The quality of GP consultation in two different salary systems

Lean Management Approach for Reengineering the Hospital Cardiology Consultation Process: A Report from AORN "A. Cardarelli" of Naples

Background: Consultations with specialists are essential for safe and high-quality care for all patients. Cardiology consultations, due to a progressive increase in cardiology comorbidities, are becoming more common in hospitals prior to any type of treatment. The appropriateness and correctness of the request, the waiting time for delivery and the duration of the visit are just a few of the elements that can affect the quality of the process. Methods: In this work, a Lean approach and Telemedicine are used to optimize the cardiology consultancy process provided by the Cardiology Unit of “Antonio Cardarelli” Hospital of Naples (Italy), the largest hospital in the southern Italy. Results: The application of corrective actions, with the introduction of portable devices and telemedicine, led to a reduction in the percentage of waiting for counseling from 29.6% to 18.3% and an increase in the number of patients treated. Conclusions: The peculiarity of the study is to apply an innovative methodology such as Lean Thinking in optimizing the cardiology consultancy process, currently little studied in literature, with benefits for both patients and medical staff.

Medical visit time and predictors in health facilities: a mega systematic review and meta-analysis

Purpose

Visit time is a crucial aspect of patient–physician interaction; its inadequacy can negatively impact the efficiency of treatment and diagnosis. In addition, visit time is a fundamental demand of patients, and it is one of the rights of every patient. The purpose of this paper is to determine factors influencing the consultation length of physicians and to compare consultation length in different countries.

Design/methodology/approach

MEDLINE (PubMed), Web of Science, Cochrane, ProQuest, Scopus, and Google Scholar were searched. In addition, references of references were checked, and publication lists of individual scholars in the field were examined. We used data sources up to June 2018, without language restriction. We used a random-effects model for the meta-analyses. Meta-analyses were conducted using Comprehensive Meta-Analysis Version (CMA) 3.0.

Findings

Of 16,911 identified studies, 189 studies were assessed of which 125 cases (67 percent) have been conducted in the USA. A total of 189 studies, 164 (86.77 percent) involved face-to face-consultations. The effects of three variables, physician gender, patient gender, and type of consultation were analyzed. According to moderate and strong evidence studies, no significant difference was found in the consultation lengths of female and male doctors (Q=42.72, df=8,I2=81.27,p=0.891) and patients’ gender (Q=55.98, df=11,I2=80.35,p=0.314). In addition, no significant difference was found in the telemedicine or face-to-face visits (Q=41.25, df=5,I2=87.88,p=0.170).

Originality/value

In this systematic review and meta-analysis, all of physicians’ visits in 34 countries were surveyed. The evidence suggests that specified variables do not influence the length of consultations. Good relationship is essential to a safe and high-quality consultation and referral process. A high-quality consultation can improve decisions and quality of visits, treatment effectiveness, efficiency of service, quality of care, patient safety and physician and patient satisfaction.

Patient-perceived responsiveness of primary care systems across Europe and the relationship with the health expenditure and remuneration systems of primary care doctors

BACKGROUND

Health systems are expected to be responsive, that is to provide services that are user-oriented and respectful of people. Several surveys have tried to measure all or some of the dimensions of the responsiveness (e.g. autonomy, choice, clarity of communication, confidentiality, dignity, prompt attention, quality of basic amenities, and access to family and community support), however there is little evidence regarding the level of responsiveness of primary care (PC) systems.

METHODS

This work analyses the capacity of primary care systems to be responsive. Data collected from 32 PC systems were used to investigate whether a relationship exists between the responsiveness of PC systems and the PC doctor remuneration systems and domestic health expenditure.

RESULTS

There appears to be a higher responsiveness of PC when doctors are paid via capitation than when they only receive a fee for services or a mixed payment method. In addition, countries that spend more on health services are associated with higher levels of dignity and autonomy.

CONCLUSION

Quality, as measured from the patient's perspective, does not necessarily overlap with PC performance based on structure and process indicators. The results could also stimulate a new debate on the role of economic resources and PC workforce payment mechanisms in the achievement of quality goals, in this case related to the capacity of PC systems to be responsive.

Health providers' perspectives on delivering public health services under the contract service policy in rural China: evidence from Xinjian County

BACKGROUND

To effectively provide public health care for rural residents, the Ministry of Health formally unveiled the contract service policy in rural China in April 2013. As the counterpart to family medicine in some developed countries, the contract service established a compact between village doctors and local governments and a service agreement between doctors and their patients. This study is a rare attempt to explore the perspectives of health providers on the contract service policy, and investigate the demand side's attitude toward the public health services delivered under the contract policy. This evidence from Xinjian County, Jiangxi Province, the first and most representative pilot site of the contract service, could serve as a reference for policymakers to understand the initial effects of the policy, whereby they can regulate and amend some items before extending it to the whole country.

METHODS

Official documents were collected and semi-structured interviews with human resources and villagers in Xinjian County were conducted in September 2013. A purposive sampling method was used, and eight towns from the total 18 towns in Xinjian County were selected. Ultimately, eight managers (one in each township health center), 20 village doctors from eight clinics, and 11 villagers were interviewed. A thematic approach was used to analyze the data, which reflected the people's experiences brought about by the implementation of the contract service policy.

RESULTS

While the contract service actually promoted the supply side to provide more public health services to the villagers and contracted patients felt satisfied with the doctor-patient relationship, most health providers complained about the heavy workload, insufficient remuneration, staff shortage, lack of official identity and ineffective performance appraisal, in addition to contempt from some villagers and supervisors after the implementation of the contract service.

CONCLUSIONS

Contract service is a crucial step for the government to promote public health services in rural areas. To inspire the positive perspective and optimal work performance of the health workforce, it is imperative for the Chinese government to fortify financial support to health providers, adopt an advanced management model and escalate administrative capacity.

The Missing Evaluation at the End of GP's Consultation

Evaluation at the end of a consultation is an element of a successful encounter. The doctor should inquire if patient's expectations were fulfilled and sum up the information given, the examinations performed, and the decisions made with the patient. This way the patient would be fully aware of what has been decided and that the problems and expectations of the patient had been taken into account. Twenty consultations of four general practitioners (GPs) in Finland were videotaped. The doctors were men and women, two of them had a long experience and two were trainees in general practice. The data (videotapes, questionnaires, and interviews) were analysed by multiple research methods with investigator and methodological triangulation. MAAS-Global Rating List was used as an assessment tool. The evaluation of the consultation was often missing or having shortages; only one-third was assessed to be better than doubtful. The assessments done by experienced GPs and the medical student were similar. According to the result of this study as well as the information in the current literature, doctors in all periods of their career should repeatedly be reminded about the importance of the evaluation at the end of the consultation.

The medico-professional quality of GP consultations assessed by analysing patient records

OBJECTIVE

To assess the medico-professional quality of consultations by analysing textual data from patient records.

DESIGN

Qualitative analyse of textual data.

SETTING

Four primary health care centres using electronic patient records (EPR) in Finland.

SUBJECTS

EPR and paired questionnaires of 175 consultations filled in by GPs and their patients independently.

MAIN OUTCOME MEASURES

Medico-professional quality of consultations, quality of care of acute respiratory infections, and hypertension.

RESULTS

The medico-professional quality of the consultations was quite good. However, 9% of the records could not been assessed at all because of missing or poor documentation and 9% were assessed as poor. The treatment of acute respiratory infections and hypertension is not in line with current care guidelines. Smoking habits or other health behaviour or lifestyle factors were seldom recorded.

CONCLUSIONS

The medico-professional quality of the consultation was quite good. Quality improvement is needed in the treatment of acute respiratory infections and hypertension. User-friendly EPR systems would improve the content of patient records.

Does patients' choice of health centre doctor depend on the organization? A comparative study of four municipalities with different forms of service provision in Finland

AIMS

The aim of the study was to examine the use of physician services and the willingness to choose an health centre (HC) doctor rather than an alternative (i.e. private, occupational healthcare, other doctor) by the working age population in four municipalities in Finland. In a Southern municipality primary health care was contracted out to a non-profit organization whereas Eastern, Western and South-Western municipalities mainly provided services themselves.

METHODS

A mail survey of a random sample of the 15-64-age population was conducted in 2002 (n = 2,000, response rate 62%). Data were analyzed using descriptive statistics as well as bi- and multivariate logistic regression analyses.

RESULTS

Of the respondents, 69% had visited an HC doctor during the past year, and of these, more than 40% had also visited another doctor outside the HC. The willingness to choose an HC doctor varied from 40% to 54% and was highest in the Southern municipality. When significantly associated variables - age, working status, perceived stress in life situation, access to an appointment, perceived interpersonal quality, and visits to doctors - were controlled for, the willingness to choose an HC doctor was, compared with the Southern municipality, less popular only in the Western municipality.

CONCLUSIONS

The tendency to choose an HC doctor rather than an alternative was quite low, probably reflecting lack of attractiveness of HC to patients. However, contracting out service production did not additionally decrease patients' willingness to choose an HC doctor. More attention should be paid to improving access, interpersonal quality and continuity of care.

The breadth of primary care: a systematic literature review of its core dimensions

Background

Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.

Methods

A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.

Results

Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.

Conclusions

A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

The quality of electronic patient records in Finnish primary healthcare needs to be improved

OBJECTIVE

To analyse the technical quality of electronic patient records in relation to legislation and to evaluate their quality associated with the quality of consultations as rated by patients and GPs.

DESIGN

Cross-sectional study of electronic patient records.

SETTING

Four primary healthcare (PHC) centres in Finland using three different electronic patient record systems.

SUBJECTS

Patient records of 175 PHC consultations by 50 GPs, rated as the best (n=86) and the worst (n=89) of a total of 2191 consultations.

MAIN OUTCOME MEASURES

Documentation of records compared with legislation, the general informative value of records, and its relation to the experienced quality of consultations and to the electronic system employed.

RESULTS

Reason for encounter was mentioned in 79% of cases and patient history in 32%. An acute problem was described moderately well or well in 84%, examination findings in 62%, medical problem or diagnosis in 90%, and treatment in 95% of cases. Medication was documented adequately in 38% of the cases where medication was documented. Concerning general informative value, 18% were assessed as poor, 62% as moderate, and 20% as good. No correspondence was found between experienced quality of consultation and general informative value in the patient records. The quality of patient records was found to change according to the electronic system employed.

CONCLUSIONS

Finnish patient records are inadequate documents of consultations and below the standard of that country's legislation. Developing better models of recording would guarantee a higher quality of work.

Is the treatment of acute COPD exacerbations in Finland shifting to general practitioners?

OBJECTIVE

To examine changes in the numbers of inpatient episodes and inpatient days and length of stay in acute exacerbations of COPD (chronic obstructive pulmonary disease) by specialization and by age group and sex distribution relative to the total population in the years 1995-2001.

DESIGN

A register-based study.

SUBJECTS

Data on inpatient episodes for patients aged 45 years or over with a principal diagnosis of COPD beginning in 1995-2001 and lasting less than 90 days were extracted from the hospital discharge register of the Finnish National Research and Development Centre for Welfare and Health.

MAIN OUTCOME MEASURES

Numbers of inpatient episodes and days by age and sex in the specialties of general practice, pulmonary medicine, and internal medicine.

RESULTS

The annual number of inpatient episodes increased by 10.9% from 1995 to 2001. The number of emergency treatment episodes supervised by a general practitioner increased by 36.8% during the same period and the number of such episodes supervised by a pulmonary specialist by 17.8%. The increase in age-adjusted emergency treatment episodes for men was 0.8% and that for women 18.5%. The average hospital stay shortened from 8.0 (SD 8.0) to 6.5 (SD 6.2) for men and from 8.7 (SD 8.5) to 7.3 (SD 6.8) for women.

CONCLUSIONS

The greater increase in inpatient episodes for exacerbations of COPD in relation to the total population among women than among men may be attributed to differences in smoking habits and ageing between the sexes. Responsibility for COPD cases is clearly shifting to general practitioners. This is due partly to the national programme for the treatment of obstructive pulmonary diseases and the associated in-service training provided for general practitioners and partly to financial reasons. More detailed investigations should be made into the quality of the treatment.