish university- and non-university hospitals were interviewed in their respective places of work.

PARTICIPANTS

Twenty Swedish clinical oncologists selected through maximum-variation sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

Elements which influence oncologists' decision-making process were explored with focus on educational level and patients' social support systems.

RESULTS

Oncologists consciously used less combination chemotherapy for patients living alone, fearing treatment toxicity. Highly educated patients were considered as well-read, demanding and sometimes difficult to reason with. Patients with higher education, those very keen to have treatment and persuasive relatives were considered as challenges for the oncologist. Having large groups of relatives in a room made doctors feel outnumbered. A desire to please patients and relatives was posed as the main reason for giving in to patients' demands, even when this resulted in treatment with limited efficacy.

CONCLUSIONS

Oncologists tailor treatment for patients living alone to avoid harmful side-effects. Many find patients' demands difficult to handle and this may result in strong socioeconomic groups being over-treated.

State and self investments in health

In this paper we consider how State investments can crowd out or reinforce self-investments in health using a theoretical model of insurance and protection. We apply this model to the smoking cessation decision made by individuals diagnosed with a cardiovascular disease using data from the 1998, 2003 and 2006 waves of the Health Survey of England. Prescription of lipid-lowering drugs, which increased substantially over this period, is used as the measure of State investment. Using bivariate and trivariate probit models, we allow for the endogeneity of the doctor's decision to prescribe and offer smoking cessation advice. We find that unobservable characteristics affecting the prescription of drugs are positively correlated with those affecting smoking advice and negatively correlated with those affecting the propensity to quit. Our results indicate that prescription of lipid-lowering drugs to individuals with cardiovascular disease increases the probability of smoking cessation by 20-28 percentage points.

Inequity in the use of physician services in Norway before and after introducing patient lists in primary care

BACKGROUND

Inequity in use of physician services has been detected even within health care systems with universal coverage of the population through public insurance schemes. In this study we analyse and compare inequity in use of physician visits (GP and specialists) in Norway based on data from the Surveys of Living Conditions for the years 2000, 2002 and 2005. A patient list system was introduced for GPs in 2001 to improve GP accessibility, strengthen the stability of the patient-doctor relationship and ensure equity in the use of health care services for the entire population.

METHOD

We measure horizontal inequity by concentration indices and investigate changes in inequity over time when decomposing the concentration indices into the contribution of its determinants.

RESULTS

We find that pro-rich inequity in the probability of seeing a private outpatient specialist has declined, but still existed in 2005.

CONCLUSION

Improved patient-doctor stability as well as better GP accessibility facilitated by the introduction of patient lists improved access to private specialist services. In particular the less well off benefited from this reform.

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study

BACKGROUND

Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.

AIM

To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level.

DESIGN OF STUDY

INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France.

METHOD

Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were 'mirrored', meaning that GPs and patients were presented with the same questions.

RESULTS

The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.

CONCLUSION

This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.

The use of antidepressants and introduction of new types in different socio-economic groups: a Danish registry-based cross-sectional study

BACKGROUND

Danish registry-based studies have found socio-economic differences in drug use. The extent to which the use of antidepressants differs between socio-economic groups is unknown.

AIM

1) to examine the association between socio-economic status (SES) and use of antidepressants 2) to evaluate the introduction of new types of antidepressants.

METHODS

A registry-based cross-sectional study linking information from administrative registries in North Jutland County, Denmark, 1995-99.

MAIN OUTCOME MEASURES

1) the prevalence proportion for use of antidepressants in different SES groups and by sex, and the estimated prevalence proportion ratio; 2) the proportion using the new drugs in different socio-economic groups through the study period.

RESULTS

Women used antidepressants more than twice as often as men with an increasing tendency for both men and women. The use of antidepressants was highest in persons outside the labour market. Among employees, the proportion using new types of antidepressants increased from 1% to 18%. High SES seemed to correlate to higher use of new antidepressants. The new antidepressants were introduced faster among men compared with women.

CONCLUSION

The study showed differences in purchase of antidepressants in different SES groups. Furthermore, it showed faster introduction of new antidepressants among men and employees with high SES.

Socioeconomic position and secondary preventive therapy after an AMI

PURPOSE

To investigate the association between socioeconomic position and use of lipid-lowering drugs and ACE-inhibitors after an acute myocardial infarction (AMI) when simultaneously considering participation in the national quality register RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive care Admissions), age, sex and previous hospitalizations of the patients.

METHODS

Population-based prospective cohort study included all 1346 AMI patients cared in the county of Scania, Sweden during 2006 of whom 1061 were register at the RIKS-HIA. Treatment with lipid-lowering and ACE-inhibiting therapy in relation to income was investigated with Cox and logistic regression modelling.

RESULTS

In the whole population of AMI patients, high income patients had a higher adherence to guidelines for pharmacological secondary prevention than low income patients (HR(lipid-lowering drug): 1.29; 95%CI: 1.12-1.49 and HR(ACE-inhibitor therapy): 1.22; 95%CI: 1.04-1.43). Among RIKS-HIA participants, patients with high income presented a better adherence to lipid-lowering treatment than patients with low income (HR: 1.15; 95%CI: 0.98-1.34).

CONCLUSION

Our investigation reveals that the Swedish goal of access to health care on equal terms and according to needs is still not fully accomplished. Moreover, since this pattern of inequity in pharmacological secondary prevention may lead to the recurrence of heart disease, these inequities are not only a matter of fairness and social justice, but also a potential (and modifiable) source of ineffectiveness and inefficiency in health care.

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

The intended and unintended consequences of clinical guidelines

OBJECTIVES

First, we examine whether clinical guidelines, designed to improve health care and reduce disparities in clinical practice, are achieving their intended consequences. Second, we contemplate potential unintended consequences of clinical guidelines.

METHOD

As part of a factorial experiment we presented primary care doctors (n = 192) with clinically authentic vignettes of a 'patient' with already diagnosed diabetes with an emerging foot neuropathy. Their proposed clinical actions were compared with established practice guidelines for this clinical situation.

RESULTS

After establishing the existence of consistent socioeconomic disparities in the proposed management of the case presented, we found that reported use of practice guidelines had no measurable effect towards their reduction (one intended consequence). However, the reported use of practice guidelines appeared to precipitate more clinical actions, without eliminating documented disparities.

CONCLUSIONS

Consistent with other research we find that clinical practice guidelines are not producing a principal intended result, and may even produce unintended consequences.

[Social inequality and health care among the aged]

In this article the association between social inequality and selected aspects of health care among the aged is analysed. Analyses are based on German data (release 1) of the 'Survey of Health, Ageing and Retirement in Europe' (SHARE) in 2004. Data from 1921 respondents aged 50 years or more are analysed. Three indicators of social inequality are used (education, income, and financial assets). In terms of health care, indicators of geriatric assessment by the general practitioner of the respondent (questions about balance, physical exercise, and drugs as well as examination of balance and weight control) and secondary prevention (mammogram, endoscopic examination of colon, eye examination) are included. Results of cross-tabs and logistic regression analyses show that geriatric assessment is less comprehensive among people in a comparatively high socioeconomic position. On the other hand, people in a higher socioeconomic position use screening examinations more often than those in a lower position. Inconsistency of results indicates the necessity to distinguish different areas of health care when analysing social inequalities. Moreover, results indicate that no simple answer can be given to the question whether and to what extent social inequalities in health among older people can be explained by inequalities in medical care.

Socio-demographic factors influence chronic proton pump inhibitor use by a large population in the Netherlands

BACKGROUND

Chronic proton pump inhibitor (PPI) use is common in the Western world. Socio-economic status and socio-demographic factors have been shown to influence decisions related to prescribing of various drugs, but the influence of these factors on chronic PPI use is uncertain.

AIM

To study the influence of SES and socio-demographic factors on chronic PPI use.

METHODS

Data were collected from a database of a Dutch health insurance company. Subjects having had at least one prescription for a PPI were identified and followed up for 6 months. Patients were then subdivided into chronic PPI users. Socio-demographic status was based on neighbourhood level of residence. Logistic regression was performed to determine socio-demographic factors associated with PPI use.

RESULTS

A total of 2 001 787 insured individuals were included, 85 253 subjects were chronic users. Both low income (OR 1.55; CI 1.52-1.58) and low educational level (OR 1.33; CI 1.31-1.36) were associated with chronic PPI use. Other independent predictive variables included use of 10 or more concomitant medications (OR 5.33; CI 4.96-5.72) and the use of prokinetic drugs (OR 10.01; CI 9.22-10.88).

CONCLUSIONS

Patients of a lower socio-demographic status are more likely to use PPIs on a chronic basis. The observed gradient in PPIs use may reflect differences in health, healthcare use or healthcare supply.

Therapeutic traditions, patient socioeconomic characteristics and physicians' early new drug prescribing--a multilevel analysis of rosuvastatin prescription in south Sweden

PURPOSE

To investigate the role that both patient and outpatient factors related to health care practice (HCP) play in physicians' early adoption of rosuvastatin.

MATERIALS AND METHODS

Generalized estimation equations (GEEs) and alternating logistic regression (ALR) with pair-wise odds ratios (PWORs) were used to measure similarities in rosuvastatin prescription within HCPs for all individuals with statin prescriptions in Skåne region, Sweden.

RESULTS

After 12 months, 53% of the HCPs had adopted the new statin. Rosuvastatin prescriptions co-occurred within certain HCPs 3.56 times more often than one would have expected based on a random distribution. Private HCPs had four times higher probability of prescribing rosuvastatin than public HCPs.

CONCLUSION

Contextual characteristics of the HCP seem to be relevant for understanding physicians' motivation to adopt rosuvastatin. Moreover, our study reveals inequity in health care as the socioeconomic status of the patients appears to influence the prescribing behavior of the physicians irrespective of medical reasons.

How are patient characteristics relevant for physicians' clinical decision making in diabetes? An analysis of qualitative results from a cross-national factorial experiment

Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as 'think-aloud') techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients' demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work.

Variations in activity and practice patterns: a French study for GPs

OBJECTIVES

To identify the different practice profiles of general practitioners (GPs) in order to test the hypothesis of heterogeneity in physician behaviour.

DATA

For the year 2000, 4,660 GPs from two regions in France.

VARIABLES

volume and structure of the physicians' medical activity, income level, personal characteristics, socioeconomic and geographical environment, characteristics of their patients.

METHODS

A cluster analysis to identify different practice profiles and a regression analysis to display the determinants of the physicians' activity.

RESULTS

Four different homogeneous groups can be identified, each one associating a physician's level of activity to his socioeconomic status. The level and the intensity of medical activity depend on individual factors, patients' characteristics as well as the socioeconomic context.

CONCLUSIONS

There is no uniformity in the way GPs practice medicine. An immediate consequence is that any cost-containment measure that is applied uniformly to all GPs inevitably results in different outcomes according to the physicians' category type.

Impact of pharmaceutical promotion on prescribing decisions of general practitioners in Eastern Turkey

Background

Commercial sources of information are known to have greater influence than scientific sources on general practitioners' (GPs) prescribing behavior in under developed and developing countries. The study aimed to determine the self-reported impact of pharmaceutical promotion on the decision-making process of prescription of GPs in Eastern Turkey.

Methods

A cross-sectional, exploratory survey was performed among 152 GPs working in the primary health centers and hospitals in Erzurum province of Eastern Turkey in 2006. A self-administered structured questionnaire was used. The questionnaire included questions regarding sociodemographics, number of patients per day, time per patient, frequency of sales representative visits to GPs, participation of GPs in training courses on prescribing (in-service training, drug companies), factors affecting prescribing decision, reference sources concerning prescribing and self-reported and self-rated effect of the activities of sales representatives on GPs prescribing decisions.

Results

Of 152 subjects, 53.3% were male and 65.8% were working at primary health care centers, respectively. Mean patient per day was 58.3 ± 28.8 patients per GP. For majority of the GPs (73.7%), the most frequent resource used in case of any problems in prescribing process was drug guides of pharmaceutical companies. According to self-report of the GPs, their prescribing decisions were affected by participation in any training activity of drug companies, frequent visits by sales representatives, high number of patient examinations per day and low year of practice (p < 0.05 for all).

Conclusion

The results of this study suggest that for the majority of the GPs, primary reference sources concerning prescribing was commercial information provided by sales representatives of pharmaceutical companies, which were reported to be highly influential on their decision-making process of prescribing by GPs. Since this study was based on self-report, the influence reported by the GPs may have been underestimated.

Thiazide diuretics for hypertension: prescribing practices and predictors of use in 194,761 elderly patients with hypertension

BACKGROUND

Although several small studies have reported underuse of thiazide diuretics for elderly hypertensive patients, those factors which influence initial choice of first-line antihypertensive treatment are unknown.

OBJECTIVES

: The objective of this study was to explore prescribing practices for antihypertensives in the elderly and determine which factors are associated with thiazide diuretic use as first-line treatment

METHODS

This population-based cohort study used linked administrative databases for all elderly patients (> or =66 years of age) first treated for hypertension between July 1, 1994, and March 31, 2002, in Ontario, Canada.

RESULTS

Of the 194,761 patients in our cohort, 68,858 (35%) were prescribed a thiazide diuretic as their first anti-hypertensive agent. On multivariate analysis, factors associated with being prescribed a thiazide as first-line treatment included age (adjusted odds ratio [AOR], 1.72 [95% CI, 1.67-1.78] for octogenarians compared with patients aged 66-69 years) and having multiple comorbidities (AOR, 1.24 [95% CI, 1.16-1.29] for Charlson scores of 2 and AOR, 1.52 [95% CI, 1.37-1.61] for Charlson scores of > or =3). On the other hand, men (AOR, 0.64 [95% CI 0.63-0.65]) and hypertensives with diabetes (AOR, 0.22 [95% CI, 0.21-0.23]) were substantially less likely to be prescribed thiazide diuretics as first-line treatment. Socioeconomic status was not associated with use of thiazide diuretics.

CONCLUSIONS

One third of initial antihypertensive prescriptions for elderly patients were for thiazides in our publicly funded health care system with universal drug coverage. Socioeconomic status did not influence use of thiazides, but age, sex, and comorbidities did.

Gender differences in health care use among the elderly population in areas of Norway and Finland. A cross-sectional analysis based on the HUNT study and the FINRISK Senior Survey

BACKGROUND

The aim of the study was to examine gender differences in the self-reported use of health care services by the elderly in rural and metropolitan areas of two Nordic countries with slightly different health care systems: Finland and Norway.

METHODS

Population based, cross-sectional surveys conducted in Nord-Tröndelag Norway (1995-97) and in rural and metropolitan areas of Finland (1997) were employed. In the Norwegian data, a total of 7,919 individuals, aged 65-74 years old were included, and the Finnish data included 1,500 individuals. The outcome variables comprised whether participants had visited a general practitioner or a specialist, or had received hospital care or physiotherapy during the past 12 months. Gender differences in the use of health care services were analysed by multiple logistic regression, controlling for health status and socio-demographic characteristics.

RESULTS

In Norway, elderly women visited a specialist or were hospitalised less often than men. In Finland, elderly women used all health care services except hospital care more often than men. In Norway, less frequent use of specialist care by women was not associated with self-reported health or chronic diseases.

CONCLUSION

The findings revealed differences in self-reported use of secondary care among different genders in areas of Norway and Finland.

Thinking like a nurse: a research-based model of clinical judgment in nursing

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Influence of pharmacists' opinions on their dispensing medicines without requirement of a doctor's prescription

OBJECTIVE

To assess the influence of pharmacists' opinions on their dispensing medicines with a "medical prescription only" label without requiring a doctor's prescription.

METHODS

We performed a cross-sectional study of 166 community pharmacies in northwest Spain. The opinions of pharmacists on the following were collected as independent variables through personal interview: a) physicians' prescribing practices; b) the pharmacist's qualifications to prescribe; c) the responsibility of the pharmacist regarding the dispensed drugs; d) the customer' qualifications for self-medication; and e) the pharmacist's perception of his or her own work. The dependent variable was the pharmacist's demand for a medical prescription for 5 drugs, which in Spain require a prescription. Multiple linear regression models were constructed.

RESULTS

The response rate was 98.8%. A total of 65.9% of pharmacists reported dispensing antibiotics without a prescription. This percentage was 83.5% for nonsteroidal anti-inflammatory drugs, 46.3% for angiotensin-converting enzyme inhibitors, 13.4% for benzodiazepines, and 84.8% for oral contraceptives. Further results showed that pharmacists with a heavier workload and those who underestimated the physicians' qualifications to prescribe but overestimated their own qualifications to prescribe less frequently demanded medical prescriptions. In contrast, pharmacists who stressed the importance of their duty in rationalizing the consumption of drugs more frequently demanded medical prescriptions.

CONCLUSION

Our results suggest that to increase the quality of dispensing: a) the importance of the pharmacist's duty in controlling drug consumption should be stressed; b) pharmacies' workload should be optimized; and c) perceptions of physicians' prescribing practices among pharmacists should be improved.

Do pharmacists' opinions affect their decision to dispense or recommend a visit to a doctor?

PURPOSE

To assess the relation between the pharmacists' opinions and the decision to dispense drugs without medical prescription and to recommend a visit to a doctor.

METHODS

We carried out a cohort study on a sample of 166 pharmacists in North-West Spain. Pharmacists' opinions on prescription practice of the doctors, on pharmacists' qualification to dispense drugs without medical prescription, on their responsibility about dispensed drugs, on clients' qualification for self-medication, and pharmacists' perception of their work were collected through a personal interview. Dispensing and the recommendation to the patient to visit their doctor were measure in the follow-up. We constructed logistic regression models.

RESULTS

The response rate to the first questionnaire was 98.8% and the participation rate in the follow-up was 60%. Pharmacists who considered that doctors prescribed excessively were less likely to dispense without medical prescription (OR = 0.48) and to send the client to the doctor more often (OR = 2.33). On the other hand, those who considered themselves to be capable to dispense without prescription do so frequently (OR = 1.24). A major appreciation of the pharmacist as a health educator was associated with a higher dispensing (OR = 3.81). Pharmacists who considered that customers' qualification for self-medication was good recommended, more frequently visiting a doctor (OR = 1.58).

CONCLUSIONS

Our results show that the pharmacists' opinions are associated with their practice of counseling. Therefore, any program designed with the purpose of changing dispensing habits of the pharmacists should identify and take into account their opinions.

Prescription de buprénorphine haut dosage par des médecins généralistes

BACKGROUND

Since 1996, prescribing buprenorphine in high dosage as a drug maintenance treatment has been allowing French general practitioners to undertake drug addicts with a pharmacological support. In France, buprenorphine prescriptions seem to spread over general practitioners (buprenorphine was given to 74,300 patients in 2001). This paper assesses the different factors associated with buprenorphine prescription by general practitioners and with the different degrees of general practitioners' commitment in actually caring drug addicts with the help of buprenorphine.

METHODS

Two representative samples of private general practitioners, either prescribing buprenorphine (345 over a population of 876) or not prescribing (355 over a population of 1380) have been questioned through a phone interview in the department of South-Eastern France in November and December 2002. Samples have been constituted with the help of a random stratified survey according to sex, age and volume of services (acceptance rate: 65.5%). Survey data have been completed with general practitioners' activity data from Health Insurance and local socioeconomic data from Insee.

RESULTS

37.5% of general practitioners have at least once prescribed buprenorphine during the considered period, but only 26% of the prescribers treated 75% of patients. Prescribers are most often men, younger than 49 years, working in the fixed fees sector and having group practice. They are also most often members of a health care network, trained for drug maintenance treatments and, from an individual point of view, have relatives suffering cancer, or having HIV, or hepatitis C, or who are drug addicts. Low socioeconomic status of the area where GPs exert seems to be particularly associated with general practitioners' prescription of buprenorphine.

CONCLUSION

Data handled in this paper show that supply of substitutive treatments is concentrated among a reduced number of general practitioners and in particularly deprived geographic areas. Workload in deprived areas combined to great professional commitment in maintenance treatment reveals unexpected and unwanted specialisation behaviours by general practitioners, as well as more isolated behaviours by general practitioners who do not ask for particular training program or help by colleagues. These results question the consistency of the general framework of support to general practitioners proposed by health authorities with general practitioners actual practice and needs.

Delivering generics without regulatory incentives? Empirical evidence from French general practitioners about willingness to prescribe international non-proprietary names

France presents a unique situation in which the take-off of a generic drug market depends, out of regulatory incentives, on whether physicians choose a prescription method (international non-proprietary names, INN) that can lead to the delivery of these drugs and on whether patients accept them. This paper is aimed at pointing out factors explaining general practitioners' (GPs') willingness to prescribe in INN through data collected from a South-Eastern France representative sample of 600 GPs in March 2002. The main results shed light on the key-role played by GPs' information about drugs and the source which they take it from, by GPs' volume of services and caseloads, and slightly by socio-economic characteristics of patients.

Effect of patient socioeconomic status on perceptions of first- and second-year medical students

BACKGROUND

Physician decision-making and perceptions of patients are affected by a patient's socioeconomic status (SES). We sought to determine if the perceptions of first- and second-year medical students are similarly affected. We also wanted to determine whether a student's own SES affects his or her perceptions of patients from a low or high SES background.

METHODS

Two similar videos of a physician-patient interview were created. One video featured a patient of apparently high SES and the other featured a patient of apparently low SES. Differences in SES were portrayed by means of clothing, accessories and dialogue. First- and second-year medical students at the University of Western Ontario were recruited to view 1 of the videos and to answer a questionnaire using a 5-point Likert scale.

RESULTS

Responses were obtained from 205 (89%) of the 231 medical students invited to participate. Respondents' perceptions of the low SES and high SES patients were significantly different in the following respects. The low SES patient was perceived to be less compliant in taking medications and less likely to return for follow-up visits; was perceived to have a lower level of social support, poorer overall health and a worse prognosis; and was perceived to be more adversely affected in his occupational duties by illness (p < 0.05). Furthermore, second-year students who watched the video with the low SES patient were less inclined to want that patient in their practice than second-year students who watched the video with the high SES patient (p = 0.032). One hundred and six students (52%) were categorized as having high SES and 37 (18%) as having low SES (the remaining students were categorized as having mid-level SES). Among students who watched the video with the low SES patient, the level of agreement with the statement "This person is the kind of patient I would like to have in my practice" was greater among low SES students than among high SES students (p = 0.012).

INTERPRETATION

First- and second-year medical students have negative perceptions of low SES patients on several dimensions.

Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study

OBJECTIVE

To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.

DESIGN

Observational study nested within a randomised controlled trial.

SETTING

Five general practices in three settings in the United Kingdom.

PARTICIPANTS

847 consecutive patients, aged 16-80 years.

MAIN OUTCOMES MEASURES

Patient preferences and doctors' perception of patient pressure and medical need.

RESULTS

Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.

CONCLUSIONS

Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.

A review and commentary of the social factors which influence stroke care: issues of inequality in qualitative literature

Stroke is the third most common cause of death in the UK and a major cause of adult disability. Stroke services have long been criticised for being deficient and there is evidence that some aspects of care provision vary across different population groups. While there is information about the patterns of service provision, questions remain about processes which might underlie these variations. The present paper sought to assess how well the processes which might lead to inequity in the delivery and uptake of stroke services are currently understood by reviewing the qualitative literature in the area. The review was carried out by systematically searching online literature databases, using keyword and bibliographical searches, within a particular time frame. In total, 55 articles were reviewed, including studies related to primary and secondary clinical care, as well as social care. Articles focused on both professionals' and patients' perspectives. The review reports the cultural factors and processes which have been identified as possible causes of barriers to professionals' delivering stroke services, as well as issues which influence patients' uptake of services. Issues identified in the literature were categorised into four broad thematic areas: conceptualisations of stroke illness and ageing, socio-economic factors, resource allocation and information provision. These themes are then revisited through the hypothesis that the concept of social and personal identity could cast new light on our understanding of how inequity in stroke care provision might arise. It is argued that the ways in which professionals and patients view themselves and each other influences their interaction, and in turn, the delivery and demand for services. Finally, the authors suggest areas where further research is warranted.

Urban deprivation and public hospital admissions in Christchurch, New Zealand, 1990-1997

The present paper examines the relationship between deprivation and changing patterns of public hospital admissions in Christchurch, New Zealand, between 1992 and 1997, during a time of economic restructuring and rapid change in the health sector. The total set of admissions into Christchurch Hospital was geocoded according to the meshblock domicile of each patient. Domiciles were classified into 10 decile categories using the NZDep91 and NZDep96 measures of deprivation. Regression analysis was used to measure changes in the relationship between deprivation and different types of admissions. Differences between admission rates for people living in the most and least deprived areas increased over time, especially following the implementation of the 1993 health reforms. This was most marked for younger adults (ages = 25-44 years), day patients, and especially, acute day patients, ambulatory-care-sensitive admissions and re-admissions. The average length of stay also varied by deprivation and appeared to be an important cause of the increasingly high rate of re-admissions. On average, patients from more affluent areas are hospitalised longer than low-income patients, although the differences narrow over time. The results suggest that the widening social gap in hospitalisation rates is a result of the effects of poverty and problems of access to primary care. However, more research on different admission pathways and causes of admissions for different patients from different parts of the city is needed to confirm these observations.

Physician evaluation of obesity in health surveys: "who are you calling fat?"

Previous research on status generalization suggests that physicians may use non-medical factors in their evaluation, interpretation, and treatment of persons presenting for care. This study compares physicians' evaluations of obesity with physical measurements of body stature and fat collected from a large national health examination survey. While the anthropometric measures are strong predictors of physician evaluations of obesity, between 13% and 19% of the respondents were classified in ways that could not be predicted from the anthropometric measures. Moreover, personal and status characteristics were related to physicians' evaluations of obesity. Women, especially White and taller women, were more likely to be evaluated as obese than would be predicted from the anthropometric measures-African American women were less likely than their White counterparts to be so classified. Physicians' evaluation of obesity was least consistent with measured obesity for older respondents. Indeed among men, age was the most important status characteristic shaping physician evaluations: older men were more likely to be evaluated as obese. The findings suggest that the cluster of status characteristics is important to physicians during medical evaluations.

Social disadvantage: its impact on the use of Medicare services related to diabetes in NSW

OBJECTIVE

To use Medicare data to examine the impact of social disadvantage on the use of health services related to diabetes.

METHOD

Information on number of diabetic individuals and number of services for select Medicare item codes were retrieved by New South Wales postcodes using a Health Insurance Commission data file. The postcodes were graded into quintiles of social disadvantage.

RESULTS

People at most social disadvantage were significantly less likely to be under the care of a general practitioner (adjusted OR 0.41; 95% CI 0.40-0.41) or consultant physician (adjusted OR 0.50; 95% CI 0.48-0.53), despite this group having the highest prevalence of diabetes. The difference in attendance to other specialists was less marked but nevertheless significant (adjusted OR 0.71; 95% CI 0.68-0.75). Once under a doctor's care, patients at most disadvantage were slightly more likely to undergo HbA1c or microalbuminuria estimation (adjusted OR 1.04; 95% CI 1.00-1.10 and adjusted OR 1.22; 95% CI 1.12-1.33, respectively) but were less likely to undergo lipid or HDL cholesterol estimation (adjusted OR 0.81; 95% CI 0.48-0.53 and adjusted OR 0.85; 95% CI 0.79-0.90, respectively).

CONCLUSION

While access to medical care is decreased for people at most social disadvantage, once under a doctor's care they receive a level of monitoring that is relatively equal to that provided to people less disadvantaged.

IMPLICATION

Strategies are required to ensure equal access to medical services for all persons with diabetes, especially for persons who are at most social and medical disadvantage.