Obstacles on the path to a primary-care led National Health Service: complexities of outpatient care

Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study

BACKGROUND

Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood.

OBJECTIVES

To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored.

METHODS

A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software.

RESULTS

Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care.

CONCLUSIONS

A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.

Patients' perspectives on the medical primary-secondary care interface: systematic review and synthesis of qualitative research

OBJECTIVES

To synthesise the published literature on the patient experience of the medical primary-secondary care interface and to determine priorities for future work in this field aimed at improving clinical outcomes.

DESIGN

Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore patients' perspectives of the medical primary-secondary care interface.

SETTING

International primary-secondary care interface.

DATA SOURCES

EMBASE, MEDLINE, CINAHL Plus with Full text, PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection, Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index, and grey literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were eligible for inclusion if they were full research papers employing qualitative methodology to explore patients' perspectives of the medical primary-secondary care interface.

REVIEW METHODS

The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data.

RESULTS

The search identified 690 articles, of which 39 were selected for full-text review. 20 articles were included in the systematic review that encompassed a total of 689 patients from 10 countries. 4 important areas specific to the primary-secondary care interface from the patients' perspective emerged: barriers to care, communication, coordination, and 'relationships and personal value'.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Patients should be the focus of any transfer of care between primary and secondary systems. From their perspective, areas for improvement may be classified into four domains that should usefully guide future work aimed at improving quality at this important interface.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42014009486.

Informing the design of a national screening and treatment programme for chronic viral hepatitis in primary care: qualitative study of at-risk immigrant communities and healthcare professionals

Background

Effective strategies are needed to provide screening and treatment for hepatitis B and C to immigrant groups in the UK at high risk of chronic infection. This study aimed to build an understanding of the knowledge, beliefs and attitudes towards these conditions and their management in a range of high-risk minority ethnic communities and health professionals, in order to inform the design of a screening and treatment programme in primary care.

Methods

Qualitative data collection consisted of three sequential phases- (i) semi-structured interviews with key informants (n = 17), (ii) focus groups with people from Chinese, Pakistani, Roma, Somali, and French- and English-speaking African communities (n = 95), and (iii) semi-structured interviews with general practitioners (n = 6). Datasets from each phase were analysed using the Framework method.

Results

Key informants and general practitioners perceived that there was limited knowledge and understanding about hepatitis B and C within high-risk immigrant communities, and that chronic viral hepatitis did not typically feature in community discourses about serious illness. Many focus group participants were confused about the differences between types of viral hepatitis, held misconceptions regarding transmission, and were unaware of the asymptomatic nature of chronic infection. Most welcomed the idea of a screening programme, but key informants and focus group participants also identified numerous practical barriers to engagement with primary care-based screening and treatment; including language and communication difficulties, limited time (due to long working hours), and (for some) low levels of trust and confidence in general practice-based care. General practitioners expressed concerns about the workload implications and sustainability of screening and treating immigrant patients for chronic viral hepatitis in primary care.

Conclusions

Strategies to reduce the burden of chronic viral hepatitis in immigrant communities will need to consider how levels of understanding about hepatitis B and C within these communities, and barriers to accessing healthcare, may affect capacity to engage with screening and treatment. Services may need to work with community groups and language support services to provide information and wider encouragement for screening. Primary care services will need ongoing consultation regarding their support needs to deliver hepatitis screening and treatment programmes.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Aggregation of qualitative studies--From theory to practice: Patient priorities and family medicine/general practice evaluations

OBJECTIVE

Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas.

METHODS

The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic.

RESULTS

Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers.

CONCLUSIONS

We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach.

PRACTICE IMPLICATIONS

An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness.

Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups

BACKGROUND

Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis.

RESULTS

Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research.

DISCUSSION

By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger

BACKGROUND: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own. METHODS: Information was triangulated from three sources in two rural districts in Niger: first, 46 semi-structured interviews with health centre nurses; second, 42 focus group discussions with an average of 12 participants - patients, relatives of patients and others; third, 231 semi-structured interviews with referred patients. RESULTS: Passive patients without 'voice' reinforce authoritarian attitudes of health centre staff. The latter appear reluctant to refer because they see little added value in referral and fear loss of power and prestige. As a result staff communicates poorly and show little eagerness to convince reluctant patients and families to accept referral proposals. CONCLUSIONS: Diminishing referral costs and distance barriers is not enough to correct failing referral systems. There is also a need for investment in district hospitals to make referrals visibly worthwhile and for professional upgrading of the human resources at the first contact level, so as to allow for more effective referral patterns.

Primary and secondary dental care: the nature of the interface

Specialist dental services are scarce resources and are often oversubscribed. A key element is how these services relate to their referral base, in other words the interface between primary and secondary dental care. Dentistry has several unique qualities when compared with medicine and the nature of the interface between primary and secondary dental care is consequently very different to the medical interface, whilst apparently sharing common features. This paper examines the nature of that interface, the drivers for patient flow between services and outlines the properties of an ideal interface. This model can then be used as a way of describing some of the problems facing specialist dental services and of assessing any proposed solutions.

Returning a referral for erectile dysfunction to the referrer by two different routes

OBJECTIVE

To compare the prescribing pattern and attitude of general practitioners (GPs) in response to a clinic returning a patient referred for erectile dysfunction (ED) to the referrer by two different methods.

METHODS

Referrals on a waiting list for an assessment of ED were reviewed and a subgroup of patients with criteria enabling them to be eligible for a prescription under the National Health Service (NHS) identified. The GP was informed either in writing or by telephone that the clinic had written to the patient, suggesting he make direct contact with his GP. A follow-up questionnaire was sent to each GP one month after the initial letter to the patient and contact with the GP.

RESULTS

Of 91 questionnaires sent to GPs, 66 (73%) were completed; an additional five GPs corresponded by letter rather than completing the questionnaire. The long waiting time for assessment had led to 35% of patients having already tried sildenafil, and by the time the questionnaire was completed, 57% of patients had tried sildenafil. Ten times as many referrers indicated that they were happy to initiate a prescription for sildenafil than not to do so, for those men eligible for an NHS prescription. More GPs who had received a letter returned the completed questionnaire (80%) than those who had received a courtesy telephone call (64%). There were no differences between the groups of GPs in their attitude to our contact with their patient and no difference in prescribing pattern. Conclusion The provision of guidelines and advice to GPs either by telephone or letter is acceptable practice in reducing long waiting-list times for ED. Safe, simple and effective treatments are available for GPs to use under NHS guidelines.