Should visit length be used as a quality indicator in primary care?

Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel

Background

Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician’s role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers.

Methods

We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire.

Results

55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035).

Conclusions

Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician’s professional life, including medical school, pediatric residency and continuous medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00537-6.

Behaviour-change interventions in primary care: influence on nutrition and on the metabolic syndrome definers

The purpose of this paper was to examine whether interventions influenced patients' (i) consumption of fish; whole grain products; fruits and vegetables; (ii) overall nutrition, that is, the three former as an index; and (iii) clinical outcomes in terms of metabolic syndrome definers. A questionnaire was delivered to adult patients entering the nine health centres on November 2006 (n = 1211). During the year the ward personnel conducted intervention on patients with unhealthy habits. The 12-month follow up was conducted by mailings. Also clinical data of pre- and post-intervention values of metabolic syndrome definers were collected. For the analyses, intervention was divided into brief (≤ 15 min, at most three visits) and extended (> 15 min, more than three visits) intervention. Logistic Regression and manova were used to measure changes in the outcomes. Nutrition-related intervention was conducted on 218 patients (brief intervention n = 179, extended intervention n = 39). In the extended intervention group it was three times more likely to have a positive change in the nutrition index than in the brief intervention group (P = 0.017, confidence interval 1.223-7.773). In conclusion, brief interventions were commonly used in the primary care. However, they were not enough to produce changes in the patients' nutrition or in the clinical outcomes.

Physician's production of primary care in Ontario, Canada

This paper examines the factors affecting the number of patient visits per week reported by family physicians in Ontario. The way that a physician is paid is potentially endogenous to the number of patients seen per week, thus an instrumental variable method of estimation is employed to account for the endogeneity bias. Once account is taken of the endogeneity of remuneration as well as relevant physician and practice characteristics, the estimated elasticity of output with respect to hours worked is 0.74; 0.68 in group practices and 0.82 in solo practices. Physicians paid on a non-fee-for-service (NFFS) conduct 15-31% fewer patient visits per week in comparison to those paid under an FFS scheme. Certain patient populations in practices affect patient visits in important ways, as do a number of physician and practice characteristics.

Clients' experiences of a community based lifestyle modification program: a qualitative study

There is little information about how clients attending lifestyle modification programs view the outcomes. This qualitative study examined the clients' experience of a community based lifestyle modification program in Hong Kong. Semi-structured interviews were conducted with 25 clients attending the program. Clients perceived the program had positive impacts on their health and nutrition knowledge. They experienced frustration, negative emotion, lack of motivation, and pressure from others during the program. Working environment and lack of healthy food choices in restaurants were the major perceived environmental barriers for lifestyle modification. Clients valued nutritionists' capability of providing professional information and psychological support in the program. Our results suggest that nutritionist's capability of providing quality consultations and patient-centered care are important for empowering clients achieve lifestyle modification.

Time-related communication skills from the cancer patient perspective

OBJECTIVE

Although it is well recognized that skilled communication is an essential element of effective cancer care, lack of time to communicate is often cited as an explanation for the ongoing cancer care communications problems patients report. In this study, we sought to answer the question: How do cancer patients describe and explain the effects of health care communication upon their experience of time?

METHODS

We conducted a qualitative secondary analysis, using interpretive description methodology, on a large data set that comprised transcribed interview data from two studies of cancer communication from the patient perspective. One primary study represented a cross-sectional study of helpful and unhelpful communications (n=200) and the other a longitudinal study of changes in communication needs and preferences over the illness trajectory (n=60).

RESULTS

We found time a meaningful and symbolic construct for cancer patients. They describe clinician time-related attitudes and behaviors as significant factors in shaping the impact of clinical encounters on their overall psychosocial cancer experiences. They report a number of ways in which clinician communications have been particularly effective in buffering and manipulating the impact of time pressures and describe a capacity within exceptionally skilled clinicians to manufacture a perception of available time even in the context of such pressures.

CONCLUSIONS

We believe that the patient perspective on cancer care communication provides an important angle of vision from which to discern strategies that may assist clinicians to buffer the untoward effects of the time pressure under which most care systems currently operate.

Ambulatory care visits and quality of care: does the volume-control policy matter?

Using claims data from the Bureau of National Health Insurance (BNHI) in Taiwan and primary data collected from 940 patients who visited their physicians at out-patient clinics to complete questionnaire, we investigated the effects of the hospital volume control policy on the frequency of visits, medical expenses and patient satisfaction. We found that the volume control policy on ambulatory care decreased physician fees and increased both the number of visits and co-payments. However, it did not result in any change in the total medical expenses. A shift in ambulatory care expenditure from BNHI to patients did not improve patient satisfaction. While the patients were comfortable with the waiting line, they were not satisfied with the providers’ strategy of limiting quota of visits during a period of time.

Natural settings trials--improving the introduction of clinical genetic tests

Approaches to genetic testing differ in the research setting and the clinical setting. More data are needed to develop approaches that will best facilitate the use of new genetic tests in the clinical setting, especially settings where genetic testing has not been widely used, such as in primary care. Furthermore, data are needed to establish the clinical utility of new genetic tests in the general practice setting. Natural setting trials are proposed as a strategy to develop this information. While natural setting trials are clinical research studies and will expose participants to some degree of risk, the risks are different, and arguably less than the risks those same individuals would otherwise face if the test went directly into clinical practice. Ultimately, clinical practice and safety of new genetic tests can be improved by adding the evaluation provided by natural setting trials.