Patient preferences for care by general internists and specialists in the ambulatory setting

Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore

Background

Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke.

Method

Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0–3 months (early) and 4–12 months (late) post-stroke.

Results

For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits.

Conclusion

We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01405-z.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

"Very humble" vs. "Not humble": What do ratings of fictitious physician profiles with humility descriptors reveal about potential patient preferences and behaviors?

OBJECTIVES

The current study examined the impact of physician humility on future medical interactions and physician-related outcomes (e.g., patient patronage, loyalty) using a non-patient, community sample.

METHODS

Participants (N = 417) were recruited online through Amazon Mechanical Turk (mTurk) and paid a nominal fee for their participation. They reviewed randomly assigned fictitious physician profiles that differed in humility (high, low), general effectiveness (high, low), physician gender (male, female), and specialty (family practice, orthopedic surgery). Then they reported their likelihood to trust, adhere to recommendations, and be satisfied with the physician. They also conveyed how likely they would select and recommend this physician to others, and how much out-of-pocket money they would be willing to spend to see the physician.

RESULTS

Humble physicians were rated higher than their non-humble counterparts on all five outcomes. For physicians who were generally ineffective, the physicians low in humility scored lower on intended adherence, trust, and anticipated satisfaction than the physicians high in humility. Additionally, for physicians specializing in family practice, physicians low in humility scored lower on anticipated satisfaction and out-of-pocket expenditure than the physicians high in humility.

CONCLUSIONS

Findings from this study highlight how physician humility can affect the process of care even before it begins.

PRACTICE IMPLICATIONS

The study emphasizes the need for deliberate pursuit of humility to improve outcomes for patients and physicians.

Evaluating reimbursement of integrated support services using chronic care management (CCM) codes for treatment of hepatitis C among Medicare beneficiaries

The New York City Department of Health and Mental Hygiene (DOHMH) implemented Project INSPIRE, an integrated model of hepatitis C care coordination and telementoring services, from 2014 to 2017. We evaluated the use of chronic care management (CCM) codes to sustain the intervention. DOHMH data were collected as part of a Healthcare Innovation Award from the Centers for Medicare & Medicaid Services (CMS). A retrospective cohort medical billing study was conducted by assigning INSPIRE activities to procedure codes in both facility and nonfacility settings. Rates for procedures were extracted from the CMS's 2018 fee schedules and added across the eligibility periods for Medicare enrollees. Reimbursement was adjusted on the basis of expected patient attrition and compared to costs. The minimum number needed to treat (NNT) to break even was calculated in each setting. Facility reimbursement was higher than costs, whereas nonfacility reimbursement was lower (both P < .01). The NNT was 23 patients in facilities and 33 patients in nonfacilities; 24 patients per care coordinator were treated annually in INSPIRE. CCM fees alone were insufficient to fully reimburse the costs in either setting. Implementation of an appropriate risk financing strategy is necessary to mitigate financial shortfalls when providing CCM services in facility settings.

Validation of a tool to assess patient satisfaction, waiting times, healthcare utilization, and cost

AIM

Patients' experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) - a tool that collects patients' experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH).

BACKGROUND

The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH's dimensions.

METHODS

This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test-retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing).

FINDINGS

Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1-29). Only out-of-pocket utilization possessed an ICC<0.70. Patients reported that items were relevant and appropriate to measuring quality of care. No floor or ceiling effects were present. Criterion validity was reached for all items assessed. A priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient's continuum of care.

Parents' perception and willingness to maintain provider care continuity for their children under universal health coverage

Background

Provider continuity of care (COC) is closely related to patient outcome in pediatrics. However, no study has investigated how parents perceive the importance of COC and whether their perceptions affect their willingness to make effort to maintain good provider COC for their children under universal health coverage.

Methods

A cross-sectional survey was conducted between August 2017 and February 2018 across 6 different practices: 2 medical centers, 2 regional hospitals, 1 district hospital, and 1 clinic (n = 825). Parents' and caregivers' perceptions and perceived value of COC were evaluated using 7 items. The contingent valuation method was used to estimate willingness to pay and spend time.

Results

Of all respondents, only 47% (n = 394) were willing to spend >30 minutes to have their children see the regular physician if the regular physician relocated. Approximately 38% (n = 302) respondents were willing to pay more than New Taiwan Dollar (NT$) 300 per month to maintain provider COC. The perception that high COC is important was associated with willingness to spend more time for maintaining high provider COC.

Conclusion

Parents' perception of COC does not affect their willingness to pay for maintaining high provider COC for their children but affects their willingness to spend more time to maintain COC.

Deprescribing in the context of multiple providers: understanding patient preferences

OBJECTIVES

Deprescribing could reduce the risk of harm from inappropriate medications. We characterized patients' acceptance of deprescribing recommendations from pharmacists, primary care providers (PCPs), and specialists relative to the original prescriber's professional background.

STUDY DESIGN

Secondary analysis of national Patient Perceptions of Discontinuation survey responses from Veterans Affairs (VA) primary care patients with 5 or more prescriptions.

METHODS

We created 4 relative deprescribing authority (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) "Imagine…a specialist…prescribed a medicine. Would you be comfortable if your PCP told you to stop...it?" and (2) "Imagine…your VA PCP prescribed a medicine. Would you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?" Multinomial regression associated patient factors with RDA.

RESULTS

Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than 65 years (60%). A total of 281 (38%) respondents said no to both questions (PCP-N/Pharm-N) and 146 (20%) said yes to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist's medicine but yes to a pharmacist stopping a PCP's (PCP-N/Pharm-Y). A total of 153 (21%) said that a PCP could stop a specialist's medication but a pharmacist could not stop a PCP's (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with greater medication concerns were more likely to respond PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09-1.92). Those with more interest in shared decision making were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92). Those with greater trust in their PCP were less likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34-0.81) but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13-2.98).

CONCLUSIONS

Understanding patient preferences of RDA can facilitate effective design and implementation of deprescribing interventions.

Model for allocation of medical specialists in a hospital network

Introduction

As human diseases are becoming increasingly complex, the need for medical specialist consultation is more pronounced, and innovative ways to allocate medical specialists in hospital networks are essential. This study aimed to construct allocation models using a multi-objective programming approach in a large private hospital network in Thailand.

Methods

Our study included 13 medical specialist types in four main disease groups of the Bangkok Dusit Medical Services network. Mixed-integer linear programming models were developed using inputs from a modified Delphi survey of executives, the Physician Engagement Survey, and the Physician Registry (PR) databases and featuring three objectives: 1) minimizing travel expense, 2) optimizing physician engagement, and 3) maximizing the chance of direct patient encounters with respective medical specialists who were formally qualified for the clinical complexity of the patients, as measured by the case mix index (CMI).

Results

The constructed models included the core components but varied by a combination of whether part-time medical specialists are included or not (noPT) and whether CMI is included (CMI) or not (noCMI). Because the noPT + CMI model had the highest capability to solve for specialist allocation, it was further improved for some specialist types in terms of flexibility for sensitivity analysis of the variables. Moreover, to assess the feasibility and practicality of the models, a web-based system incorporating the final model was developed to support the central executives' decision to allocate medical specialists to the network, especially for finding the most optimal and timely solution for widespread shortages.

Conclusion

The linear programming models that accommodate critical components for allocating medical specialists in the hospital network were feasible and practical for the central executives' timely decision making. The models could be further tested for their application in hospitals in the public sector or other private hospital networks.

Referral determinants in Swiss primary care with a special focus on managed care

Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24’774 patients with 42’890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.

[Potential Use of Healthcare Professions by Privately Insured Considering Complementary Medical Benefits]

BACKGOUND

Patient preferences are becoming more and more important in healthcare and research. The aim of this study was to gain information about potential consultation of health professionals among a population of clients of a private insurer, considering complementary health care services of the insurer.

METHODS

Based on 7 hypothetical afflictions (pain in chest, allergy, digestive complaints, depressive mood, knee swelling, reducing addictive substance, child with febrile infect) the surveyed were asked to indicate who they would turn to in the first and second place. The options were: a general practitioner, a conventionally-oriented specialist, a complementary-oriented specialist, an alternative practitioner, a pharmacist, and others.

RESULTS

1,960 insurants (74.1% male; 62.4 ± 10.2 years) completed the questionnaire. In all potential afflictions the surveyed would prefer to consult a general practitioner in the first place, followed by a specialist. Only in case of allergy (12.5%) and depression (11.8%) or reduction of addictive substances (18.6%) they would also consider a complementary-oriented specialist as first choice. In case of depressive mood, allergy, digestive complaints, and angina pectoris the compliance was high, with Kappa >0.5. Moreover, a sensitivity analysis regarding gender and education showed a markedly higher compliance when the population was homogenized.

DISCUSSION

Irrespective of the affliction, for the majority of the surveyed the general practitioner and specialist seem to be the first choice when it comes to health problems. Complementary-oriented specialists seem to be relevant only in specific disorders.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

Background

Demand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.

Objective

This research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.

Design

The approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.

Setting

Primary health care.

Main outcome measures

Referral from primary to secondary care.

Review methods

Systematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.

Results

From a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.

Conclusions

The findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.

Study registration

The study is registered as PROSPERO CRD42013004037.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

How can psychological science inform research about genetic counseling for clinical genomic sequencing?

Next generation genomic sequencing technologies (including whole genome or whole exome sequencing) are being increasingly applied to clinical care. Yet, the breadth and complexity of sequencing information raise questions about how best to communicate and return sequencing information to patients and families in ways that facilitate comprehension and optimal health decisions. Obtaining answers to such questions will require multidisciplinary research. In this paper, we focus on how psychological science research can address questions related to clinical genomic sequencing by explaining emotional, cognitive, and behavioral processes in response to different types of genomic sequencing information (e.g., diagnostic results and incidental findings). We highlight examples of psychological science that can be applied to genetic counseling research to inform the following questions: (1) What factors influence patients' and providers' informational needs for developing an accurate understanding of what genomic sequencing results do and do not mean?; (2) How and by whom should genomic sequencing results be communicated to patients and their family members?; and (3) How do patients and their families respond to uncertainties related to genomic information?

Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

BACKGROUND

Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown.

METHODS

Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables.

RESULTS

Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect.

CONCLUSIONS

Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction.

Health-related quality of life as a main determinant of access to rheumatologic care

To evaluate a rheumatology outpatient consultation access system for new patients. New patients seen from April 2005 to April 2006 at our rheumatology clinic (n = 4,460) were included and classified according to their appointment type: ordinary appointments (OA) to be seen within 30 days, urgent appointments (UA) and work disability appointments (WDA) to be seen within 3 days. Age, sex, diagnosis, and health-related quality of life (HRQoL) as determined by the Rosser Index were recorded. Logistic regression models were run to identify factors that contribute to each type of appointment. OA was the method of access for 1,938 new patients, while 1,194 and 1,328 patients were seen through WDA and UA appointments, respectively. Younger male patients, and those with microcrystalline arthritis, sciatica, shoulder, back, or neck pain, were more likely to use the faster access systems (UA or WDA), whereas patients with a degenerative disease were mainly seen through OA (<0.001). Subjects with poor (3.96; 95 % CI, 2.8-5.5) or very poor HRQoL (70.8; 95 % CI, 14.9-334) were strongly associated to visiting a rheumatologist through the WDA or UA access systems, respectively, compared to OA. Age, gender, diagnosis, and mainly health-related quality of life are associated with the referral pattern of access to rheumatologic outpatient care. Among new patients subjects with the worst HRQoL were more likely to access with faster methods (UA or WDA) than those with better HRQoL.

Relational barriers to depression help-seeking in primary care

OBJECTIVE

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

METHODS

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

RESULTS

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

CONCLUSION

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests.

PRACTICE IMPLICATIONS

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Treatment goals of depressed outpatients: a qualitative investigation of goals identified by participants in a depression treatment trial

Treatment goals and preferences of depressed patients are important, but they are rarely empirically studied. Although clinicians are likely to discuss goals with individual patients, research that clarifies overall patterns in the treatment goals of depressed patients could be useful in informing new interventions for depression. Such research could also potentially help address problems such as poor adherence and psychotherapy drop-out. In this preliminary qualitative investigation, we examined treatment goals established by depressed outpatients in the context of a trial of behaviorally oriented psychotherapy. The treatment goals that were most commonly articulated included improving social and family relationships, increasing physical health behaviors, finding a job, and organizing one's home. These results underscore the fact that, in addition to improvement in the symptoms of depression, functional improvements are viewed as key treatment goals by depressed individuals.

Patients' views of interpersonal continuity of care in four primary health care centres of urban oman

OBJECTIVES

Interpersonal continuity of care (consulting the same physician) is widely regarded as a core value of primary care and a crucial component of quality of care. Nonetheless, interpersonal continuity as experienced by patients remains a neglected topic in Arab countries including Oman. The aim of this study was to explore how patients view interpersonal continuity of care in the primary care setting in Oman.

METHODS

Four primary health centres (PHCs) were selected from two urban cities in Oman. In the period June to August 2008, adult patients were surveyed by questionnaire at their PHC while waiting to see their primary care physicians (PCPs).

RESULTS

We interviewed 319 (71%) of enrolled participants. Their ages ranged from 18-70 years. The majority of patients (223 - 70%) thought interpersonal continuity was very important for them; 232 (73%) patients felt that they obtained better care with interpersonal continuity. 225 (71%) patients preferred interpersonal continuity if they had personal, family or social problems. Nonetheless, compared to male patients, female patients had less chance to maintain interpersonal continuity (p = 0.018). Interpersonal continuity increased as the number of consultations increased (p = 0.030). Preference for interpersonal continuity was associated with increasing age (p = 0.020) and with the presence of chronic illnesses (p = 0.001). Patients with chronic illnesses, who reported more preference for interpersonal continuity, were also found to be more compliant with medications and committed to carrying out recommended advice compared to patients without such illnesses (p = 0.027).

CONCLUSION

Omani patients perceived interpersonal continuity as an important aspect of primary care. Health planners should note patients' preference for interpersonal continuity and take visible measures to support it. A larger study is needed to survey more of the PHCs of Oman.

How much do patients' preferences contribute to resource use?

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

Patients' perceptions of safety if interpersonal continuity of care were to be disrupted

OBJECTIVE

To determine if patients vary in perceptions of safety if interpersonal continuity were to be disrupted. If so, which characteristics are associated with feeling unsafe?

BACKGROUND

The extent to which patients' preference for continuity with a personal physician is due to perceptions of safety is unclear.

DESIGN

Observational study (Wisconsin Longitudinal Study Graduate and Sibling Survey).

SETTING AND PARTICIPANTS

A total of 6827 respondents (most aged 63-66 years) who completed the 2003-06 survey round.

MAIN VARIABLES STUDIED

Age, gender, marital status, education, health insurance type, illnesses, medications, length of relationship with provider and place, personality type, decision-making preference and trust in physician deliberation.

MAIN OUTCOME MEASURES

Safety perception when visiting another doctor or clinic if own doctor were not available.

RESULTS

Twelve percent of respondents felt unsafe. After adjustment, as compared to those who felt safe, those who felt unsafe were more likely to be women (Odds ratio=1.65, 95% confidence interval=1.35-2.01), have more chronic conditions (1.27, 1.08-1.50) and have a longer relationship with a usual provider: 5-9 years (1.53, 1.11-2.10) 10-14 years (1.41, 1.02-1.95) and 15 or more years (1.62, 1.20-2.17) compared to 0-4 years. Those who preferred active participation in decision making and had trust in their physician were less likely to feel safe (1.63, 1.10-2.41).

CONCLUSIONS

Certain older adults perceive being unsafe if not seeing their usual physician. Further research should investigate reasons for perceptions of safety if continuity were disrupted and any implications for care.

Older patients perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries

CONTEXT

Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.

OBJECTIVE

To assess older Americans' perceptions of the need for tests and referrals that their personal physician deemed unnecessary.

DESIGN

Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).

STUDY PARTICIPANTS

Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor ("one you would see for a check-up or advice if you were sick") whom they described as a generalist ("doctor who treats many different kinds of problems").

MAIN OUTCOME MEASURE

Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).

RESULTS

Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is "better for a patient to have one general doctor who manages most of their medical problems" than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they "probably did not need to see a specialist but could if they wanted to." For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want "special tests" for the chest pain.

CONCLUSIONS

When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients' perceptions regarding the need for these services.

The importance of interpersonal treatment goals for depressed inpatients

Increased understanding of the treatment goals of depressed patients may lead to improved treatments and assist researchers and program evaluators in choosing clinically relevant outcome measures. To characterize patients' depression treatment goals, we interviewed hospitalized depressed patients about their treatment goals. Common responses included improving relationships, decreasing sadness or anxiety, and finding a job or improving job performance. On a written questionnaire, patients also ranked decreasing suicidal thoughts highly. These results suggest that for many severely depressed individuals, primary treatment goals include improvements in social and occupational functioning in addition to symptomatic improvement.

The Influence of Patients' and Primary Care Practitioners' Beliefs and Expectations About Chronic Musculoskeletal Pain on the Process of Care

OBJECTIVES

To review qualitative, empirical studies exploring the influence of patients' and primary care practitioners' beliefs and expectations on the process of care for chronic musculoskeletal pain.

METHODS

A multidisciplinary review group searched 9 bibliographic databases. The group worked in pairs to screen titles and abstracts for relevance, to quality appraise relevant studies, to extract data from high-quality studies and to undertake a thematic analysis of this data.

RESULTS

We identified 12,994 abstracts from our searches, of which we obtained 113 full-text articles as their abstracts contained insufficient information for us to decide on their eligibility. We appraised 22 qualitative studies, 15 of which were included in the analysis. Themes identified included; (1) beliefs about pain, (2) expectations of treatment, (3) trust, and (4) patient education. Both patients and practitioners wanted clear communication within the consultation and to be respected, but conflicts existed on nearly all other aspects of the consultation, some of which at present may seem insurmountable and may lead to difficulties in achieving positive outcomes.

DISCUSSION

To tackle the challenges and conflicts identified within the review, change may have to occur, not just in individual patient and practitioner beliefs and behavior, but also at an organizational and system level, for example, changes in undergraduate and postgraduate education and changes in the organization and availability of health services.

Racial and ethnic differences in patients' preferences for initial care by specialists

PURPOSE

To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences.

METHODS

We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes.

RESULTS

Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites.

CONCLUSION

Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.

Perceptions of value of routine care among patients with cystic fibrosis and their families

Routine quarterly visits are an integral part of effective disease management for patients with cystic fibrosis (CF), regardless of the patient's age. The objective of this study was to explore the relationship between perceptions of the value of routine visits and perceived overall quality of care. The population in this study consisted of 194 patients at a single CF center. Telephone interviews were completed with 162 parents of children or adult patients (response rate, 84%) in May-June 2000. Among other satisfaction-related questions, respondents were asked to rate: 1) overall quality of care, 2) importance of routine clinic visits in providing good preventative care, and 3) helpfulness of routine clinic visits in providing knowledge for CF care. They were also asked open-ended questions concerning the reasons for their ratings. Perceived helpfulness and importance of routine visits were negatively associated with patient age and positively associated with perceived overall quality of care, especially for parents of teenage patients. The most common reason for low importance ratings was that the patient's health is perceived to be good, making routine clinic visits unnecessary. The most common reasons for low helpfulness ratings were that the visits are too repetitive or routine, and the family learns nothing new from them. In conclusion, tailoring routine visits to respond to different age-based needs and making routine visits less repetitive may add value to routine visits, which could result in increased perceived overall quality of care, especially for parents of teenage patients.

Determinants of patient satisfaction in chronic illness

OBJECTIVE

To determine whether primary care provided by generalists versus subspecialists resulted in different levels of patient satisfaction among persons with chronic illness.

METHODS

A survey containing the Primary Care Provider Questionnaire and the Health Status Questionnaire (HSQ) was mailed to 2 population-based cohorts of patients with rheumatoid arthritis (RA) or diabetes mellitus (DM). All subjects were at least 35 years old and Rochester, Minnesota residents. Descriptive statistics, Spearman correlation coefficients, and multiple regression models were used to describe and compare the determinants of patient satisfaction.

RESULTS

A total of 86 people (74% female) with RA and 208 people (56% male) with DM responded to the survey. Age range was 41-95 years and median disease duration was 8.7 years (RA) and 13.0 years (DM). Most patients described their health as fair or good. After adjusting for sex differences, RA patients were more likely than DM patients to report having a specialist as their primary care doctor. RA patients, whether reporting seeing a specialist or a generalist, had comparable HSQ physical health, mental health, social functioning, vitality, and bodily pain scores. DM patients seeing a specialist had more bodily pain and poorer physical functioning than those seeing a generalist. Across both chronic illnesses and physician specialties, median scores for patient satisfaction ranged from 17-18 for overall satisfaction (maximum 20); 30-33 for interpersonal skills (maximum 35); 23-26 for technical quality (maximum 30); and 20 for access to care (maximum 25). Multiple linear regression models revealed that 6.8-7.3% of the variation in satisfaction could be explained by HSQ scores, patient demographics, and physician specialty.

CONCLUSION

Both RA and DM patients were highly satisfied with their care, regardless of the specialty of the provider. Physician specialty, patient demographics, and HSQ scores explained only a small proportion in the variation in satisfaction. These findings point to the need for additional research to further elucidate the determinants of patient satisfaction.

The mismatch between urban women's preferences for and experiences with primary care

Socioeconomic disparities in women's primary care experiences have been described previously. To better understand whether these disparities reflect personal preferences for primary care, rather than insurance or other access barriers, we conducted a telephone survey of a community-based sample of 1,205 women in Washington, DC. The study found that women of lower socioeconomic status had poorer primary care experiences compared with higher income counterparts, despite similarly high preferences for primary care. The poorer primary care experiences of lower socioeconomic status women were attenuated by better access to primary care. Differences in primary care attainment are not solely a matter of personal preferences; rather, they appear to be more strongly related to barriers to obtaining care.