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Björk J, Hirsch A. An "ethics of strangers"? On knowing the patient in clinical ethics. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:389-397. [PMID: 38850498 PMCID: PMC11310239 DOI: 10.1007/s11019-024-10213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
The shape and function of ethical imperatives may vary if the context is an interaction between strangers, or those who are well acquainted. This idea, taken up from Stephen Toulmin's distinction between an "ethics of strangers" and an "ethics of intimacy", can be applied to encounters in healthcare. There are situations where healthcare personnel (HCP) know their patients (corresponding to an "ethics of intimacy") and situations where HCP do not know their patients (corresponding to "an ethics of strangers"). Does it make a difference for normative imperatives that follow from central concepts and principles in medical ethics whether HCP know their patients or not? In our view, this question has not yet been answered satisfactorily. Once we have clarified what is meant by "knowing the patient", we will show that the distinction is particularly relevant with regard to some thorny questions of autonomy in healthcare (e.g., regarding advance directives or paternalism in the name of autonomy), whereas the differences with regard to imperatives following from the principles of justice and beneficence seem to be smaller. We provide a detailed argument for why knowing the patient is ethically valuable in encounters in healthcare. Consequently, healthcare systems should provide fertile ground for HCP to get to know their patients, and structures that foster therapeutic continuity. For this to succeed, a number of questions still need to be clarified, which is an important task for medical ethics.
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Affiliation(s)
- Joar Björk
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden.
- Department of Research and Development, Region Kronoberg, Sweden.
| | - Anna Hirsch
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
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Lee IH, Choo E, Kim S, Je NK, Jo AJ, Jang EJ. Relationship between continuity of primary care and hospitalisation for patients with COPD: population-based cohort study from South Korea. BMJ Open Respir Res 2024; 11:e002472. [PMID: 39209352 PMCID: PMC11367395 DOI: 10.1136/bmjresp-2024-002472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 08/05/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVES The existing evidence for the impacts of continuity of care (COC) in patients with chronic obstructive pulmonary disease (COPD) is low to moderate. This study aimed to investigate the associations between relational COC within primary care and COPD-related hospitalisations using a robust methodology. DESIGN Population-based cohort study. SETTING National Health Insurance Service database, South Korea. PARTICIPANTS 92 977 adults (≥40 years) with COPD newly diagnosed between 2015 and 2016 were included. The propensity score (PS) matching approach was used. PSs were calculated from a multivariable logistic regression that included eight baseline characteristics. EXPOSURE COC within primary care. MAIN OUTCOME MEASURES The primary outcome was the incidence of COPD-related hospitalisations. Cox proportional hazard models were used to estimate HRs and 95% CIs. RESULTS Out of 92 977 patients, 66 677 of whom were cared for continuously by primary doctors (the continuity group), while 26 300 were not (the non-continuity group). During a 4-year follow-up period, 2094 patients (2.25%) were hospitalised; 874 (1.31%) from the continuity group and 1220 (4.64%) from the non-continuity group. After adjusting for confounding covariates, patients in the non-continuity group exhibited a significantly higher risk of hospital admission (adjusted HR (aHR) 2.43 (95% CI 2.22 to 2.66)). This risk was marginally reduced to 2.21 (95% CI 1.99 to 2.46) after PS matching. The risk of emergency department (ED) visits, systemic corticosteroid use and costs were higher for patients in the non-continuity group (aHR 2.32 (95% CI 2.04 to 2.63), adjusted OR 1.25 (95% CI 1.19 to 1.31) and expβ=1.89 (95% CI 1.82 to 1.97), respectively). These findings remained consistent across the PS-matched cohort, as well as in the sensitivity and subgroup analyses. CONCLUSIONS In patients with COPD aged over 40, increased continuity of primary care was found to be associated with less hospitalisation, fewer ED visits and lower healthcare expenditure.
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Affiliation(s)
- Iyn-Hyang Lee
- College of Pharmacy, Yeungnam University, Gyeongsan, Korea (the Republic of)
- Department of Health Sciences, University of York, York, UK
| | - Eunjung Choo
- College of Pharmacy, Ajou University, Suwon, Korea (the Republic of)
| | - Sejung Kim
- Department of Data Science, Andong National University, Andong, Korea (the Republic of)
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busan, Korea (the Republic of)
| | - Ae Jeong Jo
- Department of Data Science, Andong National University, Andong, Korea (the Republic of)
| | - Eun Jin Jang
- Department of Data Science, Andong National University, Andong, Korea (the Republic of)
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Choi E, Lee J, Choo E, Jang EJ, Lee IH. Continuity of care between dyslipidemia patients and multiple providers: A cohort study. PLoS One 2024; 19:e0300745. [PMID: 38696494 PMCID: PMC11065238 DOI: 10.1371/journal.pone.0300745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/04/2024] [Indexed: 05/04/2024] Open
Abstract
OBJECTIVE This study aimed to investigate the impacts of continuity of care (COC) between patients and multiple providers, i.e., doctors and community pharmacists, on clinical and economic outcomes. METHODS This is a retrospective cohort study and analyzed Korean national claims data for ambulatory care setting between 2007 and 2018. Patients with dyslipidemia newly diagnosed in 2008 were identified. COC between providers and patients was computed using the continuity of care index (COCI). Based on COCIs, the study patients were allocated to four groups: HM/HP, HM/LP, LM/HP, and LM/LP. Each symbol represents H for high, L for low, M for doctor, and P for pharmacist. The primary study outcome was the incidence of atherosclerotic cardiovascular disease (ASCVD). RESULTS 126,710 patients were included. Percentages of patients in the four study groups were as follows: HM/HP 35%, HM/LP 19%, LM/HP 12%, and LM/LP 34%. During the seven-year outcome period, 8,337 patients (6.6%) developed an ASCVD, and percentages in the study groups were as follows; HM/HP 6.2%, HM/LP 6.3%, LM/HP 6.8%, and LM/LP 7.1%. After adjusting for confounding covariates, only the LM/LP group had a significantly higher risk of ASCVD than the reference group, HM/HP (aHR = 1.16 [95% confidence interval = 1.10~1.22]). The risk of inappropriate medication adherence gradually increased 1.03-fold in the HM/LP group, 1.67-fold in the LM/HP, and 2.26-fold in the LM/LP group versus the HM/HP group after adjusting for covariates. Disease-related costs were lower in the HM/HP and LM/HP groups. CONCLUSIONS The study shows that patients with high relational care continuity with doctors and pharmacists achieved better clinical results and utilized health care less, resulting in reduced expenses. Further exploration for the group that exhibits an ongoing relationship solely with pharmacists is warranted.
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Affiliation(s)
- Eunyoung Choi
- College of Pharmacy, Yeungnam University, Gyeongsan, Republic of Korea
- Department of Pharmacy, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Juhee Lee
- Department of Statistics and Probability, Michigan State University, East Lansing, MI, United States of America
| | - Eunjung Choo
- College of Pharmacy, Ajou University, Suwon, Republic of Korea
| | - Eun Jin Jang
- Department of Informational Statistics, Andong National University, Andong, Republic of Korea
| | - Iyn-Hyang Lee
- College of Pharmacy, Yeungnam University, Gyeongsan, Republic of Korea
- Department of Health Sciences, University of York, York, United Kingdom
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Ljungholm L, Årestedt K, Fagerström C, Djukanovic I, Ekstedt M. Measuring patients' experiences of continuity of care in a primary care context-Development and evaluation of a patient-reported experience measure. J Adv Nurs 2024; 80:387-398. [PMID: 37485735 DOI: 10.1111/jan.15792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Continuity of care is viewed as a hallmark of high-quality care in the primary care context. Measures to evaluate the quality of provider performance are scarce, and it is unclear how the assessments correlate with patients' experiences of care as coherent and interconnected over time, consistent with their preferences and care needs. AIM To develop and evaluate a patient-reported experience measure of continuity of care in primary care for patients with complex care needs. METHOD The study was conducted in two stages: (1) development of the instrument based on theory and empirical studies and reviewed for content validity (16 patients with complex care needs and 8 experts) and (2) psychometric evaluation regarding factor structure, test-retest reliability, internal consistency reliability, and convergent validity. In all, 324 patients participated in the psychometric evaluation. RESULTS The Patient Experienced Continuity of care Questionnaire (PECQ) contains 20 items clustered in four dimensions of continuity of care measuring Information (four items), Relation (six items), Management (five items), and Knowledge (five items). Overall, the hypothesized factor structure was indicated. The PECQ also showed satisfactory convergent validity, internal consistency, and stability. CONCLUSION/IMPLICATIONS The PECQ is a multidimensional patient experience instrument that can provide information on various dimensions useful for driving quality improvement strategies in the primary care context for patients with complex care needs. PATIENT OR PUBLIC CONTRIBUTION Patients have participated in the content validation of the items.
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Affiliation(s)
- Linda Ljungholm
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
| | - Kristofer Årestedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Research, Region Kalmar County, Kalmar, Sweden
| | - Cecilia Fagerström
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Research, Region Kalmar County, Kalmar, Sweden
| | - Ingrid Djukanovic
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
| | - Mirjam Ekstedt
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Engström I, Hansson L, Ali L, Berg J, Ekstedt M, Engström S, Fredriksson MK, Liliemark J, Lytsy P. Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review. BMC Psychiatry 2023; 23:952. [PMID: 38110889 PMCID: PMC10729558 DOI: 10.1186/s12888-023-05440-1] [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: 07/20/2023] [Accepted: 12/05/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI. METHODS Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518. RESULTS We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas. CONCLUSIONS The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.
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Affiliation(s)
- Ingemar Engström
- University Health Care Center, Faculty of Medicine and Health, Örebro University, Örebro, SE-701 82, Sweden.
| | - Lars Hansson
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Lilas Ali
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Berg
- SBU - Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
| | | | - Maja Kärrman Fredriksson
- SBU - Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Jan Liliemark
- SBU - Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Per Lytsy
- SBU - Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
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Almalki ZS, Alahmari AK, Alajlan SAA, Alqahtani A, Alshehri AM, Alghamdi SA, Alanezi AA, Alawaji BK, Alanazi TA, Almutairi RA, Aldosari S, Ahmed N. Continuity of care in primary healthcare settings among patients with chronic diseases in Saudi Arabia. SAGE Open Med 2023; 11:20503121231208648. [PMID: 37915839 PMCID: PMC10617268 DOI: 10.1177/20503121231208648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Maintaining continuity of care is one of the most critical components of providing great care in primary health care. This study aimed to explore continuity of care and its predictors in primary healthcare settings among patients with chronic diseases in Saudi Arabia. Method Face-to-face cross-sectional interviews were conducted with patients with chronic diseases who had at least four visits to primary care facilities in Riyadh, Saudi Arabia, between November 1, 2022 and March 3, 2023. We determined patients' continuity of care levels using the Bice-Boxerman continuity of care index. A Tobit regression model was used to determine the effects of several factors on the continuity of care index. Results The interviews were conducted with 193 respondents with chronic diseases of interest. The mean continuity of care index of the entire sample was 0.54. Those with asthma had the highest median continuity of care index at 0.75 (interquartile range, 0.62-0.75), whereas those diagnosed with thyroid disease had a much lower continuity of care index (0.47) (interquartile range, 0.3-0.62). Tobit regression model findings showed that employed respondents with poorer general health had a negative effect on continuity of care index levels. By contrast, a higher continuity of care index was significantly associated with elderly respondents, urban residents, and those diagnosed with dyslipidemia, diabetes, hypertension, or asthma. Conclusions According to our findings, the continuity of care level in Saudi Arabia's primary healthcare setting is low. The data demonstrate how continuity of care varies among study group characteristics and that improving continuity of care among chronic disease patients in Saudi Arabia is multifaceted and challenging, necessitating a coordinated and integrated healthcare delivery approach.
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Affiliation(s)
- Ziyad S Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Abdullah K Alahmari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | | | - Abdulhadi Alqahtani
- Clinical Research Specialist, Clinical Research Department, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmed M Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Saleh A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Adel A Alanezi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Basil K Alawaji
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Tareq A Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Rawan A Almutairi
- Collage of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Saad Aldosari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Nehad Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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Adelsjö I, Nilsson L, Hellström A, Ekstedt M, Lehnbom EC. Communication about medication management during patient-physician consultations in primary care: a participant observation study. BMJ Open 2022; 12:e062148. [PMID: 36328391 PMCID: PMC9639081 DOI: 10.1136/bmjopen-2022-062148] [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: 02/21/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To explore communication about medication management during annual consultations in primary care. DESIGN passive participant observations of primary care consultations. SETTING Two primary care centres in southern Sweden. PARTICIPANTS Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis. RESULTS Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further. CONCLUSION Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.
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Affiliation(s)
- Igor Adelsjö
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
| | - Lina Nilsson
- eHealth Institute, Department of Medicine and Optometry, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
| | - Amanda Hellström
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
| | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Stockholm, Sweden
| | - Elin Christina Lehnbom
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Kalmar, Sweden
- Department of Pharmacy, UiT The Arctic University of Norway Faculty of Health Sciences, Tromso, Norway
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